This morning’s meeting had a mixed sentiment of fascination and horror. The hospital clinicians spent the better part of the morning discussing the challenges they are facing in the realm of pregnancy care at the hospital and in the community. I hardly know where to begin.

The discussion began with a case presentation. A thirty-two year old woman was admitted to the Female Ward with complaints of lower abdominal pain. She was HIV Reactive, and was coughing up blood from a tuberculosis infection, but insisted that the abdominal pain was her primary complaint. The attending clinicians soon discovered that the woman was 18 weeks pregnant with her sixth child, supposedly to her surprise. She denied the pregnancy “diagnosis”, despite admitted sexual activity. She was transferred to the treatment room, where she quietly asked the clinician to remove the fetus that was causing her abdominal pain. The examination in the treatment room revealed both the baby and mother to be healthy and alive. It became clear to the clinician that the woman arrived at the hospital with a complaint of abdominal pain in an attempt to receive an abortion. This is a frequent occurrence at the hospital, especially since the community’s two known traditional abortionists have been arrested.

Typically, the women who arrive at the hospital seeking to terminate pregnancy are very young (14-15) and unmarried. The common procedure is to first visit the village Traditional Birth Attendant (TBA), where a cassava stick is used to abort the pregnancy. Often, women will arrive at the hospital with the sticks still lodged in their cervix. The TBA will ask the woman to travel to the hospital when bleeding begins. Upon arrival at the hospital, it’s near impossible for the clinician to tell whether the abortion was spontaneous or intended (as both present with bleeding), leaving them no choice but to remove the fetus. According to the hospital obstetrician who works closely with these TBAs to facilitate safer pregnancy care, women in the community do not associate any risk with abortion, despite the incredibly high associated maternal mortality and infertility.

One clinician suggested that the hospital advocate prevention through contraception rather than termination following pregnancy (quite an interesting discussion at a Catholic mission hospital). It was noted that contraception is not highly favored in the community, as women will often attribute unrelated back aches, colds, or other sickness to the contraception shots. The situation is complicated, to say the least.

So, it seems to happen most often like this – If she has an unwanted pregnancy, the mother will first visit her community’s Traditional Birth Attendant. When the bleeding starts, she will travel to the hospital where the clinician will not be able to determine that the abortion was preformed illegally. If her community’s Traditional Birth Attendant has been arrested, or if her experience and education tell her that the TBA’s method of termination is unsafe, she will arrive at the hospital with a complaint of lower abdominal pain. She will deny knowledge of pregnancy until she has reached the treatment room, and will ask to have the fetus removed as a means to alleviate her abdominal suffering, as the clinician is more likely to perform the abortion if he believes the mother’s health is as risk. The staff at St. Gabriel’s Hospital is catching on to this pattern, and is seeking a safer way to address the situation.

This issue of unwanted pregnancy is only the beginning of the pregnancy-related concern at the hospital. Even more complicated is the discussion of how to facilitate safe pregnancies and births. It’s becoming abundantly clear that this will take immense cooperation with these TBAs. Although it’s free for mothers to deliver at the hospital (they are given government-subsidized stamps as an encouragement to deliver at the hospital), mothers are still choosing to deliver at their village’s TBA for 1000 MK. This happens for a lot of reasons. First, TBAs are typically very well known members of the community – grandmothers, aunties, and experienced mothers themselves. Second, it takes a lot of courage for a mother to deviate from the birthing methods that her community has been using for hundreds of years and to travel to a hospital instead. Third, TBAs offer privacy, intimacy, and comfort – TBAs are often females, while a hospital clinician will almost definitely be a male. Finally, and perhaps most importantly, village chiefs encourage delivery by TBAs, as they receive a portion of the profit that is made by the 1000 MK deliveries.

After almost an hour of frustration about how to approach this complicated dynamic between the community and the hospital, Dr. Kiromera paused:

“The structure of the local community, the relationships between people – this is the driving force. If we cannot take this away, maybe it’s time we start working with them.”

He made a suggestion that resonated well with the work that the 20 Global Health Technology seniors have been doing for the past year. He suggested that the hospital equip these TBAs with whatever they need to provide a safe pregnancy term. The point, after all, is to save lives. This would involve four things, he suggested – tools, training, evaluation of knowledge, and supervision. They must teach them to monitor pregnancy, and to refer at-risk mothers to the hospital for care. He suggested that the hospital reimburse them for the 1000 MK delivery cost for referred pregnancies, to keep them from losing their business.

Ah ha! Solution: Pregnancy Care Pack. I held my tongue for the moment, at least until the Pregnancy Care Pack arrives with Danielle tomorrow, and we have a chance to properly present the project to the clinical staff next Wednesday. Perhaps they will find that this project is a step towards a solution to this complicated and frustrating issue of needless maternal and neonatal deaths. I would like to introduce you to the Pregnancy Care Pack, a backpack full of tools designed for both emergency and routine care of both the mother and the child through the entire term of pregnancy and up to one month following birth: