lessons in normality

It's the last day of 2007.
Yesterday a few of the November babies I caught came to brunch at my house (yes, the parents were also invited).
A few older babies came too and we munched and sipped mimosa (well, the parents did) and as is apt to happen among new moms, everyone traded birth stories.
These are all women I have worked with who entered into giving birth within the midwifery model of care. Each woman had varying levels of success with this, depending on where she chose to give birth (a few were home, one birthing center, one hospital).
So, after some swapping dramatic tales with happy endings, somebody asks 'does anyone ever have a 'normal' birth?'
I was shocked to hear this asked in my circle of mamas! We are so conditioned to think about birth from the biomedical model that even those who escape its boundaries and have positive, self fulfilled home births, compare their experiences to the parameters of 'normal' established by obstetrics! I exclaimed very quickly that yes! you ALL had normal births! It is not abnormal for a cervix to take a pause in its dilation (even a five hour pause). It is not abnormal to go two weeks over your 'due date'. It is not abnormal for pushing to take a couple of hours. These are things the body does to get a baby out! There is nothing more normal. It is trying to place the body in a box of time management that is abnormal!
Everyone laughed and agreed.
But I had to sigh a little inside. It truly is hard to escape something so deeply engrained. It's like unlearning how to breath.
Happy new year y'all. May you all remember how very, very normal and beautiful you are!

This is like watching a train wreck

Childbirth Ecstasy

I lifted these videos from the unassisted childbirth website.
First of all, the one up top almost looks fake.
Her hair, her makeup, her smile, it's all so 'I Love Lucy'.
Does this woman get off on pain or is she really feeling THAT good?
Either way, I'll take what she is taking, please.
Additionally, are these births taking place in France?
The vaginal birth of twins (in the video below), especially a breach twin, would never be done in an American hospital. I love how quiet all of the assistants are and how they allow the babies to just come out. The mom is so wide open and calm. Totally animal. Totally beautiful. Totally resistant to the technocratic model, and yet in a hospital. Who are these women? Who are these attendants? I want an interview!

Partera

'Nuff Said

US Maternal Mortality Rate Increasing
The maternal mortality rate in the US is the highest it has been in decades, according to statistics released in August by the National Center for Health Statistics. The US maternal mortality rate was 13 deaths per 100,000 live births in 2004, compared to 12 in 2003, which was the first year the maternal death rate was more than 10 since 1977. The major direct causes of US pregnancy-related deaths are blood clots, hemorrhage, complications of medical conditions, and eclampsia and pre-eclampsia.

The report says the increase in maternal deaths "largely reflects" more states' use of a separate item on the death certificate indicating pregnancy status of the woman. A rise in the number of caesarean sections could be a factor in the increased maternal mortality rate, some experts said. Race and quality of care also factor into the maternal mortality rate. The maternal mortality rate among black women is at least three times higher than among white women. Three studies have shown that at least 40% of maternal deaths could have been prevented with improved quality of care. The rise in obesity might also be a factor. Finally, more women are giving birth in their late 30s and 40s, when risks of pregnancy complications are higher.

The report is available online at www.cdc.gov/nchs/data/nvsr/nvsr55/nvsr55_19.pdf

Yes, Chinua, Things do fall apart

Watch this on NY Times.com.
It is a short news blurb on the women of the Congo.
Some of the women I worked with in Uganda were refugees from the Congo. I feel anxious when I think about how big, how long, how devastating this war has been to so many thousands of people.

With the recent peace talks I wonder who will be the first to surrender. Surrender in Military definition is when soldiers or nations stop
fighting and become prisoners of war. Of course, nobody every mentions
that the white flag is usually conditional. There is always something
we just can't give up. Something we will still die to hold onto. And
what happens if there are multiple truths, perspectives, ideas we are
all clinging to the death for? Who surrenders what? So we negotiate
surrender. I'll give this up if you give that up, and then are we
even? Men sit around in suits and sign pieces of paper that are
contracts on other peoples lives. Surrender becomes the compromise,
and at once, the center of the story.

Its kind of like, Yes, Chinua, Things do fall apart: I can't talk my
way out of it. or into it. Just have to lay still and accept the
uneasiness as it washes over my broken body. a wave, pushing over
sand. And sometimes, when I wake, I am no longer who I thought I was
At ALL. I am only the pieces held together with blood and piss and
tears. Chaotic energy sparking into ash at your feet, blending into
the Earth as a molecule of something bursts into nothing and is gone.

Women of East Africa. Women all over who have been violated in the name of a battle being waged by men. Women who give birth and die for political violence.
I offer you my hands. My heart. My voice, which I am so privileged to have been taught how to use.
And yet I feel as powerless as you. When one woman is violated, we all are. Rape as a tool of war makes all of us prisoners. How do we shift what has already devastated? In the hearts of the men who rape. In the boys who are now growing and being raised by mothers who conceived and gave birth in violence. How do we shift the cycle?

These photos were taken by me in Uganda. Child Mothers to the left, and a TBA with a child she caught in an IDP camp to the right.

The 'Best'

I want to dialogue with the idea of 'the best' doctor.
I hear that a lot. It seems everyone has found 'the best' doctor to fit their needs.
"They have to operate, but he has the best heart surgeon in the United States".
"My gynecologist is rated number one in cervical cancer treatment".

First of all, who is doing the rating?
Second of all, what are they basing the ratings on? Lowest number of patient deaths? Highest level of training? Best bedside manner? (highly doubtful), Sexiness? (more likely.)
A small amount of research has led me to believe they base it on statistics which show the most performance with the best outcomes for the least amount of money paid by insurance companies.

It certainly is a comforting thought. Having the best.
We all want the best, but clearly, by nature of the word itself, only one person can inhabit that position. You are either 'the best' or you are not.
Seems like a strange binary for a field that needs to heal an entire world of people.

Read Rafael Campo's book 'Desire To Heal'.
It is a poetic look into empathy and the twisted business of being 'the best' doctor.

I love this belly. So often what is right beneath the skin seems so far away, so unimaginable, so un-real. And then you see the contours of a foot, skin pressing up against skin, and the distance is lessened, the body understood, everything just makes a little bit more sense.

Uter-"I"

What is a uterus?

"Uterus: 1. In the primates; The organ in which the young are conceived, developed, and protected till birth; the female organ of gestation; the womb. b. In other animals: The matrix; the ovary 1753. 2. Bot. a. = PERICARP 1676. b. In fungi: The envelope of the sporophore 1829." -- Oxford English Dictionary.

Uterus, then, appears to be a medical or botanical term. My uterus is there to perform a reproductive function, as in other animals (and fungi), and in some ways it is not dissimilar to a nut shell (pericarp -- the pod, husk or shell of a fruit). This description does seem to lack depth and breadth, being purely about physical form and function, but then that's exactly why I recognize it as a scientific definition.

So aside from its nutshell function, the cultural relationship of uterus to 'woman' is an interesting one to explore. What happens when our uterus betrays us by not holding life? Or when we lost it to illness? Or what happens when a perfectly functional uterus turns fifty and stops serving its life purpose? I am interested in a discussion of uterus vs femininity or gender roles in particular. I am most interested in an international discussion because I am sure it varies - I mean, shit, it probably varies from brownstone to brownstone here in Brooklyn.

A laying on of hands

Shamanism is in and underesourced Western medicine is... out?
I don't think so. However, this article seems to point to the idea that somewhere in the international consciousness indigenous practices may have a place. I think those spaces where what used to work, and new 'innovative' (I locate that problematically) ideas can mix, are the only potential we have for effective health care in rural communities.

Lack. Loss. Limbs. and Love.

I have been reading 'Minding The Body' a collection of essays by women writers on the body.
I read it years ago, but it strikes something different this time around.
Perhaps it is the subtlety of shared experience that evokes a sense of closeness to my own fleshy body, or maybe it is just a point of entry for discussing something that is lived and very rarely articulated. Words are at once inadequate and yet simultaneously unveil truths that mimic the expansion and contraction of the lungs with every breath. Simple and so necessary.

It seems one of the overarching themes of the book is loss, or coping with a percieved loss.
Loss of youth, body shape, children, facial features, sexuality, wildness. Each writer finds a nugget of truth or wisdom in her loss, but nevertheless her discussion begins with a lack.
Must every discussion of women's bodies begin from lack?

I think about the body and loss, generally.
The body can experience physical loss, and does so every day. The shedding of cells, hair, skin.
The body can lose entire organs, limbs, and yet still compensate, heal and function.
Is the body ever really whole?
We lose partners and its as if our bodies have failed us somehow.
We lose hair, memory, muscle- the process of the bodies slow decline back into the earth is at once growth and loss.

Our bodies are always lacking and so how do we respond? We become obsessed with losing weight. Losing wrinkles. Losing spots. Losing any sign that we are alive and changing.
We expect to gain from that loss. Even as I write this, I have friends over getting ready to go out. I am quick, perhaps too quick in my application of product, so I find myself with a half hour at least to write while they apply makeup, tie straps, spray body splash and body shimmer. Each addition in compensation for a percieved lack.

