“Supa”: A Report from Kenya
| June 22, 2009
The author, a medical doctor and writer, learned in an African village the truth behind the alarming worldwide maternal health statistics—when she was asked to treat a patient whose only resource was her mother, frantically urging her to “push.”
Like most American-trained physicians, I’m used to looking at mind-numbing statistics on a daily basis. My recent trip to Kenya helped me to reconnect with the human side of medicine.
Example. AIDS is the leading cause of death in young black men and women. In Albany, Georgia, where I work, this thought crosses my mind as I treat a previously healthy young black man with uncontrolled seizures and a strange new growth in his brain. Or, I’ve become all too familiar with the number one reason for accidental teenage death in the United States: alcohol. This thought comes home loud and clear when I treat an alcoholic offender for scrapes and bruises, but place the innocent driver of the other car on a ventilator; I take the long walk (in reality, a very short walk) to the family room and break bad news to the anxious relatives.
Indeed, I spend much of my time answering the most angst-filled questions with a detached statistic. One scenario goes a lot like this: “Doctor, what are the chances that I will go on to have a normal pregnancy since I’ve been spotting early on in my pregnancy.”
“Fifty percent. Half of these pregnancies go on to be normal, the other half end up in a miscarriage. And twenty percent of pregnant women experience this during the first trimester,” I respond.
Or I’m asked to predict the chances of a really bad result when the patient actually already knows the answer: “Doctor, I have no money for my hypertension medicine, what are the chances that I could have a stroke or heart attack, if my blood pressure stays up?”
“High” is usually my terse response, perhaps a bit irritated since this same person who can't afford his blood pressure medicine also smokes two packs a day, not a cheap habit.
Of course in Africa, the stats are even more frightening. Worldwide, Africa accounts for 90 percent of cholera cases, a diarrheal illness we simply don’t see in this country. Malaria, a completely preventable and treatable disease, claims a million people a year. Childbirth claims 500,000 women a year. (Oh, and psst: this is considered a gross underestimation.). At least one woman a minute in the developing world dies in childbirth.
Even as a woman from a developing country, the Democratic Republic of Congo—for a myriad of reasons including rape, childbirth, and HIV, Marie Claire magazine declares mine to be one of the worst countries in which to be born a woman—I still looked at these numbers dubiously. These are thoughts that I look back on with a bit of shame at my naiveté.
In Kenya, I had the chance to hold small free clinics in two impoverished villages, Kisumu and Atemo, both at least five hours away from the capital, Nairobi. Our team of 12 dedicated medical personnel provided free treatment and medications to more than 1100 people. Patients walked for miles, many times without shoes, in harsh rains and thick mud, to be treated for anything ranging from simple neck pain—no doubt from the carrying heavy loads on their heads and shoulders—to malaria, to the rarely seen Kwashiorkor, a disease that stems from a lack of protein. Little things like having anti-malarial medications and pain-relievers, and a lollipop every now and then for the children, improved quality of life for many, but we needed so much more. I was prepared for work overload, but I wasn’t prepared for the shock of how little is needed to save so many lives—until the day I was involved in the delivery of a child.
A nurse asked me to evaluate a young woman who had come to see her in the morning because she was in labor and had been unable to deliver. To my horror, what I found was a barely responsive nine- month pregnant woman on a bed with no sheets, in a bare room with no basic supplies. Much of my team, which had been encouraging the woman to push, stopped once they saw the look of consternation on my face.
The young woman, Filis, was being angrily ordered by her mother to “supa,” which means to push in Kisii, her native language. I asked Filis’ mother how long she had been in labor. Since 7 pm the night before she informed me. It was now noon.
Yes, this woman had been in labor for 18 hours. In medical jargon, she was in ‘obstructed labor’ or ‘failure to progress.’ Most places in the United States consider a labor that has gone longer than six hours without progression a clear indication to perform a c-section.
Why had she not been taken to the private hospital instead of our little clinic? Through my interpreter, I found out that in order to be seen by a private doctor in the hospital, they would have to pay 10,000 schilling or about $80. When most Kenyans earn less than a dollar a day, $80 was simply out of the question.
Filis’ mother was caught in sort of the classic African Sisyphean predicament I kept observing during my time in both villages. Yes, she loved her daughter dearly. But with the little money she did have, does she use it to help her daughter deliver safely or use it to feed the rest of the family? As I looked incredulously at Filis’ mother, she continued to command her daughter to “supa.” It was as if the harsh tone of the command could supersede the need for medical intervention.
“Surgical tray, forceps, scalpel!” I ordered, realizing the need for an emergency c-section. My requests generated no action except a confused look from the local nurse. How about some IV fluids? Another pregnant pause, er, so to speak.
I performed my exam and could see a head of hair in the vagina. I took the rudimentary tocometer, a long piece of plastic with two hollow ends, that the local nurse used to measure the fetal heart beat, and could hear a very slow heart beat—a sign of fetal distress. I knew that time was of the essence for the survival of both Filis and her child. I administered some Tylenol and antibiotics.
There was no ambulance. The only vehicle was the truck that our group rented. We’d have to travel 30 miles through some of the roughest terrain imaginable. The head of the clinic and local pastor knew the surgeon and called ahead to tell him we were bringing Filis.
By the time we arrived, the hospital staff awaited us at the gates.
While they prepared the operating room for Filis, in an area the size of a small closet, other staffers demanded 16,000 schilling for the entire stay. Filis’ mother protested, saying she had no money and that her daughter should not be admitted since she could not afford it. We paid what we had on us that day and assured her and the staff that we would deliver the balance the next day.
“Asante, asante sana,” Filis’ mother kept crying, meaning “thank you, thank you very much” in Kiswahili, a language widely spoken in East Africa. She pressed my hand to her heart for what felt like an eternity.
The surgeon performed the operation and we left. On our way back to Atemo, the pastor broke the loud silence.
“I’m glad you’re here, we could have had two deaths today,” he told me.
It was then that it dawned on me how maternal deaths worldwide could be as high as I’d heard it was. I had nearly witnessed one, because an African woman did not have $80 to take her pregnant daughter to a hospital.
The World Health Organization (WHO) calls it the “invisible epidemic,” since women who die in childbirth are not counted as a death because, well, in certain traditions women don’t count. WHO suspects that as many as half of the global maternal deaths go unreported. In poor countries, the risk of dying in childbirth is over 100 times higher than richer countries.
The main causes of maternal death are well known and disturbingly easy to prevent and rectify: obstructed labor, infection, uncontrolled hypertension, to name a few.
What isn’t so well known or easy to quantify is that these women leave a million children motherless and the children in turn are 10 times more likely to die in childhood. In rural societies, the impact of this loss of able-bodied individuals is unimaginable.
The next day, I wasn’t thinking about statistics. I went see Filis and held her beautiful boy. With Filis and grandmother looking on, I took mental notes: The baby had all 10 fingers and toes, he had all the newborn reflexes, moved the way any American newborn moved.
“What is your son’s name?” I asked Filis.
“Mana” she said with a triumphant smile. The sound of my name never sounded so sweet. I explained to her that Mana (or manna) means food from heaven from the Old Testament and she responded with a knowing smile.
Fighting back tears, I shared in her joy. It was one of the few times an overworked doctor can savor the joy of contributing to saving a life, and in this case helping a new life start.
I decided to be a little selfish and not tell Filis that Mana is actually a girl’s name.