Posted by: rhoban | March 9, 2009

Day 8 – UTH, Lusaka, Zambia

I spent four days hanging around in CO3 – the “low cost” obstetric emergency ward at the University Teaching Hospital – watching procedures and sitting in on consults, trying to be a fly on the wall.  The unit is ‘low cost’ because anyone can come and get treated for less than a dollar – but that means sitting cheek-to-jowl in a cramped room, waiting for hours to be seen.

The waiting room is located just outside the main entrance to the ward. Sitting there, you can often hear moans and cries of women within.  But few leave – they have no choice.

Some basic statistics about Zambia :

Unemployment rate:  50 percent
Median age: 16.9 years – that means half the population is younger than 17
Life expectancy at birth: males – 38.5 years, females – 38.7 years
Percentage of adults with HIV or AIDS: 16.5
GDP per capita: ~US$ 1500 (ranks 200 out of 229 countries in the world)
Infant mortality: 101 per 1,000 live births
Mortality of all children under 5 : 182 per 1,000 live births
Average number of children for a woman: 5.5
Maternal mortality rate: at least 730 per 100,000 (this is the low-end estimate)
Chances of a woman dying due to childbirth related issues over her lifetime: ~ 1 in 27
Number of people who live on less than a dollar a day : 64 percent
People who live on less than two dollars a day: 87 percent

In many ways, it was reassuring to see some women walk in with garden variety gynecologic diagnoses: fibroid tumors, pregnancy induced high blood pressure (ecclampsia), spontaneous abortion (aka, miscarriage), suspected uterine cancer, pelvic inflammatory disease.  These are issues that affect women in countries wealthy and not.

But so many others arrive with problems emblematic of Zambia.  Obstetric fistula
often develops in the wake of an obstructed labor (which would be treated with a quick caesarian section in the West).  It leaves women with a physiologic passage from the colon to the vagina, causing them to drip feces from their vaginas. It’s really awful.   You don’t see obstetric fistula in the US because 1) it doesn’t happen that often and 2) it’s fixable with a 20 minute outpatient surgical procedure if it does occur.

Other women arrived thin and weak, wasted from untreated HIV.  They remind me of the hospice patients I cared for in the early 90s, in the days before antiretroviral therapy.

One medical resident is a Congolese woman with LOTS of hair, and going in every direction.  Kind of like Einstein, but a lovely dark brown.  She sees woman after woman, sitting down at a table to write her assessments as the women stand in front of her.  Most of the more serious cases have already been assessed by the nurses.

Midwife Iness Kabamba sits opposite at the little table, prompting her:

“You should ask her about … “
“Yes, of course”

I have to laugh – it’s a lot like the way nurses prompt the residents at teaching hospitals in the states.  Later I mention this to Kabamba – I compliment her on her professionalism, her thoroughness in working with both patients and doctors. I mention that in the US, too, nurses do much of the teaching for medical residents.

We both crack up.


Midwife Iness Kabamba cleans instruments after a procedure

Midwife Iness Kabamba cleans instruments after a procedure

I was amazed at Iness Kabamba.  She was so calm, so professional, in a setting that was so … crazy.  It would have had me over the edge in days (you’ll see what I mean after you read tomorrow’s post).

One of her duties is provide “verbal anesthesia.”  If you dissect that phrase, you’ve got the concept.

U T H is a government hospital with limited funds… that means few, if any, patients get pain medication.  That includes women having procedures that are potentially painful – abortions, biopsies, incisions, etc.  Kabamba talks to them as the doctor works.

I sat in on some procedures.  Kabamba stayed near the patients, talking to them, chatting with them, asking them questions that required answers just as the procedure was getting painful.  It’s basically a form of distraction.

Here’s the comparison – it’s like the dentist’s nurse talking to you as you have a tooth pulled – without Novocain.  It’s something I’m not sure we can imagine in the US, as the data shows we are one of the world’s largest consumers of pain medication.

African countries

African countries tend to have morphine consumption of less than 0.5 mg per person, per year. In comparison, the US averages more than 35 mg per person, per year.

Post Abortion Care

Kabamba was patient and thorough working with patients. One of her primary responsibilities is post-abortion care.  She was trained by Ipas to provide PAC, and went a step further to become a PAC trainer herself.

PAC protocol consists of not just telling a woman how to care for herself after a procedure… but it’s a protocol that’s aimed towards helping women to avoid unplanned pregnancy in the future, i.e. family planning.

Kabamba works with women to find the right method of family planning (condoms… or pills… or injection of DepoProvera… or IUD).  The counseling is the same whether the woman has had a spontaneous abortion (miscarriage) or an induced abortion.

She also works with women about how to  talk to their husbands or partners about family planning.  It’s a challenge because by all accounts, the majority of women are not in a position to negotiate contraception use with their sexual partners – whether that be husbands or boyfriends.  Brand new data show that only 5 percent of married couples use condoms, use of pills + injectable methods combined equals 25 percent.   (For purposes of comparison, 18 percent of all American couples use condoms, 36 percent use pills or injectables.)

That’s why many women use the injectable contraceptive DepoProvera – their partners don’t have to know they’re using contraception.  Of course, that doesn’t protect these women from HIV

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