However, I think in its own twisted way, we like it. We enjoy the process of compensation. We enjoy finding the edges of our lack and the process of defining those boundaries. We enjoy wearing strappy heels because we know the kind of power that extra leg boost creates.

So is lack the same as loss?
If you are born without a limb is it the same as losing it? Clearly we have a different emotional relationship to loss than to lack. Inherently, we spend so much time compensating for a lack, that we lose not only the potential for relationship with these bodies we live in, but also the potential for joy, for pleasure, for intimacy.

And since this is a blog in dialogue with medicine, I have to question women's relationship with their bodies in the context of our overall health.
I think its imperitive that we start examining our own relationships to our bodies and lack. Its ok to lose, but I don't think that loss must be defined in terms of lack. Prepare for a generation of women who define their bodies by what is, not what isn't. What we carry with us now, we pass on to our daughters. Historical memory is a very, very real. Thanks Grandma.

Pain as art or painful art?

Bob Flanagan's pain journal
How can pain heal?
How can suffering push the boundaries of compassion?
Was this guy just complaining or was he on to something?

He died drowning in the fluid of his own lungs. He used his lifelong terminal illness as a medium for voice and art. Some might call it masturbatory, but I think it lives on the in the trenches between total self indulgence (I mean, what/who doesn't?) and total humanitarian effort. That makes it edgier somehow. The conditions of his emergence make possible this kind of art. Only a nicely privileged white guy would have the balls to spend years of his life exhibiting and flaunting his pain- and because of that, we learn something. About him. About ourselves. Thanks Bob.

Systems and Cycles

Bodies into the earth, earth into soil, soil into food, food into bodies.
Somebody once described death this way to me.
I am interested in the documenting of the cycle.
The medical history.
The documents that narrativize and archive the biomedical story of our bodies. The human body is performed. According to Diana Taylor our personal histories are embodied through a repertoire of learned and responsive gesture. The residue of trauma or physical pain is embodied and so is pleasure. Medical histories however, seem to only be an account of that which is diagnosed or ‘wrong’. Most of us then, have a missing narrative of our actual health. I believe there is power in the narrative. The story we tell about our body actually affects the way we care for it. In every moment there are infinite possibilities for interpreting meaning, thereby making ‘truth’ a relative term.

So I am thinking today about how that narrative is formed.
Articulated.
Brought into light.
Processing about engagement style.
Strategy.
Effectively communicating so that a point can be heard.
Cultivating space for voice.
Opening channels of and for communication.
Medical histories miss the point.
Are we asking the right questions?

How can what a woman says be so different from how she feels?
Or rather, what she feels, be so impossible to say?
Where is that gap?
What lives in the space between? I sense that this space is fertile.

I think and write a lot about cultural metaphors of the body affecting healthcare and therefore, embodiment. As Carolyn Merchant demonstrates in the Death of Nature, this model originally developed in the 1600’s by Descartes, Bacon and Hobbes assumes that the universe is mechanistic, following predictable laws, which those enlightened enough to free themselves from the limitations of medieval superstition could discover through science and manipulate through technology, in order to decrease dependence on nature. In this model, the metaphor for the human body is a machine. As it was developed in the 17th century, the practical function of the metaphor of the body as machine lay in its conceptual divorce of body from soul, and in the subsequent removal of the body from the purview of religion so it could be opened up to scientific investigation. Consequently, the men who established the idea of the body as machine also firmly established the male prototype of this machine. Insofar as it deviated from the male standard, the female body was regarded as abnormal, inherently defective, and in need of constant manipulation by man. Conceptions of the body are bound to this notion that the body is controllable and predictable… something like childbirth is a radical rupture of this model.

So it makes sense that we can't narrate our bodies.
How can we push boundaries in a system thats structure denies its own validity? Is any sort of questioning a crack in a system that has no floor to begin with?
In a medical space that is built on the model of the male body, the narration of womens bodies becomes either an act of violence to the system, or to the narrated woman, depending on how it gets used. Depending on who is listening (more on audience later).

I understand that a gentle entry is always the better way.
To become culturally competent. To work within to shape the borders. To have an understanding of or empathy for the person's experience in the world before attempting to understand the way she embodies; culturally contextualizing the symptoms manifest in her body.
I still question how we question without becoming a tool for the same mold we are trying to break.

Bodies into the earth, earth into soil, soil into food, food into bodies. Have you ever seen life leave a body? Without breath the body takes on a different shape, a different meaning. The experiences of that person are no longer connected to the body but to the memory of the body in life. The stories. The narrative. What that body passes on, will remain in the medical narratives of its children, re-invoking its own story through its constant telling. I believe that disease is truly just the body in dis-ease. If medical practitioners can engage and align with not just the measurable symptoms but the actual events and feelings surrounding the body in dis-ease, we may be faced with new questions- and with new questions come new answers, new ways to heal.

I don't feel well today.
I woke with this unquenchable thirst. Guzzled water, took a shower, hydrated my skin, guzzled water, made tea.
Felt better. Running late to lead a workshop on prepared childbirth for young pregnant mamas in the Bronx.
Got on the subway. Morning commute style. Bodies mashed into bodies, ten sets of hands on a pole, sweat mixed with perfume mixed with drycleaned suits mixed with coffee/garlic bagel breathe mixed with hormones mixed with sweat.
I am reading a book about women's health issues in Islam.
The author was describing the experience of having her genitals mutilated.
Suddenly I felt nauseous. I put the book down but it did not pass. I felt that thirst again, then hot, then cold, my knees wobbled like I couldn't stand any more. My vision was blurred. I held on tight to the pole with both hands and actually put my head on the shoulder of the man standing next to me. There was nowhere else for it to go. He looked a little concerned but didn't say anything.
I must have looked bad because the next thing I knew someone was leading me through the bodies to a seat. Phew. I thought I was going down.
I put my head between my knees and felt my breath return to normal. My pulse slow down.
As I came back into my senses I had the clarity to realize how this experience is moving through my body, literally, like a turbulent wave.
The body is this amazing, resilient, renewing cellular structure. Shedding old and taking in new all the time. And yet there is something about the way that trauma meets the cell structure... it gets stuck. It manifests in posture, in illness, rash, fear. How do we move trauma through the body to promote health?

On another note, I made it to and through the workshop.
I love teenagers. I really love New York teenagers. They are a special breed.
Some highlights:

Rachel: What do you think are some of the advantages of being able to walk in labor?
Girl dressed all in black: your boyfriend can check your ass out.

girl#1: Can I keep my underwear on when I am in labor?
Rachel: You can keep them on as long as you are comfortable... eventually they will have to come off.
girl #2: ... girl why you stressing about panties? You know white girls don't wear no panties!
girl #3: I don't wear panties either... I mean, I do when I go out, but when I'm in labor my labias be swingin'.

Girl asking question: As my pregnancy progesses, more and more people smile at me. Why?
Girl dressed all in black: Because you're fatter than they are.

Thoughts:
Maybe humor is an obvious answer to moving pain and trauma through the body. Its certainly an entry point for talking about it.

Fake it til we make it

You know, this work doesn't stop.
It spirals. Unlinear and intimately evolving.
Reflection is the ultimate power.
To see ones actions without the emotional charge, to be able to be objective with 'self' pushes boundaries and gently slaughters older versions of self, kissing her on the forhead and moving forward.
I think a lot about context. To speak of violence against women one must have context, compassion. To tell a story, to locate oneself, context is everything.
But context is relative to the teller.
One cannot speak of women without speaking of where they are.
That hospital which is running 735% over its capacity. That entire hospital is running on an annual budget of $500,000 including the salaries of everyone that works there (maternity ward, antenatal clinic, surgery ward, TB ward, isolation ward, etc ), is only marginally more disorganized than some of the New York City hospitals where one administrators salary alone might come close to 500k.
Everything is relative and context is everything.

I have fallen right back into my midwifery here. Seeing clients, attending births, answering the phone in the middle of the night to assuade discharge fears. And there is violence here. A friend of a friends baby died at an NYC hospital the other day. Her water broke at 22 weeks. Instead of hooking her up to fluids and trying to wait a couple of weeks for a viable fetus, the hospital induced. Telling here there was no other option. She did not question authority. Does the hospital truly have respect for a single black woman on medicaid? What is the value of her babies life? If this had been some rich white senator would the outcome have been the same?
Without becoming cynical, the questions must be asked. Contextualized. Brought into voice.

No matter where we are, birth is managed from a technocratic model. The story of the cells over the story of the woman. A white mans model. The two overlap and intermix, the story of the woman informing the management of the molecular tale. It is these moments of joining that fascinate me, inspire me to move forward with this work, to remain hopeful that the stories can evolve, if we give them voice.

In a world that promotes and seems to thrive on scandal, fear and violence, how do we keep hope alive and continue to walk with faith?

