October 25, 2010

An MSF midwife describes the nature and the challenges of a normal day's work in Pakistan's Balochistan province.



Pakistan 2009 © Jodi Bieber

A baby is examined at an MSF facility in Kulchak last year.

Olivia Lowe is a Doctors Without Borders/Médecins San Frontières (MSF) midwife currently working in Kuchlak, a town near the city of Quetta in Pakistan’s volatile Balochistan province. Lowe manages the antenatal and postnatal programs and the birthing unit at MSF’s mother and child healthcare center in Kuchlak. Here, in an account from September, she recounts a day of work:

6:45 AM:

My alarm goes off. No power in the house, but as this is a daily occurrence I’ve gotten used to walking around in semi-darkness. The annoying thing this morning is that there is no water. Bugger. Oh well. I’ll have to at least wash my hands with drinking water. I make cereal and boil water for tea on the gas stove and enjoy my breakfast on the flat roof where it is still slightly cool.

7:25 AM:

Leave the house accompanied by the watchman. I have changed into my shalwar kameez, the clothing worn by most women in Pakistan, and my dupatta, a huge scarf that I wear wrapped over my head and that covers two thirds of my body. I say good morning to all the Pakistani staff as we climb into the minivan and then off to work. Female MSF staff ride in one and male staff members in another vehicle. I text the Project Coordinator and Office Manager to let them know we are heading to the clinic.

8:00 AM:

I arrive at the Kuchlak Birthing Unit, 30 minutes outside Quetta, and I text the project coordinator and office manager to say we’ve arrived safely. The Lady Health Visitors (LHVs)—midwives for us westerners—take me straight away inside to a premature baby boy who’s just been born. He looks to be about 30 to 32 weeks and is struggling to breathe. I need to get him transferred to a hospital in Quetta urgently. I need to make sure that we don’t run out of oxygen in the meantime and hope he keeps working hard at breathing in the ambulance.

9:00 AM:

I get a phone call from the LHV who accompanied the baby to the local hospital. There is no incubator available, but they are treating him as best they can in the hospital ward.

9:45 AM:

 Another baby is born in the Birthing Unit. It’s a girl. It’s the mothers’ ninth child. Baby is well, a healthy 3.2 kg (7.4 lbs). I hand her to her grandmother.

10:00 AM:

The LHV at the hospital in Quetta calls me again. She has finally arranged for the newborn to be placed in an incubator at another hospital. He’s stable, for now (But as I am writing this, 2 days later, I get a text message that he died in hospital).

10:15 AM:

The baby girl’s mom, Yasmin, is in danger. Considering she has not birthed the placenta and is at high risk of heavy bleeding, things are not good. She’s also developed major complications, a cervical prolapse, and is at risk of contracting a uterine infection.

10:30 AM:

Yasmin starts to bleed. It’s only me and two other LHVs in the Birthing Unit. We try to assist in removing the placenta. We put an IV line into her arm and we start oxytocin and ergometrine delivery to her bloodstream to stop the bleeding and help deliver the placenta. We put up antibiotics to prevent any infection and more IV fluids to counteract the effects of the bleeding and to keep her blood pressure stable.

We need to stabilize Yasmin and then to transfer her to a hospital as soon as possible. There are a dozen patients and relatives quietly staring at us as we run around with the antenatal clinic having obviously come to a standstill.

“She’s got no pulse. She’s got no blood pressure,” the LHV shouts. I rush into the room. Yasmin is breathing but is not responsive and not maintaining her airway well. I shout to call out for the doctor next door and grab the oxygen. Is she going into shock? Two doctors arrive. More IV lines and more fluids. Yasmin’s blood pressure is 90/40, very low, but I am a little happier than a couple of minutes ago. We push more fluids, but another attempt at manually removing the placenta fails. I hear someone saying something in Urdu and one of the LHVs leaves the room.

