Friday, March 13, 2015

Cultural Humility at the Nexus Between Life and Death

“GRAB AN ONION!”  This is what the midwife said when baby Jose was born with the cord wrapped 3 times tight around his neck and he came out floppy and not breathing.  By this time Essence and I were familiar with the onion routine.  This was our third experience.  Mom or baby having a breathing issue?  Wave an onion in front of their nose and they perk right up.  Well, theoretically.

The first time we became acquainted with the onion was a few days after we arrived.  
“Sarah!  Come quick!”  Of course I thought it was a birth.  It wasn’t.  It was a woman who had given birth several hours earlier and had been having convulsions at home.  Instead of bringing her to the hospital they brought her to us. (Great.  Thanks.)  She wasn’t speaking, her skin was cold and doughy, and I couldn’t find a pulse or hear a blood pressure but she was breathing.  Barely.  While we were busy taking her vitals and assessing the situation she went into convulsions in front of us.  She seemed to stop breathing for a moment and her eyes rolled further back into her head.  That’s when the onion appeared.  Someone (one of her relatives) waved an onion under her nose and for a moment she opened her eyes and her consciousness came back in the room.  It was enough to get her breathing again.  At that point Essence and I were both impressed with the onion.  But clearly she needed much more.  Somewhere in that scene we called an ambulance and soon the woman was escorted to the hospital.

The next time we saw the onion we had a baby that was born at 4 1/2 pounds, prolapsed cord (cord coming before the baby--life threatening), limp and not breathing at birth.  I went full swing into neonatal resuscitation the way I have been taught, which involves giving the baby breaths.  When I came up for air, there was.... the onion, being held under the baby’s nose.  My instinct was to bat the onion out of my way so I could get back to work saving the baby’s life.  When I tried that, the midwife came right back with the onion.  She wasn’t about to accept my rejection of her favorite revival technique.  We settled into a rhythm (with a fair amount of reluctance on my part) of taking turns with me giving breaths and her waving the onion in between. I didn’t want to incriminate myself as some kind of arrogant midwife that rejects traditional ways and yet of course I wanted to save the baby and was sure that my way was his best chance.  After a good long time of our little routine he finally came around to breathing on his own, though with a fair amount of difficulty.  He continued to be limp, was super tiny and did not at all look like a happy camper.  I really really really wanted him to go to the hospital.  I was pretty sure if he didn’t go soon he could perish.

I talked with the midwife about it and she talked with the family in Mam.  Nothing seemed to be happening.  I said something again and the midwife simply said, “No quieren.”  They don’t want to.  That seemed to be that.  End of discussion. 
“Uhhhh, what?  What do you mean they don’t want to?  The baby is not well.  He’s limp, he’s hardly breathing.  He could die.  He needs to be in the hospital.”  

“No quieren.”  

It was a predicament.  The woman herself was not so good with Spanish.  I talked with her husband.  I talked with the mother-in-law.  They listened and then did nothing.  The husband told me a story about some other baby that was born not breathing and he is fine now.  “No.  You don’t understand.  This baby is limp.  He is struggling.  He could die if you take him home.”  No response.  I tried numerous times, talking with the family, talking with the midwife.  My pleas were clearly going nowhere.

This has never happened to me.  I am not used to people not taking my advice as a midwife.  If I say we need to go to the hospital, they go.  I do not take the decision lightly.  I hate sending people to the hospital but I do it when I have to and have never had someone just ignore me like that.

I talked with the midwife in private about it.  “Why won’t they go?”  I asked.  

“This is just how people are,” she said.  “They don’t want to go.”

“Is it because of money?” I asked.  

“Most likely,” she said.  It costs a lot of money and the government doesn’t pay for it.  People prefer to take the baby home and if it lives, it lives, and if not, then it’s God’s will.”

I cried.  I let go.  

“Don’t be sad,” she said.  “This is just how it is.”

I switched my tactics from trying to get them to the hospital to giving them instructions for caring for the baby at home.  I taught them about dropper feeding (I gave them one of my empty dropper bottles and showed them how to do it) because the baby didn’t even have enough life force to nurse, and I taught them about kangaroo care.  We got mom and baby naked together and I had the midwife explain everything about skin to skin contact.  I have no way of knowing if they followed my advice after they went home.  Before we knew it, they were packing up to go home and I clearly had nothing to say about it that they cared to hear.  I would have preferred they spend the night and said so but that was also falling on deaf ears.

I asked them to come back in two days and explained to them why I wanted to check on both baby on mom.  I asked the midwife to explain in Mam.  I told them there would be a doctor here that day (which was true) and they agreed to come back.  They never came.  We did not hear again from the family though they have the phone number of the birth center and could call if they need us.  I don’t know what happened to the baby.  I wish I did.  I think about the experience a lot.

In my mind, I am present at births for many reasons, one of them being to save lives and to let people know what needs to happen in order for lives to be saved.  This experience poked a huge hole in that assumption.  Who am I to tell a family that my priorities of saving their baby’s life in the ways that I know how are more important than theirs, whatever they are?  I can’t know all the reasons why it was so obvious (there seemed to be no discussion amongst them) that they would not go to the hospital no matter how much I insisted, explained, warned, etc.  Nor can I know why they did not come back.

What I do know is that I learned something about cultural humility.  It’s not ultimately my choice.  I am simply a servant and a witness.  I have expertise but I cannot insist that others receive my offering.  They will do what they want to anyway.  Is it right?  Wrong?  Should I, could I have done something else?  I don’t know.  I don’t want to throw my hands up and say “it’s not my problem” and neither do I want to push my agenda on someone else.  But when someone’s life is on the line...and that little being cannot speak for himself....what to do?  It’s a big question.  And the humility is acknowledging that I don’t have the answer.

As for the baby I mentioned above, with the cord around the neck, it was a breeze in comparison to these other experiences.  With the onion, and some vigorous stimulation, he came around to breathing and was totally fine after that.  These ladies swear by their onion.  I, on the other hand, am simply remaining open to what I don’t know and what I don’t know I don’t know.

1 comment:

  1. This is so beautifully expressed Sarah. I have gotten a lot out of reading it. I appreciate the insights your express as well as your ability to weave the story together. It has a 'the sum is greater than the parts effect' which serves to carry the deeper meanings of what you are saying so well. It makes me wonder if there are further outlets that could be found for your writing! It really deserves to be read. Be well.