In the national newspaper today there was an article specifically about the health care crisis brought on by the National Health Insurance Scheme (NHIS). NHIS was introduced last year with the goal of providing affordable health care to the population at large. A nominal fee is charged at the time of enrollment but then, once enrolled, services are essentially free. The government is supposed to reimburse hospitals for the actual cost. The recently established policy of free antenatal and delivery care goes a step beyond NHIS. According to the article, within just one year of instituting NHIS, the government already owes hospitals millions of Cedis (US$1.00 = 1.14 Cedis) and as a result many public health centers are on the verge of collapse. The article also stated that the government expects hospitals to cover much of their operating expenses but at the same time has created a system in which hospitals do not generate income. Effectively one problem has been traded for another, a great percentage of the population were unable to access health care and now they have been granted access but the care available is rapidly deteriorating.
Today was my second day in the Prenatal clinic at MCH. The process is very similar to that at Bottom with some slight improvements. Women arrive in the morning and pass through a series of stations - history taking, blood pressure, weight, belly checks, dipping urine for protein and glucose, and treatment (here there are a couple extra stations). All women have labs drawn twice during the pregnancy, all women are tested for HIV (done confidentially by specially trained counselors), and all receive one ultrasound during the pregnancy. Within the prenatal care clinic, the only space with relative privacy is reserved for the belly checks, the rest of the stations are located within the large open waiting area. There is a constant flow of women around the room, which is maintained by the staff and it seems that unless a woman is very determined to mention an issue to a nurse, it might be overlooked. The clinic continues until the flow stops. Today that was around 11:30am (it was teen clinic so there were not as many women) but apparently on Fridays and Mondays clinic closes around 4pm). I have been in the belly check station. I was happy to see that measurements are made with a measuring tape. If women have an accurate date of delivery (based on either their last menstrual period LMP or dating by ultrasound) the uterine measurements should correspond fairly closely with the gestational age. If the measurement is off by more than 3cm in either direction then we would refer the woman for further investigation (e.g. if the gestational age is 24 weeks the measurement from the pubic symphasis to the fundus should be between 22 and 26cm). But ironically, even with possibility of calculating an accurate date of delivery, gestation is measure by hand. So, for example, if the top of the uterus reaches her belly button the nurse will say she is 20 weeks and then perhaps on her body the measurement from her pubic symphasis to that point is only 16cm. This method severely limits the value of obtaining a specific measurement. I have also already been told that the women do not know their LMPs. I was told this at Bottom too but I found that if you ask a woman and give her a few seconds to think about it she can usually come up with an exact date. I had the same result here with one woman, we’ll see how it goes.
Most women who come to MCH are quite poor, many of them work as vendors in the nearby Ketejia market. Dr. Annie said that because they would rather save the little money they earn they will not eat for the entire day, until they return home. Around town one of the most common items to sell is water (water and handkerchiefs since everyone is constantly sweating). Women buy a satchel containing 30 individual water bags (500ml each) for 1 Cedi and sell - eventually one by one, walking back and forth between traffic with a basket of water their heads, competing with each other for customers - for a grand total of 1.50. Will 50 pesewas even purchase enough food to replenish the lost calories? Due to the poor diet, as in Malawi, anemia in pregnancy is a common problem. Yet, even with severe anemia by US standards women are transfused rarely. Dr. Annie says that the blood is supposed to be free but if you get the free blood it means unscreened blood, to obtain screened blood each pint costs at least 15 Cedis (you if transfuse a child and use less than one pint, the price is still 15 Cedis).
I am not surprised by the conditions. The summer between nursing school and midwifery I went to Bolivia and spent and few weeks in a public maternity hospital there La Maternidad. I wanted to see what birth was like for poor women of the world. There I was shocked. A midwife mentor in the US set me up to observe at a clinic in Santa Cruz that she herself had helped establish. The clinic was immaculate, well stocked, and the staff were welcoming but the births were few. So, after hearing about the public hospital with 50 births a day I decided to go there. I walked into La Maternidad wearing scrubs, bearing a letter of introduction from another physician, and carrying my nursing school ID, and asked if I could observe. I was given permission. La Maternidad is a large teaching hospital with many staff and numerous medical students.