I always talk about 'faking it until you make it'- that positive affirmations, even if you are feeling down, can lead to actual manifestations. We believe our own bullshit, why not believe our own positives?

I have always been involved in women's work. Gatherings, ceremonies, ritual, comfort, laughter- the bonding that takes place to heal 'wounds' that just being a woman in this world invokes. It seems I was born into a generation and community of women who are given the space to do this.

Medicalized birth is managed from a mans perspective. The war that men create affects the way that women give birth, the care they receive. The research methods developed by men carve paths that women jump into, but rarely have voice enough to change. Men plant seeds, literally. Women negotiate that garden.

So where is the space for mens work? For positive evolution? Who is doing this work?

Women's work can only go so far without the men.

In all of the madness in the world right now, it seems particularly necessary for men to have a space to process and communicate with honesty, creativity and even vulnerability.

I want to invite the men in my life to question their own roles as partners, fathers, healers, teachers, leaders, and participants in the world.

You may not all jump to join into groups and bond with eachother, but keep the questions alive and active.

I also want to invite the women in my life to get behind every man you know who is open to the idea of activating this process.

Let's fake it will we make it people.

What are you fighting for?

How to write about Africa

Binyavanga Wainaina

some tips: sunsets and starvation are good

Always use the word 'Africa' or 'Darkness' or 'Safari' in your title. Subtitles may include the words 'Zanzibar', 'Masai', 'Zulu', 'Zambezi', 'Congo', 'Nile', 'Big', 'Sky', 'Shadow', 'Drum', 'Sun' or 'Bygone'. Also useful are words such as 'Guerrillas', 'Timeless', 'Primordial' and 'Tribal'. Note that 'People' means Africans who are not black, while 'The People' means black Africans.

Never have a picture of a well-adjusted African on the cover of your book, or in it, unless that African has won the Nobel Prize. An AK-47, prominent ribs, naked breasts: use these. If you must include an African, make sure you get one in Masai or Zulu or Dogon dress.

In your text, treat Africa as if it were one country. It is hot and dusty with rolling grasslands and huge herds of animals and tall, thin people who are starving. Or it is hot and steamy with very short people who eat primates. Don't get bogged down with precise descriptions. Africa is big: fifty-four countries, 900 million people who are too busy starving and dying and warring and emigrating to read your book. The continent is full of deserts, jungles, highlands, savannahs and many other things, but your reader doesn't care about all that, so keep your descriptions romantic and evocative and unparticular.

Make sure you show how Africans have music and rhythm deep in their souls, and eat things no other humans eat. Do not mention rice and beef and wheat; monkey-brain is an African's cuisine of choice, along with goat, snake, worms and grubs and all manner of game meat. Make sure you show that you are able to eat such food without flinching, and describe how you learn to enjoy it—because you care.

Taboo subjects: ordinary domestic scenes, love between Africans (unless a death is involved), references to African writers or intellectuals, mention of school-going children who are not suffering from yaws or Ebola fever or female genital mutilation.

Throughout the book, adopt a sotto voice, in conspiracy with the reader, and a sad I-expected-so-much tone. Establish early on that your liberalism is impeccable, and mention near the beginning how much you love Africa, how you fell in love with the place and can't live without her. Africa is the only continent you can love—take advantage of this. If you are a man, thrust yourself into her warm virgin forests. If you are a woman, treat Africa as a man who wears a bush jacket and disappears off into the sunset. Africa is to be pitied, worshipped or dominated. Whichever angle you take, be sure to leave the strong impression that without your intervention and your important book, Africa is doomed.

Your African characters may include naked warriors, loyal servants, diviners and seers, ancient wise men living in hermitic splendour. Or corrupt politicians, inept polygamous travel-guides, and prostitutes you have slept with. The Loyal Servant always behaves like a seven-year-old and needs a firm hand; he is scared of snakes, good with children, and always involving you in his complex domestic dramas. The Ancient Wise Man always comes from a noble tribe (not the money-grubbing tribes like the Gikuyu, the Igbo or the Shona). He has rheumy eyes and is close to the Earth. The Modern African is a fat man who steals and works in the visa office, refusing to give work permits to qualified Westerners who really care about Africa. He is an enemy of development, always using his government job to make it difficult for pragmatic and good-hearted expats to set up NGOs or Legal Conservation Areas. Or he is an Oxford-educated intellectual turned serial-killing politician in a Savile Row suit. He is a cannibal who likes Cristal champagne, and his mother is a rich witch-doctor who really runs the country.

Among your characters you must always include The Starving African, who wanders the refugee camp nearly naked, and waits for the benevolence of the West. Her children have flies on their eyelids and pot bellies, and her breasts are flat and empty. She must look utterly helpless. She can have no past, no history; such diversions ruin the dramatic moment. Moans are good. She must never say anything about herself in the dialogue except to speak of her (unspeakable) suffering. Also be sure to include a warm and motherly woman who has a rolling laugh and who is concerned for your well-being. Just call her Mama. Her children are all delinquent. These characters should buzz around your main hero, making him look good. Your hero can teach them, bathe them, feed them; he carries lots of babies and has seen Death. Your hero is you (if reportage), or a beautiful, tragic international celebrity/aristocrat who now cares for animals (if fiction).

Bad Western characters may include children of Tory cabinet ministers, Afrikaners, employees of the World Bank. When talking about exploitation by foreigners mention the Chinese and Indian traders. Blame the West for Africa's situation. But do not be too specific.

Broad brushstrokes throughout are good. Avoid having the African characters laugh, or struggle to educate their kids, or just make do in mundane circumstances. Have them illuminate something about Europe or America in Africa. African characters should be colourful, exotic, larger than life—but empty inside, with no dialogue, no conflicts or resolutions in their stories, no depth or quirks to confuse the cause.

Describe, in detail, naked breasts (young, old, conservative, recently raped, big, small) or mutilated genitals, or enhanced genitals. Or any kind of genitals. And dead bodies. Or, better, naked dead bodies. And especially rotting naked dead bodies. Remember, any work you submit in which people look filthy and miserable will be referred to as the 'real Africa', and you want that on your dust jacket. Do not feel queasy about this: you are trying to help them to get aid from the West. The biggest taboo in writing about Africa is to describe or show dead or suffering white people.

Animals, on the other hand, must be treated as well rounded, complex characters. They speak (or grunt while tossing their manes proudly) and have names, ambitions and desires. They also have family values: see how lions teach their children? Elephants are caring, and are good feminists or dignified patriarchs. So are gorillas. Never, ever say anything negative about an elephant or a gorilla. Elephants may attack people's property, destroy their crops, and even kill them. Always take the side of the elephant. Big cats have public-school accents. Hyenas are fair game and have vaguely Middle Eastern accents. Any short Africans who live in the jungle or desert may be portrayed with good humour (unless they are in conflict with an elephant or chimpanzee or gorilla, in which case they are pure evil).

After celebrity activists and aid workers, conservationists are Africa's most important people. Do not offend them. You need them to invite you to their 30,000-acre game ranch or 'conservation area', and this is the only way you will get to interview the celebrity activist. Often a book cover with a heroic-looking conservationist on it works magic for sales. Anybody white, tanned and wearing khaki who once had a pet antelope or a farm is a conservationist, one who is preserving Africa's rich heritage. When interviewing him or her, do not ask how much funding they have; do not ask how much money they make off their game. Never ask how much they pay their employees.

Readers will be put off if you don't mention the light in Africa. And sunsets, the African sunset is a must. It is always big and red. There is always a big sky. Wide empty spaces and game are critical—Africa is the Land of Wide Empty Spaces. When writing about the plight of flora and fauna, make sure you mention that Africa is overpopulated. When your main character is in a desert or jungle living with indigenous peoples (anybody short) it is okay to mention that Africa has been severely depopulated by Aids and War (use caps).

You'll also need a nightclub called Tropicana, where mercenaries, evil nouveau riche Africans and prostitutes and guerrillas and expats hang out.

Always end your book with Nelson Mandela saying something about rainbows or renaissances. Because you care.