The next moment she is back with a newborn wrapped in a blanket. “Who’s baby is this?” I wonder. Then I get it: another baby has just been born in a car outside the Birthing Unit and the LHV wants oxytocin to aid in birthing the placenta. We ring for the LHV doing home visits to come back to the Birthing Unit and help. Because one LHV needs to accompany the bleeding mother to hospital, that would leave me and only one other LHV alone at the clinic while more women arrive.

10:40 AM:

Yasmin isn’t bleeding quite as much anymore and her blood pressure is better at 110/60. We manage to cover her up and veil her. Two staff help put her on a stretcher and carry her to the ambulance. First we need to get consent from the husband that we can take her to hospital. I phone the hospital and let them know Yasmin is on her way.

11:00 AM:

I’m shaking—but there’s no time to sit about. The antenatal clinic activities continue. We prescribe antibiotics yet again, as many women have urinary tract infections at the moment, as with fasting for Ramadan they became dehydrated. I send another woman for an ultrasound to a private doctor in town as she tells me she’s had bleeding today and yesterday.

We have only one woman in labor. Her name is Noor Bibi. She has had more than five pregnancies. She is dilating and keeps pointing to her thigh. She wants us to give her an oxytocin injection to speed up her labor. This is a common but an illegal practice in Pakistan that claims hundreds of lives every year. We encourage her to walk and drink some juice.

11:30 AM:

A woman comes in with her baby to be seen by us. The baby is four days old and jaundiced. It’s lost too much weight for a newborn but other than that looks well. We find out she’s only been breastfeeding two to three times a day (it's advisable to breastfeed six to eight times a day). We give her breastfeeding education and tell her to come back on Wednesday so we can check up on the baby and in order for both to be vaccinated. I get a phone call from the LHV who accompanied Yasmin to hospital; she has been seen by doctors.

12:30 AM:

All the antenatal clinic patients have been seen. Noor Bibi delivers and both mother and baby are well. Two hours later she’s on her way home. She can’t wait any longer. Her taxi is waiting outside to take her home.

1:30 PM:

Back in the minivan to go back to the office in Quetta. I text the Project Coordinator and Office Manager to say I’m leaving.

2:00 PM:

We arrive at the office. Text again. I go straight back to the house for lunch which is two houses down from the office. I have lunch with two of my housemates, the Logistician and Project Coordinator.

2:45 PM:

Back to the office. I finish off my monthly reports and email them to the Medical Coordinator

4:00 PM:

The office manager tells me that there have been two bomb blasts in Quetta, two kilometres [1.2 miles] from our house. The first was in the bazaar and the second was 15 minutes later in the same place. The result: 42 people dead and 250 wounded. All MSF staff, national and international, are safe, but some are struggling to get home and others struggling to get to the nightshift, which starts at five during Ramadan.

4:30 PM:

I ask one of the day shift LHVs if she can stay on tonight as one of the LHVs is definitely not going to be able to make the nightshift. I head home for the day. I greet a newly arrived international staff member from Islamabad on his way to the flood zone. He’s the ninth person in two weeks to arrive to assist in the flood relief work.

5:30 PM:

The Logistician and Project Coordinator come home. The Head of Mission has put us on a higher security alert and therefore only the minimal number of staff will work tomorrow. I phone LHVs and make sure I will have only two members of staff on duty and that they can get to work. I phone the referral nurse who visits our patients transferred to hospital. I make sure she’s safe and that she only visits patients she really has to.

7:00 PM:

I have dinner with my housemates and we watch a movie.

11:00 PM:

Bedtime. I’m allowed a lie in tomorrow, as I’m not allowed to go to work or leave the house really. I’ll study and work from the house. It’s hot but I fall asleep to the buzzing of the fan which I know will go off in a couple of hours when the power cuts out. I’m on call 24 hours a day, 7 days a week—as I will be for the next 9 months. I am not sure the LHVs are going to manage to phone me when they need to because the cell phone reception has been on the blink recently. I hope they’ll be okay.