News and notes

It is time to bid adieu to someone who has become an old friend of yours over the last ten days. His name is Richard, and he went home yesterday. He is cured of whatever he had, and he is fine. Before he goes, I thought you might want to see two pictures of him before he left the clinic. You can readily see that he is a happy, healthy, not to mention beautiful baby.

Now, on to other events.

Last Sunday morning, the baby girl that you see in the following pictures was born in the road leading up to the clinic. The pictures were taken approximately 30 minutes after the birth. The baby still had several leaves on her body when the mother and baby arrived in the clinic. The mother was brought in on a wicker stretcher after she delivered. The cord was then cut, and the baby was cleaned off. The Burundian method of tying off the cord is as follows: two strings tightly around the cord, and then the abdomen is wrapped in gauze. If the mother is still present in the clinic the next day, the gauze is changed. If not, which is more likely the case, the gauze is ultimately removed by the mother at home.

This baby is small: a little bit less than 4 pounds. The mother is 20 and this is her third child. She did not know her due date, but we thought that the baby was delivered at term. I was called immediately to examine the baby, which, as you can see by the pictures, I am doing. The baby appears to be doing fine, and the physical exam, despite the baby's small size, is normal. The mother, as you can see by the picture, breast-fed the baby immediately. There may be something to be said for the Burundian way of delivering babies. Not a lot of fuss, and fancy technology. I don't think they go to a lot of Lamaze classes. I also don't think they need to go to a lot of Lamaze classes.

The mother and baby went home the next morning, both in good condition. The grandmother of the baby came to the hospital to help the mother take the baby home. The grandmother, age 42, was herself pregnant with her tenth child. Her daughter, the mother of the baby, seems to be on the same path: three children by the age of 20. (Much more about the family situation in Burundi in future blog posts).

Obstetrics is, as you might expect, much different here than at home. Melino is our Kigutu obstetrician. It is he who is responsible for seeing the pregnant women for their prenatal visits. Those prenatal visits usually start late in the pregnancy. The vast majority of the women who do prenatal care here at the clinic do not deliver at the clinic; they deliver at home. Melino sees about 100-125 pregnant women per month. However, the average number of deliveries at the clinic is only 4-5/month. As you know by the size of the families here, that number is infinitesimal compared to the number of deliveries that occur on a monthly basis in the community.

So what then is the point of seeing doing so many prenatal visits if so few of those women deliver at the clinic? For the simple reason that Melino can identify the women at risk during pregnancy. He will then do an ultrasound on those women to determine if there is indeed a problem and the nature of that problem.

As an aside, Melino is a magician with his portable ultrasound, and loves doing them. At a moment's notice, he will ultrasound any organ that needs an ultrasound, the heart being his favorite. I have seen him take more than an hour doing a cardiac ultrasound, gathering all the data that he needs to gather: visualizing all the heart valves and assessing cardiac function. During the entire procedure, the patients lay there completely immobile, not saying a word, never protesting the length of time that the procedure takes, never questioning Melino as he does his work.

Returning to my story: if Melino determines that there is a problem with the pregnancy, he can then refer to an obstetrical center at Rumonge, a town an hour away (remember, all distances quoted here are distances on foot). There is no such thing as a Caesarian section at the clinic, but a C-section is possible at the center in Rumonge. However, if a woman in labor comes into the clinic, and it is determined that the baby is in breech presentation, there is no other option but to deliver that baby vaginally here at the clinic. It would be impossible to transport her to another hospital, even one relatively close, like Rumonge. That is why Melino has delivered countless numbers of breech babies, even footling breeches (the worst kind), vaginally. Moreover, he has done so without complication.

I give you now an example of prenatal care in Kigutu. This is an example that occurred yesterday. A woman in the ninth month of pregnancy was admitted to the clinic approximately ten days ago for pre-eclampsia. She is 35 years old, and having her eighth child. The reason she was admitted was because she had significant edema of the lower extremities, as well as protein in her urine. Her blood pressure over the ten days in the hospital remained stable, and the edema gradually improved with bed rest. She wanted to go home at that point, and it was decided that we could safely discharge her.

Melino performed an ultrasound prior to her discharge to determine if there was a problem with the baby. What he found was that the baby was in the breech position, with the head in the upper left part of the abdomen, and the baby's body curling around so that the feet ended up in the lower left part of the abdomen. The estimated size of the baby, according to the ultrasound, was somewhere between 8 1/2 and 9 pounds. In view of the baby's size, there was no chance that he would turn so that he was in the normal vertex position.

Melino strongly recommended that the mother go to Rumonge in order to be admitted to the obstetrical unit there. He was concerned on two fronts: one, that vaginal delivery would be difficult with a large baby in that position; two, that, this being her eighth delivery, her uterus had been so weakened by previous births that she risked uterine rupture during a vaginal delivery. A uterine rupture would be an almost certain fatal complication.

The mother refused Melino's advice. She insisted on having the baby at home. And the reason for her refusal? She had seven children at home who had already been without their mother for ten days. But what about her husband, you ask. Couldn't he take care of the children during her absence? Apparently not. That's because he, the father of her present child, had another woman with whom he had three children, plus another on the way. He was living with the other woman at the time.

So what had happened during those ten days that the woman was in our clinic? Who had taken care of the children? She had older children, including ones who were fifteen and eighteen; presumably, they had taken care of the little ones when they were home. However, during the day, the older ones were in school, leaving a seven year old, a four year old, and a two year old to take care of themselves during that time that the older ones were in school. The father had stopped by occasionally to make sure that no harm had come to the little ones. However, he had not done so on anything like a regular basis.

Now one understands the mother's motivation to remain at home for the remainder of her pregnancy. Fortunately, after much cajoling and insistence, Melino was able to convince the mother to go to the hospital at Rumonge. She was taken there in a car, and she will be there until she delivers.

So what will happen to her small children when she is away? Nothing has happened so far, so, hopefully, nothing will happen in the future. I am sure that you find it hard, if not impossible to believe that one could leave two, four, and seven year old children to take care of themselves for an extended period of time. I do not, not here in Burundi anyway. I have seen many small girls, no more than six or seven year old themselves, carrying around smaller children on their backs or hips. I can only assume, based on this, that a six or seven year old Burundian child can take care of a two year old. I hope so anyway.