The deepest love

Becky comes to us for breakfast two days after her baby died. She has been released from the hospital where she stayed for two weeks before giving birth. She is wearing a piece of cloth wrapped around her waste and a thin red shirt with no bra. She wears a piece of blue cloth around her head. A symbol of mourning. Her breasts are noticeably swollen and heavy beneath the fabric. She has taken the braids out of her hair and it stands about one inch tall in a halo around her head.
She sits at the table as we pass eggs and fresh bread, sim sim paste mixed with honey and mango marmelade. She does not eat. I pour her some tea and she stirs it with vague interest.
How is your boyfriend, I ask. She replies that she has not seen him since he came to take the babies body from the hospital.
I missed the burial, she says looking down into the milky tea.
Then she begins to cry. A tear at first and then deep sobs. Ash se cries her breasts begin to leak milk. The fluid seeps through the thin fabric of her shirt and spreads across her front. When she finishes, she gulps her tea down like she hasn’t taken liquid in days.
Then she takes bread as well and eats it with such speed I am tempted to offer her the whole loaf. I leave her at the table.
I go to my bedroom and return with a bra. Black and lacy, it is stretched out, I can’t remember when I bought it, but know that it has been around almost as long as I have had breasts. Perhaps I got it when I was seventeen like Becky. Aimee helps her put it on and she flashes a little contented look.
We ask her to tell her story to out camera. We filmed her for two weeks in labor. Our camera needs to know what happened, but only if she feels strong enough. She lifts her eyebrows up and down quickly, a Ugandan gesture for ;’yes’ and begins to speak slowly into the camera, giggling every so often. She speaks the facts, the doctor asked her to pay 40,000 shillings for the cytotec, about $22 but more than two months salary for her family. She borrowed it from her aunt, who borrowed it from her husbands first wife. The family paid for the drug that killed the baby.
I don’t think she knows this irony but I feel chills as she speaks into the camera. I cannot ask her anything else.
We part with a long embrace, both aware that it may be a liong time before we see one another. She places her head on my shoulder and I tell her I am proud of her. I give her a bunch of clothes I am leaving in Uganda and am going to pay her school fees so she can finish high school and live in the safety of a boarding school. She will start next week.

I am leaving Gulu. It is hard to part from my sisters at St. Monicas. We have grown close. It has been what Aimee calls our African Sound of Music fantasy. Each of these sisters is so special and have provided a depth of connection and support that has been crucial in this work. I have never in my life understood the drive to become a nun, except for here. In a place where most of the relationships and sex are based on either forced family obligation or just violent force, the call to have a relationship with God instead is attractive. And these women have fun. Their community is rich with laughter and music and the sustenance of giving. Sister Pauline says don’t go Rachel, you have become a true sister. What would I do here? I ask. It would take a lot of work to make me a nun. It is ok she says, you will be our first ever Jewish sister. The offer is mildly tempting, I realize it is because the comfort of such sustained faith and generous love is something I have never experienced with such dedication and seriousness.
I have been overwhelmed by the urge to run away so much in the last month, to just be free, far away from the trauma and the pain. The comfort of community life is tempting. Alas, I am afraid I would make a very bad nun.... for more reasons than one.

My backpack is heavy but I have successfully shed enough stuff to only carry the one bag. I am so tired I feel I have lost every drop of my personality. Just breathing and moving from one place to another takes all that I have. Almost like when I had mono in high school. Aimee and Sister Grace accompany me to the bus park where I will ride the six hours into Kampala. I embrace them both and we all cry. Aimee and Kevin are headed to Rwanda tomorrow. My bus is called ‘The White Cock’, which it announces in bold letters across the front. On the back it says “Try The Cock!”. Somehow I feel safe. (Another sign that I should not become a nun.) Irony of ironies, the person in the seat next to me has two live white cocks stored at our feet. I look around for another seat but this is it. I take a deep breath, let the fear of having my toes pecked by chickens go, and relish in my window seat. We wait for two hours before the bus is full enough to leave. We make about four false starts, rolling forward, then back as one final person squishes in, and then we are off. After ten feet we stop for gas and to change a tire. And then we are off. After ten minutes we stop as the bus is bum rushed by merchants selling goat on a stick, roasted corn, cassava, water, porridge, roasted banana, mango and boiled eggs, and live chickens. Hands fly out of the bus and deals are negotiated as the merchants throw goods up into the windows and money is placed hastily into hands as the bus takes off again. This repeats itself about every twenty minutes along the journey. After a series of potholes that make me wish I still had my bra, I settle into some sort of sleep. It feels feverish and I wake because something is funny. My feet are overly hot and sweaty. One of the cocks has nested on them. Startled, I kick him off. He skwawks and pushes back under the seat. My neighbor laughs at me. The chicken has shit on my toes. I wipe them with the paper my cassava snack was wrapped in and then squirt purrell all over them. The ‘White Cock’ pulls into the Kampalla bus yard four hours later.
I hop on another bus to Entebbe and arrive at the airport just in time for my flight to Nairobi.
I feel off center as we take off into the air.
Zawadi is waiting for me when I arrive. She is family and I am instantly calmed by her presence. We drive to a restaurant and indulge in a beautiful meal before crawling back to her house where I take the longest hot shower and climb into her soft bed for a sleep that feels like angels. Her is house is eerily like mine. A bold red wall, pillows stacked in corners, tapestries on the walls. I wake and Zawadi has left for work but she has left a note.
Don’t leave. I have a surprise for you at 11:00.
I shower again relishing the hot water and all of her salt scrubs and lotions. The doorbell rings. A woman with a massage table is standing outside. The next two hours are peppermint and lavender oil bliss. I melt into being held and spend the rest of the visit in and out of bed and eating and going out to listen to music at night.

The plane ride home is hard. I feel anxious. I wrap my scarf around my head and cry. Something new is stirring. I am not sure what but it pushes me beyond where I am comfortable. This will take a long time to process. To really be able to speak about.

I arrive home to the deepest love imaginable. The women just carry me. I am so held. So blessed. Massage and a clean home stocked with food and light and blessings. Healthy kittens and fresh sheets and a hot meal. I could not be more held. What a perfect gift to have this family so profoundly, present. Thank you. I could not do this without you.

I feel a lack of poetry.
Like words cannot begin.
Like every day starts and finishes in the same breath.
Like my heart, which is now so full, is aching something awful.
Is that pleasure or pain?
My hands smell of latex and even after I have scrubbed them, the rubber scent from glove after glove after glove lingers.
Like an animal I miss my old scent.
The one that was salty sweet and mine.
Will I be able to find my way home without it?
I wash again, this time my whole body.
The shower is cold and I feel my teeth chattering on their own.
I slather in salt scrub, rub dry with coconut oil.
That’s better.
I notice my feet are still a darkish red/brown color, like burnt clay.
It’s all I can do to describe the moment.
This body.
I feel such gratitude. Such love.
Mixed with such anger. Such sadness.
The combination is saltysour and it burns my lips.
And so I feel anxious, something small on the edge
I want to sleep it off
or run it off
peel it off in layers
watch the center drop between my legs
trickle to the floor in
silent droplets
of dissolusion
processed like sugar into something digestable
sweet
place it moist to my lips
The most beautiful poetry is what is not said.
What’s between the lines…

… I enter a dimly lit room in the back of the hospital. There are no windows so the only light comes from the hall. Becky (my friend with epilepsy who spent a week in early labor) is laying on a straw mat in the corner. She is sleeping. I know that something is wrong by the shape of her stomach. She has delivered in the night. But where is the baby?

This is the center of the story. The middle. I begin here because this is where every good story starts. In your gut. In the moment where you know it is a story and not just another moment passing. It only becomes a story in the moment when it is told. It doesn’t matter much where you start, because to trace its origin would be to go all the way back to the conception of all of those involved, the conception of their parents, grandparents, and friends. Start in the middle. The moment. Just start.

…Becky’s baby died.
Aimee calls me on the phone to tell me.
I vomit.

The doctor grew impatient with her slow labor and gave her cytotec to speed things along. Cytotec, while used in the USA is extremely controversial and is not FDA approved for use during labor. It is not FDA approved because it kills people. It also has a different name. The abortion pill. The doctor gave her two pills, four times the amount used in USA to induce a labor. The placenta detached from the uterine wall and the baby died. She gave birth twelve hours later to a dead baby. A girl.
I want to scream. Not again. Not this one. Will it ever stop?

Aimee and I write up a report and document many of the cases that were mishandled since we have been here. We highlight three cases that ended with either maternal or fetal death (or both) as a result of negligence and misuse of druggs. I state concerns and create a long list of simple suggestions. We share it with the head midwife. She is receptive. She says thank you and gives us gifts of sim sim paste. She shares it with the doctor and he becomes angry. He confronts me on the labor ward. I am gloved up and ready to catch a baby. He paces the room until I finish and come to him.
He wants to talk about Becky’s baby since she was in the report. He says the drug is safe. Otherwise why would the ministry of health give it to them to use? Especially since abortion is illegal here. I show him the passage in a midwifery book that talks about its dangers. He looks surprised. Says he will have to read more literature. I suggest he read the literature before he administers any drug. He says then he will become very tired. He is right and he is wrong. He is right. He has not been trained properly. He needs to read more. To be supervised by senior doctors. He is overworked. The issue is larger than him. He is wrong. His ignorance, forgetfulness and apathy are killing women and babies. Every day.