At that point I had already seen many births in the US but birth was very different in La Maternidad. As I witnessed my first birth there I felt myself start to lose consciousness several times and each time I had to either sit on the floor rush to the hall. For a few hours afterwards I doubted whether or not I had chosen the right profession until I realized that the trigger was not the birth but the violence. When the laboring women arrived in the hospital they were examined in a room with four exam beds. The women could not see each other as screens were set up between beds but from the desk in the center of the room where groups of 10 or more students and staff often gathered, you had full view of all exposed women. If someone determined that the woman was in active labor she would be sent to the labor room, which consisted of about eight beds pushed against the wall, no screens, no privacy. Women were made to undress and lie or sit on the beds. In the event that there were more than eight laboring women their shared beds.
Once a woman was fully dilated and read to push she was made to crawl off the bed onto a gurney which would be pushed hurriedly across the hospital to the delivery room. Once in the delivery room she crawled from the gurney onto a delivery table, her legs were tied into stirrups with pieces of IV tubing and then staff yelled at her to push. All women delivering for the first time received episiotomies as well as many second time mothers. If the woman was not pushing to the liking of the person sitting between her legs, they might yell insults, slap her legs, or a nurse would stand on a stool besides her and apply fundal pressure with her forearm by jumping into the woman’s abdomen as the woman pushed. As soon as the baby was out it was whisked away to lie under a heating lamp in the next room and await a pediatric exam, which was sometimes a very long time wait. No one told the woman anything about the baby. Once when a mother asked whether she had had a boy or a girl the doctor quipped, “They always want to know the gender as though nothing else matters.” That hospital was a nightmare.
I did meet a couple physicians and students who were kind to the women and understood my sense of horror but they were in the minority. Women were shouted at when they cried while their poorly anesthetized perineums were sutured. I had one physician call me away from the bedside of one young woman in the labor room who was terrified of the pain and the nearing delivery to tell me that I should not touch the patient or stand too close because, “These women are dirty and you never know what you might catch.” I remember another woman who had four previous deliveries which were all conducted at home. She was a poor indigenous woman who was now coming for her first hospital delivery with her fifth pregnancy (probably as advised by a traditional birth attendant who was trained to refer all grand-multips to the hospital). The physician asked then who had conducted the previous deliveries when the woman responded that it was her husband the physician laughed sarcastically to a colleague, “Oh is he a physician too?” It took all my restraint not to punch her. Who would want to deliver in such an environment regardless of risk? Another day I found a teenage girl left alone to miscarry her fetus of about 20 weeks. There was only one sink at the end of the hall which separated the delivery rooms from the post-miscarriage care ward. Rosa was lying on a bed in stirrups crying, “mi bebe, mi bebe” with a small inert body half exposed between her legs. Anyone washing their hands had a full view. I went in to sit by her. If I had had any midwifery training I would have completed the delivery and sat with her but I had not so I just sat with her and talked with her while she waited there with her baby between her legs and nurses next to her, separated by a curtain, ate their lunch, laughing and chatting completely deaf to her cries. At one point a student walked over after taking in the view from the sink and yelled at Rosa, “Did you do this to yourself?” I gently asked her to leave and then I closed the door. I had reserved 6 weeks to spend observing but I barely made it through three. I will never forget those women.
When I returned to San Francisco I began asking the Latina women who had previously delivered in either Central America or Mexico about those deliveries. Their stories were depressingly similar. At least with regards to the humanity shown laboring women, Bottom is leaps and bounds above La Maternidad, and MCH seems to be a little better staffed and stocked than Bottom. But in general they all fall way below acceptable. If we consider that these are not three individual cases but examples of hundreds of thousands of similar facilities, what do we do? Do we just get overwhelmed and close our eyes? Do we critique and blame? Do we stand and hand hold within a crumbling system? Do we build up a collage of private clinics? It seems something more fundamental must change to really transform these places. All these places are health care facilities which cater to the poor; certainly no woman with a choice would choose to deliver in such a place (unless granted some control over the situation, like hand picking her midwife and physician). Our attitude towards the powerless and the poor must change. If we considered the poor and powerless our equals these places would not exist. Evidently many physicians at La Maternidad despised the poor indigenous women with outright passion but what do I share with those physicians? What judgments do I hold about the homeless on the streets of San Francisco? Why do I quicken my pace when I pass the man sitting in a heap dressed in rags black with filth? What do I fear? What could be different if I address my own fears? Is not the existence of La Maternidad, Bottom, MCH, and countless others proof enough that globally we believe the poor are dispensable? That our commitment to international aid is superficial or politically motivated? Why are governments and leaders who prioritize the well-being of their citizens over the strength of political alliances demonized? What do we fear? What could be different if we address our fears?