…I go to Becky in the evening and she is still sleeping.
She has not woken since she gave birth.
I sit with her.
Rub her feet with arnica.
She wakes after some time and smiles at me.
Rachel, she says
Yes
Can you buy for me some ice cream?
I feel the urge to cry.
Yes, I can buy you some ice cream.
I return with a frozen bar melting in my hands.
It is growing dark.
Power is out and the room has no windows.
I know I need to go home. Dinner is waiting. My body aches. I need to cry.
But not here.
Wait, she says, don’t go. I feel scared of the dark tonight.
Ok. I sit a bit more. I tell her to close her eyes and lead her on a visualization.
Down safe tunnels of light that carry her and the spirit of her baby.
She begins to weep.
I ask her if she has named the baby.
She laughs and says Rachel, the baby is dead.
Right. The baby is dead.
But it may help you. Even if it is just in your head.
She shakes her head a little and falls asleep. Her breathing is deep.
I leave and feel my hands shaking.
They smell of rubber. I wash them but the scent lingers.

The baby I was up with the other night died this morning.
Her mother was down in the cesarean recovery room and she had remained in the maternity ward on oxygen, an extra soul in the room.
This week has been hard.
Simple.
The relationship between living and dying so intrinsic and real. Raw.
As a midwife, one who ushers in life, I am exploring what it feels like to hold death as well.
It is hard and hard is good.
As a midwife, one who is with women, I am exploring what it feels like to have to set boundaries... and not always be there.

This week needs to be about working with the administration of the hospital to help implement some better practices... some standards of care and accountability amidst the chaos and trauma of working in this environment.

I am working the evening shift tonight and will spend the morning preparing a report and creating some worksheets that can be used on the labor ward to create accountability.
Simple.
Charts to document the fetal heart every hour... that must be turned in at the end of a shift.
Checklists for post partum care.
Cleaning each bed with bleach after every birth.
Infant CPR training.
Breastfeeding and HIV/AIDS transmission training.

I could go on and on. But some simple changes in practice might determing where women and babies stand in the line between life and the line between death

Red dirt

The woman with sepsis whose baby died, also died yesterday.
She was 17.
I didn't sleep again last night after I heard news of her death. I tried to wrap myself in a protective energy robe. My eyes were twitching. There was a loud thunder storm and rain beat down like a drum on the metal roof. I felt haunted and restless. A spider bit my foot at some point and I spent the rest of the dark night examining my foot and transferring my middle of the night paranoia onto the bite (if this is a poisonous bite how will I know? Will I die? Or maybe have my leg amputated..... one should never over think in the night) , as flashes of lightning allowed me glimpses into light.
Somehow morning came and once again a cold shower and a hot cup of coffee were my best friends.

We attended the burial at 1:00. Walked 4k deep into the bush, hiking up our skirts to avoid puddles, rocks and red ants as her brother led and a man hacked a path with a machete in front of us. The sun beat down and the red dirt stuck to my beading sweat in a patterned film on my skin, the natural lines mirroring the intricate work of a henna tattoo.
I imagined walking this path in labor to get to the hospital. How long it must feel. How the earth stretching out for miles in every direction could induce deep comfort or fear.
We passed corn fields and millet fields and fields and fields of grass until we came to a circle of 75 people. Our girl was wrapped in a cloth in the center. They unwrapped her face so we could see it. She was beautiful. Her eyes shut she looked like she was out of the anguish we have seen her in for the last week. We bent down, said silent prayers, and they lifted her body and placed her into the earth. Four men went down into the hole with her and began to pull the red dirt in with them. As the grave filled, they climbed higher and higher until they were standing on level ground.
Our girl's five mothers sat on a straw mat and watched silently. Her birth mother lay down unable to watch. As soon as the last shovel of dirt was placed on the grave the silence broke. A loud wail went up and suddenly all fifty women were screaming and crying and beating their chests, a communal wail that must have reached reverberated off the empty plains and fields, almost like a clap of thunder. It was impossible not to weep as well the communal permission to grieve felt much larger then just a sadness over this death, it felt like we were weeping together for all of the moments of suffering that led to this one.
Our girls mother got up first and placed her flip flops on the grave and led the procession back out of the bush into the IDP camp.
We followed behind, trembling but also feeling a sense of closure, this story, like so many others, does not end as the dirt covers the body. It lives on, in our living bodies- in the hearts that feel so much, the cheeks that support the tears, the eyes that take it all in, the lips that share the tale, and the ears that listen with compassion... and advocacy.

I have so much to write.

Lines in the dirt

When we left the hospital three days ago we left a seventeen year old in active labor. She was 9cm, fetal heart was great, and we had spent the day laboring with her. She was open to walking the halls, singing, massage, and we spent moments between active pushing as her doulas. She had a group of women with her, her mama and her father’s five other wives- also her mamas. We assumed we would arrive in the morning and get to meet her baby. Instead we were told she had needed a cesarean and the baby had died. The story from the Doctor was that he had been called in the morning because her labor was obstructed. The story from the women on the hall was that she had become fully dilated around 10 at night but was having trouble pushing properly. The midwives told her they would hit her if she cried and to call them only if the head was coming out. Then they went to sleep. At 4am, her mother woke a midwife in a panic. Her daughter was asking them to bring a hoe, which in Acholi culture is a sign of death. Sure enough, the midwives checked and the baby’s heart rate was dangerously low. The head had been in the vaginal canal for 6–8 hours. The doctor was called but he did not pick up his phone. Another was called but he said he would not come until morning. A 9 in the morning a cesarean was done, and the baby was dead.

We spent the day trying to find out the real story. In the report book it stated that the mother was ‘found’ in second stage of labor and that the baby was already dead. I know this is not true. Aimee and I (but mostly Aimee) labored with this woman and her live baby all day.
When we visited her, they had not yet told her that the baby was dead. Instead, the doctor told her the baby was very sick. His explanation was that he needed to prepare her, the shock of finding out her baby had died would be too much, so this lie was to ease her into the loss. She lay on the bed with a puss filled incision, her eyes darting back and forth, her breathing shallow, her pulse quick. We sat with her and cried with her and when she asked us to please make sure her baby was ok, we didn’t know what to say.
But I did know the hospital, the current system, was responsible for this babies death. Neglect and lack of action. I felt an anger that was deep. A sense of right and wrong violated like a line drawn in the dirt, blurring and more and more people step on it.

Day two. We return after a sleepless night to find this mother in septic shock. She learned her baby had died, shit herself and cried until she passed out. Now she is completely unconscious, has a raging fever, her stomach is distended, her breathing is shallow, lungs filled with fluid and her eyes are rolled back in her head. She will die unless she is transferred to another care facility. She too, is being neglected. The lack of management in this hospital mixed with apathy and trauma of staff makes for a standard of care, a culture of care, that is dangerous. The midwives are as traumatized and sick as the patients.

We spend the day arranging an ambulance to another hospital. Aimee pays for the gas. The family stands vigil around this young mama, they lay a bible on her head and pray and pray and pray. I begin to cry and have to step out of the room. She is only seventeen. We get her in the ambulance. All six mamas, her brothers, her husband, Aimee and I crawl in with her. She is on a straw mat on the floor of an old ambulance that has to be roll started. We have to straddle her to hold her still as we crawl through the unpaved and bumpy streets. A stop for gas and a half hour later we arrive at another care facility where she is immediately attended to with IV antibiotics, clean equipment, two doctors and three nurses. She is transferred to intensive care with a fighting chance for life. For the first time in two days I feel like I can breathe. This hospital has no more supplies, but strong management and a culture of caring.

Returning to the hospital much has happened. A woman has died of hemorrhage. Another woman who we worked with earlier in the week has had a cesarean and her baby is dying on a table. I feel the trauma of the day in my body. My neck begins to spasm and I am tired. I place a shaky hand on the baby’s forhead, she has a raging fever. The nurses seem indifferent. Please I beg of them, call the doctor, this baby needs help. They stare at me blankly, it is night time. They will get in trouble if they call the doctor unless it is an ‘emergency’. A dying baby girl is not an emergency. I hold this baby and with a broken bulb syringe spend time suctioning bloody mucus that has already become infected. I drip clean water into her mouth and place cold washcloths on her forhead.

I felt the urge to lick this baby, like a cat, take her, inflamed, in my mouth , soften and clean, until it doesn't hurt anymore.
The baby gasps, I think she has died, and then she breaths again. Softer.
Here I am, miles from home, in Uganda, where the dirt and the heat
blend my sweat with my tears
my hands
her skin
desire to lick
take her in my mouth
that urge
to draw closer
saliva
and moist cheeks
dried by the sun
and I wonder
if it will ever be right
or if it ever was
and how I come to know myself
enough to
figure out
the difference
between the spaces

the difference
between a lick
that heals
a lick that cleans
and a lick that draws lines in the dirt

I send out a text for those closest to me to pray for her. The response is enormous. My father is holding the torah for her. Clare and James are sending Reiki. My girlfriends are praying. My community is so rich.
When I get into bed though, sleep cannot find me. I feel panicky. My back hurts and the foam mattress feels absorbs my shape, my tears, my sweat. I finally sleep and wake to a cold shower and strong coffee. Human resiliance is truly amazing.

The line between right and wrong is a relative line depending on which side you stand. I feel the pull to understand and the pull to trust my instincts because it is the only way that I know how to function.

We had a lovely workshop with the child mothers at St. Monica’s yesterday. Thirty child- mothers, thirty babies, a story circle and some ‘working’ sessions on defining supportive roles for each other. We sang a lot and danced a lot and the overall feeling was full.
It is this relationship of extremes that is so challenging, Dynamic.
One moment a traumatic experience watching death and life converge with the premature cutting of a cord or the neglect of an obstructed labor; the next moment is pure hope as we put on ‘plays’ about how to support one another as mothers and young mamas sculpt one another into images of love.
The work evolves. So do we.

Freud said that depression is anger turned inward. I think this is astute. I also think that when anger and depression become so internalized that they define a practice, violence is born. It is hard for me to just say that there is some serious neglect and malpractice happening in this hospital. I have spent the last month kind of dabbling around the issue, intervening at moments and keeping quiet at others. It is hard for me, as a westerner who is concerned with issues of hegemony and cultural representation to say that the care is truly sub-par, and lack of funds and supplies are not the main issue. I have to check myself and the academic bullshit. It is wrong for women to be left bleeding on cold metal tables for hours on end while their babies die and the midwives sleep. It is wrong for women to be hit and screamed at while pushing a baby out. It is wrong for the bulb syringe and the fetuscope to be taken off the busy labor ward and not returned for days while babies suffer with ingested mucus and low heart rates. It is wrong to discharge young mothers with no resources who are clearly showing signs of depression and whose babies are not yet breastfeeding. It is wrong to leave women laying for hours in puddles of their own blood and feces. It is wrong to drink alcohol while on shift. It is wrong. It is bad medicine and it is violence against women. Only the poorest women come to this hospital because it is free. This is a human rights issue. This is so deeply layered there is nowhere to point a finger. Apathy is easier.

The issues are multi- layered, as most issues are. They may start with the administration or maybe with the war, or perhaps poor training, exhaustion, anger or maybe it is tribal hatred as one young mother suggested to me. As an outsider I may never know but I also feel that these issues need to be exposed so that they can evolve, take new form.

I am too tired to describe the events of yesterday, but they were traumatic. I have not yet processed for myself. Dead babies due to neglect, administrative lies to cover up malpractice, and very sick women still left unattended and laying in their own urine. For a moment I considered just walking away. Not my problem. But I slept last night and awoke this morning feeling like that is exactly the issue. It is too easy to walk away and allow practices to continue. It is too easy to say this is not my problem. But it is. It is all of our problem. As women. As mothers. As sisters. As men. As humans in the world.
I am not sure of the next step, only that I have been here as witness, and now I need to share.

A book can be a mother

Waking before as the sun rises and sleeping as it sets, the day takes on a new rhythm. It is fuller somehow, as if a person’s sense of time is actually connected to the circling of the sun. We forget that with electricity. I worked the evening shift last night. There was no power so we caught babies by candlelight. The halls of the hospital were quiet and laboring women moaned and cast long shadows across the room. I had to pee and my torch burnt out along the way. I walked slowly, sliding along the walls and using an internal sense of direction to guide me to the pit latrine. I had a moment of panic as I feared a mouse running across my feet while I squatted down, but it passed in a wave and I returned to the ward relieved.

What is medicine without intuition?
Can one be a true healer without also being intuitive?
I don’t mean psychic. I mean awake. Finding one’s way in the dark. Perceiving that which bubbles under the surface. Listening for that which is not spoken, that which cannot be put into words. Remaining open enough to take in another’s energy and feed it back, transformed.

Is the doctor or midwife or psychiatrist or natropath or nutritionist or massage therapist or witch, who heals you best, intuitive to your needs? Do you feel heard? Special? Understood? I read a study once that determined that 97% of people who sue their doctors in malpractice suits did not feel heard.

Healers who know how to listen are more effective. Healers who can listen both to what is spoken and what is unspoken are magical.

Here medicine is by the book. It’s an old book, but it’s a book. The book is like missionary position sex under a fluorescent lamp, totally dry and no room for improvisation… or intuition. I find myself constantly pushing up against the book, trying to turn the lights off, to listen and to move beyond the edges, to expose each woman as her own story, her own body, her own unique set of needs. It’s a dance to maintain balance; to keep relationships healthy and the narrative ribbon of dialogue moving back and forth. I turn the light switch off, my colleague flips it back on. I say the book can change, she says it’s a book, the print is permanent. I say try, she says why. We laugh and share a meal, chalk it up to cultural difference and connect over a mutual distaste for Miranda grape soda.

My young friend Becky is still in labor. Intuitively, I believe it’s because she has nowhere to go once she delivers. I think she is holding on as long as she can. The walls of the hospital offer shelter and some small amount of attention. She cried hysterically again today and called out for her mommy. Aimee and I sat with her, massaging feet with essential oils and satiating tears with small offerings of chocolate and tea. I imagined the comfort of having a mother while you make the transition into motherhood, and the utter feeling of loss if she were not there as witness, protector, and most of all, knowledge. The midwives feel my friend should go for a cesarean, because the book says she has labored for too long. I shudder at the thought unless the fetus or mother is in extreme distress. While the fetal heart rate is strong and the membranes still intact, I continue to advocate for rest, food and love to move things along at a snails pace.

Aimee witnessed a C section yesterday. I stayed on the ward while she went down with an obstructed labor to the ‘Theater’. She filmed it and showed it to me afterwards. The doctors ended up ‘extracting’ (their words) two ‘undetected’ (their words) twins. In order to do this they performed a three hour long surgery with a gas mask, and came close to killing the mother, slicing her open vertically from pubic bone to breast, shredding the womb and performing a tubal ligation without her permission. In Uganda, if a woman has more than five babies a doctor is allowed to perform a tubal ligation during cesarean. She bled so much she is still not conscious. This ‘by the book’ performance is supposed to save lives.

I do not mean to spend so much time in critique. Nor do I mean to privilege my instincts over those of others. I cannot imagine what it takes to have survived this conflict and still maintain a daily sense of togetherness. Perhaps surviving in the bush, living by gut and instinct, moving through the darkness of not knowing who to trust, where to sleep, how to protect your body, makes the comfort of a ‘book’ a necessary coping mechanism. It is comforting to have something that ‘knows’, something you don’t have to question because it is right. Like a mother. A book can be a mother.

There is so much strength here, so much determination, so much willingness, so much so much.

This afternoon I lay on a blanket in the grass and held baby Peace who is now three weeks old. She sucked on her fingers and I read a story by Isabel Allende. The sun felt comforting and consistent, an old friend. Something I know, trust, and can refer back to. A mother.

Heart

At the end of the day sometimes I realize that I have been running on emotional autopilot. That in order to work effectively amidst trauma after trauma, I tuck my heart safely into my back pocket and only bring her out for fresh air when I get home. (Clare says I am queen of compartmentalizing). It scares me to work with a woman and then forget her name and her story two days later because I have worked with so many others between that time. I am trying to write it all down, but at the end of the day, I am tired.

On Friday a girl came to the clinic in early labor. She immediately struck me as different. Something about her energy, nothing concrete. Amidst five other laboring girls I did not have much time to speak with her, just a quick exam and instructions to walk the halls and drink a lot of tea.

After two women delivered and hemorrhaged, I sat down needing some water. I must have been sitting for ten minutes when I realized that this girl was sitting right next to me, quiet and almost ghost like.
Her English was good and we began to speak. Softly at first, and just formal exchanges, but soon her story started to spill out. Her name is Becky. She came alone. Her parents both died in the conflict and she has been on her own since she was eleven. She lived in the bush, surviving mostly on termites and crickets, until a year ago, when she met a man. She married him and got pregnant immediately. His parents disapproved the union and threatened to disown him if she kept the baby, so she was once again, out on her own. She had not eaten in three days when she arrived in early labor.

I was moved by the story, but I am not sure why I was more moved by her story then any of the other fifty stories I have heard that parallel hers. I went home that night thinking of her and returned on my day off to check on her. She still had not delivered and was sitting outside looking very despondent. We chatted for a bit but she was so disengaged that she didn't acknowledge the food or baby blanket Aimee and I had brought for her. She appeared in my dream last night.

Today, Monday, I did not see her when I arrived, but she was not in the delivery registry. I was elbow deep in a woman who had a prolapsed uterus when she was carried into the maternity ward on a stretcher. She was having a seizure. She was still pregnant. I immediately felt my heart jump from my back pocket into its proper feeling place. I sat with her and stroked her hair and massaged her feet until she came back into consciousness. When she awoke she began to sob. It was the first time since I have been here that I have seen raw and unapologetic human emotion.
I stayed with her most of the day. Feeling pulled in a way that I have not felt since I arrived.
When I left the hospital she still had not delivered and I will not be surprised if she is still in labor when I arrive tomorrow. I think she is psychologically holding herself back because she does not know where she will go when she delivers the baby. Tomorrow is her 18th birthday.

I feel joyfully aware that my heart is guiding me. I surrender and trust.

Also, read Aimee's blog.
She is writing about the same experiences from a different perspective.

http://www.akuganda.blogspot.com/

Questioning

This is hard. I feel quiet again. Like I cannot process enough to turn these experiences into words that are condensed enough to put forward as an offering.

E.M Forster believed narrative could be ‘truer than history because it goes beyond evidence, and “each of us knows from his own experience that there is something beyond evidence”.

There are not words to speak the body. Language is inadequate, lacking the depth of perception and affect to describe textured sensations such as sight, sound, smell, touch and taste. To narrate the body through words is in some ways is to miss it entirely.

Humans frame understanding of experience in terms of narrative account. When we try to understand why things happen, we put events in temporal order, making decisions about beginnings, middles and ends or causes and effects by virtue of imposing plots on otherwise chaotic events. Yet, the stories of the bodies that birth are separate from the accounts that the women give of themselves. I believe this to be a global truth.

It is not surprising that the dominant metaphors describing birth in the late twentieth century are characterized by mechanical images in which a woman’s body is fragmented into working parts over which she has little control. As Emily Martin in The Woman in the Body: A Cultural Analysis of Reproduction, phrases it “medically, birth is seen as the control of laborers (women) and their machines (their uteruses) by managers (doctors) often using other machines to help”. The canonical obstetrics text-book Williams Obstetrics encapsulates the mechanicity of the dominant medical view; it defines birth as “the complete expulsion or extraction from the mother of a fetus”. In every act of childbearing two stories are simultaneously produced, a story of what the ‘body’ does and a story of what the ‘woman’ does; the ‘body’ might dilate slowly while the ‘woman’ screams out for help. The body and the woman intersect and influence one another while still managing to maintain independent realities.

A traumatic day (for me) at the hospital- the necessary equipment just isn’t there. There is no suction. No suture kits. No sterile gauze. And I don’t think it’s that the midwives don’t care, but there is some sort of passive acceptance of the situation, so in an emergency it feels like everybody just walks away. Attempts to save babies or hemorrhaging women are half hearted and then the blame is placed on poverty and a lack of supplies. In truth, some of the supplies could be here. Sterile cotton wool and suture kits are in the hospital, there is just no consistent method of getting them from the supply room into the maternity ward. The suction device simply needs a new plastic tube in order to work…but nobody is advocating to get it fixed, even though a baby dies here once a month for lack of it working. I feel stuck in an impossible situation. Acceptance of poor conditions means nothing will change and my outsider perspective is received as hope for a handout. I can buy some cotton wool for the hospital, but it will be gone in a week. Sustainability comes with accountability. Where is the anger? I wonder. Perhaps to anger is also a privilege.

Sister Rosemary's sister was describing to me a bridge she has to cross occasionally. It has no railings and she feels close to death every time she crosses it. She is upset about it. She feels the government should put up rails to fix it. Her daughter jumped into the conversation and said yes but mommy, they cross it every day so for them it is normal. You are an outsider so the conditions anger you, but for them, it is just the way things are. Is this what is happening in the hospital? Acceptance of sub par conditions because it is just ‘the way things are’? Is this what keeps a slave a slave? A victim a victim?

The women I have engaged with in the labor ward remain stoic with their emotions. Almost apathetic. The midwives work quietly and without showing a trace of feeling, except for anger. If a woman is not pushing effectively, the midwives will begin to yell and slap her into pushing. After the birth, she will return to her normal static state. Almost like New Yorkers in a traffic jam. The anger bubbles to the surface but then disappears after the incident.

Pregnant women walk quietly, kneel down on the floor as a sign of respect for the midwives when they enter the labor ward, and then often remain stoic throughout early labor. If asked how they are they will without exception answer ‘fine’. Some look a bit sad or scared, but of course this is my interpretation and may have no reflection of the actual truth. The hall is full of women who remain calm and collected, almost detached, until they are in second stage of labor and are allowed entry into the maternity ward. The moment a woman places her plastic sheet on the metal bed, it is as if permission is given to set the apathy aside. Many women instantly and almost inevitably begin to scream and wail and fling their limbs about wildly. They roll on the bed and ask for Jesus to save them. Eyes glaze over and women pee and shit all over themselves without seeming to notice or care. It is a dramatic performance of extremes and is staged by almost every woman I have witnessed give birth at Gulu Hospital. The moment the baby is born, the melodrama ends. Women become stoic again, show no interest in seeing their babies and at most may flash a smile or a quiet thank you to the midwives. The moment of possession is over. The scene of childbirth offers permission to emote, but it is a package deal when it is over, it is over.

I want to explore apathy. It doesn’t seem like an authentic human emotion. Children aren’t born apathetic. It is learned. Is learned the right word? Perhaps it comes into existence through traumatic experience and suppression of emotion. Maybe it is passed down and transmitted from mother to child, brother to sister. What purpose does it serve?
How can childbirth be a vehicle for processing emotion and raising voices?

I do not have answers. Only more questions. Which I love. I am grateful for the opportunity to see and to emote freely and to question, question question. What a gift.

The better it is, the worse it is!

Beans Beans Beans
The more you eat the more you poop
The more you poop the better it is!

This ‘rhyme’ sung to me by Sister Beatrice while I cooked dinner for the nuns is a perfect metaphor for much of post-colonization post-war Ugandan culture. The original song, brought in from an outside source, has been orally transmitted so many times that it has lost all but the shell of its former self, and yet it is still being sung with utter conviction and without questioning. The fact that it makes no sense is irrelevant. Is it about proper nutrition or diarrhea?

Aimee and I sang Sister Beatrice the version we know.

Beans Beans good for your heart
The more you eat the more you fart
The more you fart the better you feel
So eat your beans with every meal.

She liked it, but I liked her version better and we spent the afternoon shelling beans and making up new ditties, all ending with either ‘the better it is’ or ‘the worse it is’ depending on the circumstances of our improv.

The metaphor translates perfectly to the hospital. Western medicine, brought in by colonizers fifty to one hundred years ago, has not been 'updated' because nobody wanted to come to a war torn country to train doctors. What remains is the shell of 1950's medical practice. The med school at Gulu regional teaches student doctors to make vertical incisions on cesarean sections; women rest afterwards on dirty foam mattresses, go home when they can walk and there is no follow up care for infections. Women come in with stitches that are oozing puss and are told to purchase antibiotics. Hardly anyone can afford antibiotics. Are these practices really saving lives if the risk of dying of a post- op infection is almost as high as death from an obstructed labor? Were there as many obstructed labors when women used local herbs to speed labor along and before women were forced to lay on their backs on metal gurneys in a hospital with no running water?
And yet the practice is not questioned. It is Western. It is right.

What a privilege it is to be able to tell a story!
We interview women for this film and ask them to tell us their birth stories and we get the facts. She was born on this day, I felt the labor pains at 3:00 and she was born at 8. She weighed 4 Kilos. How did you feel? We ask. Fine. The women answer. I felt fine.
Or maybe it is a privilege to think that your birth experience is special and worth talking about. The concept of a doula does not translate. People spend thousands of dollars to have someone massage them and advocate to make their experience meaningful and positive?

This weekend we went to two IDP camps to meet with TBA’s from all around the North. Over one hundred TBA's showed up in all. They had prepared skits and songs for us to show us how they work. Our intention was to host some Red Tent like events where women shared birth stories, either their own or ones they had attended. The first group turned into a story group about abnormal births- one woman attended a birth where the woman began to push and one thousand black fly’s flew out of her vagina in a thick cloud. They took her to the hospital and there was no sign of a pregnancy. Another woman attended a birth where all that came out was some mucus and a set of human eyeballs. At the end of this story the translator looked at me and said ‘What was that? She would like to know specifically.”
Aimee said she was tempted to say ‘An alien’. Instead we used the question as another moment to exemplify that we do not know, and try to dialogue around what the TBA’s thought could have been the cause of such abnormalities. The two most feasible answers were malnutrition and the devil.

At the end of our session we were fed a large meal. Potatoes and cassava and boiled greens and beans and rice and goat meat and chicken meat and coke. The meat here is really not stored well and so we have used the Jewish religion as an excuse to not take meat at a meal and offend our hosts. It has worked well. However at this camp they understood it too well. "If the issue is the way that the meat is killed, then you can kill it on your own!" They came to us with a bag of eggs, a pot of homemade peanut butter, and a live duck in a bag.
“You can take this and kill it the Jewish way. Please, it is our offering to you!”
We were remiss to say no, and walked out of the camp with our duckie and plans to set him free. We sent Aimee's husband Kevin a text on the ride home 'Travelling with live duck. Help!"
Duckie met is fate however, because we re-gifted him to the midwife who was translating for us so that she could feed her family.

And then there is the hospital. Some days it is insane and other days it is quieter. Yesterday there were only two births on my shift, but there were six women laboring in the hall. One got so frightened watching another woman push that she took off in a sprint out of the hospital. She returned a few minutes later realizing she could not escape the intensity. Aimee massaged her with lavender oil and she calmed down, even came to assist the next birth.

I have noticed that we have to resuscitate an alarming number of babies. I am pretty sure there are two contributing factors. One is that women lye on their sides throughout their labors and are not encouraged to walk around. When a woman is fully dilated she is told to lye on her back or side until the head is crowning. One of the midwives says this is to save gloves. Another says it is because women get too tired if they push. Often there will be meconium and the fetal heart will be scarily low or high, but there is no active pushing. Because of this babies spend a very long time squished in the vaginal canal and come out in distress. Aimee and I have encouraged pushing in cases like this and are promptly shut down by the other midwives who say that the women will get tired. The question becomes- is it more important that she is full of energy or that her baby comes out alive?

The second contributing factor is the clamping and cutting of the cord. The UN has issued a health statement that in order to prevent mother to child transmission of HIV cords should be clamped and cut immediately after birth. Broad spectrum this is the best way to prevent transmission. However, the cord is connected to the placenta, which provides the baby with oxygen. If a baby is not breathing they are still getting oxygen for a few moments from the cord. We have no suction devices at the hospital. The one bulb syringe is too large to fit in a babies nose and is often not sterile. When cords are cut immediately a baby gasps for air and sucks in all sorts of mucus and meconium before there is time to massage or wipe it out. Since there is no suction, babies end up with enormous amounts of fluid in their lungs. One died a few days ago from ingesting too much fluid. I don’t know if she could have been saved, but to me it would make sense that women who have been tested and tested negative would get to keep their babies on the cords at least until the baby is breathing properly on her own.

Realizing that in a country that has no economy there is almost nothing that can be done that is sustainable is scary. And yet, the little things give birth to enormous satisfaction. Placing lavender oil on the third eyes of one hundred new born infants. Watching a Ugandan midwife try for the first time to massage a womans’ perineum with almond oil so that she doesn’t tear. Dancing and drinking homemade pineapple wine with the nuns.

And so it goes. On and on.
I question my role every day.
I straddle worlds and ideas and stories.

Last night at dinner Joy, a two year old came and ate a mango on my lap. I call her the little opportunist. She is one of those toddlers who knows how to love you when she wants something and completely ignores you the rest of the time. And then you hear her story. Her mother is a child mother who was abducted when she was ten years old and escaped the rebels, (her captors, her rapists and the father of her child), when Joy was two days old. She strapped Joy to her back, stole a gun, and set off into the bush with the baby and the gun. She came to a road, saw some American soldiers who waved her down. She pointed her gun at them and said she wouldn’t come over to them until they put their guns down first. They did and she got rescued. She was brought to St. Monica’s and has been here for the last two years. The image of a fifteen-year old mother with a child on her back and a gun in her hand haunts me. I watch Joy slurp her mango and hug her a little tighter. Another woman, Nancy had her jaw hacked off with a machete. She had it sewn on again and the result looks like a beginning seamstress attempting to sew the face onto a Raggedy Anne doll. She delivered her baby (nobody knows who the father is) last week and she named her Peace.

The simple facts of a human life create these stories that weave in and out of one another, creating this enormous web of human suffering, perseverance and dignity.

Babies Babies Babies
The more you see the more helpless you feel
The more helpless you feel the worse it is!

Babies Babies Babies
The more you catch the more you see
The more you see the better it is!

silence

It is quieter now.
Or perhaps I have settled a little.
The same work feels more joyful and the connections more concrete.
Still straddling the line between observing and engaging- learning more and more every day.
I have been thinking a lot about silence.
What does it mean to be silent? To be silenced?
How is silence an integral and essential part of having a voice?

There was an earthquake last night. Nothing big, just a little trembling of the earth. Everyone was outside drumming and dancing and as the ground began to shake the singing turned into yells, and then, silence. For one moment, even the crickets were silent. And then laughter. The croak of a frog. The hum of the generator. Business as usual.

Today is Saturday, a day of rest for this Jewish girl.
I have offered to cook dinner for the nuns (mostly because I am sick of potatoes and goat every night) so I am headed to the market.

Love.

I have been at a loss for words. The days pass by like months and then with a spark they are over. Last year this hospital was refuge for the girls who were night commuters; they sought safety in the sweat soaked walls from the terrorists from whom they escaped. Now these girls come back to this place to deliver their babies. They return with mothers, aunties, sisters, or alone. They bring with them a piece of plastic, which they lay on the seventy year old metal gurney to birth on, and a blanket to wrap the baby in. If they have a little more money, they may bring two blankets. There are five metal birthing beds. Soon after one woman delivers, the plastic is removed and another woman comes to take her place.

Often there is only one midwife on the floor. Or maybe just the woman who does the cleaning. She has become a lay midwife by virtue of spending time in that space. Women labor in the halls and come onto the beds to be examined and when they are close to pushing. The first baby of the day is strong and comes out with a cry. As we deliver the placenta a woman who has delivered at home comes in because she is hemorrhaging. She has a displaced uterus and is HIV positive. I triple glove, push it back up inside of her and massage it into place. She must lay on the floor because all of the labor beds are in use. I send her auntie to make her tea. Another woman pushes for three hours while two more deliver. We have one set of clamps and a pair of dull scissors. If the power is out they cannot be sterilized so we use string and a razor blade to clamp and cut the cord. Even if the power is on, there is not enough time between each birth to sterilize. The child mothers seem to take the longest because they are young and they are scared. One girl refuses to push for two hours while her baby waits just below the pubic bone with a very low heart rate. She is scared she will poop on the bed and no amount of coaxing will convince her that this is an ok thing to do. Another woman lays in fetal position and cries out for Jesus to save her. She has been in labor for two days. We have packed a small lunch of sim sim paste and mango marmalade on stale white bread. We take five minutes and while we are gone another woman has been admitted. Late in the day a woman comes in from the Congo. She has a group of seven Congolese women with her. They wear charcoal on their eyes and bright red blush. They stand around her and rub her and speak to her softly, holding her hands and feet as she labors. As she pushes they begin to wail, flailing their arms around, beating their chest and then they begin to slap her and strangle her (there is no way to contextualize this properly, but from what I can gather this practice is used to stop a woman from blowing out her nose when she pushes) this baby has the cord around his neck very tightly. The sisters are still wailing and strangling this mother and I have to scream at them to stop. They stare at me strangely, but pull their hands away from the birthing mother. The clamp and scissors are in use so I hold the head while Aimee uses the string and razor to cut him free. When he comes out he is lifeless and blue. I flash to the first baby of the day and feel the tears well up in my chest. I push them down. This time the bulb syringe is clean so I am able to suction him and massage him into breathing. While I am working on him his mother gets off the metal bed, cleans up the fluid (they all clean up after themselves) from her birth and walks out. One of the seven women comes to take the baby and I explain that she must keep him very close to her body for warmth. His skin is still blue, clammy and cold, but he is breathing and his heart rate is good. With each mother I make a connection and then forget her name. When one returns because she is bleeding too much I cannot remember if she has delivered today even though she is the one who spent three hours pushing. The placenta bucket is overflowing and one of the orphans who lives in the hospital brings it out to empty it in the placenta pit. There is a moment of silence and while one young mother pushes (it will be a while) and another tries to sleep I step outside to see the sun setting.


We leave the hospital at 6:30. Two hours after we were supposed to leave, but this is when the night shift midwife shows up. I feel I have no personality left. The nuns invite us to tea and it is all I can do to sit for ten minutes as the milky warm liquid swishes in my mug. When I return home I step into the cold shower, immerse myself and cry. The water beads up and trickles slowly into the drain. The cold feels shocking and real. The dinner bell rings but I cannot imagine eating. My head is swimming with images of placentas and tears, spurting blood, amniotic fluid and feces. This was today. I cannot remember the ten women whose babies I caught yesterday.
I feel numb but also terribly alive. The aches in my back and feet, the pulse in my chest, the chapped skin on my hands from all of the gloves, the washing, the purell, converge together as both witness and testimony to my day.

Aimee and I stay up late talking. She re-enacts parts of the Congolese drama that I missed because I was so focused on the baby and the cord, I laugh hard for the first time today. We question ourselves. What are we doing here? What can we do that will really impact this situation?The medical information being used is dated. There is no one here to update it. One of the midwives was talking about how the TBA’s are contributing to maternal death rates because they only refer women to the hospital when labor is obstructed. I wonder though, if there is anything in that hospital that could help an obstructed labor. All we have are razor blades and string. Perhaps the herbs and gentle coaxing of a TBA would better move a labor along. Of course it sounds ‘better’, it sounds like progress from a western governmental perspective to send women to a hospital, but when the circumstances are dire, I am not convinced.

The individual stories are pieces of one larger story. We will hold our first story circle on Saturday, and then a mini ‘conference’ for the hospital midwives where we will exchange best practices. Ideas flow in and then out. At the end of the day I fall into a deep sleep and I dream of working in a clinic where legs are falling off and women carry double headed babies on their backs. This is a lot to process. I have been at a loss for words.