At 34 Emma was healthy and pregnant with her second child. On April 27th, she delivered him by c-section. Within 24hours Emma’s abdomen began to swell and when clinicians reopened her surgical wound, they discovered a perforated bowel. Part of her treatment involved the creation a temporary colostomy. After this surgery Emma remained hospitalized for a month. In Malawi hospitals provide occasional meals to patients depending on availability of funds, but generally patients rely on family members to bring food. Emma’s mother and her husband were her only support. To lessen the financial stress on Emma’s husband, her mother took their toddler back to her village several hours away. Emma’s husband was left to cook and bring meals, wash Emma’s clothes by hand, care for the baby, and search for day labor to keep them going. Her husband was attentive, but Emma was often alone. Sometimes there was no food. Emma’s appetite diminished with her hope. Over the month Emma became emaciated. Her milk stopped flowing. This is how and where our nurses found her. While still in the hospital they began visiting Emma and enrolled her baby in our program. Once she was discharged, Emma returned to the one room home she shared with her husband. In her condition she could no longer care for her baby or even herself. During the early visits the nurses found her despondent, lying on a grass mat. In response to their questions about her health, she would talk about dying. At each visit the nurses brought enriched porridge and beans, they would assess her baby and educate her husband on how to care for the baby and for Emma. They met with her neighbors and encouraged them to sit with Emma while her husband was out. The nurses returned monthly and slowly Emma regained her health. Eventually she had a final surgery to anastomose her bowel. Before she was discharged from our program, she received the equivalent of $10 to start a small business. Emma began selling vegetables, her profits now provide the couple enough on a weekly basis to supplement their diet. Recently Emma told the nurses that she had been sure she would die, but their visits gave her hope. At times the beans and porridge supplied by the nurses were the only food items in the home and that nutrition enabled her body to recover. Emma’s story illustrates the impact of severe maternal morbidities, which often are unseen and uncounted. Her unexpected health crisis during delivery led to financial strain, depression, threatened the survival of her healthy newborn and almost resulted her own death. In the end Emma credits her survival to the compassion offered during brief monthly visits, several kilograms of beans and porridge, and $10. We can do this.
Twenty-one babies were enrolled this month (10 orphans, 5 babies whose mothers are admitted in the ICU, 1 baby whose mother is not producing milk, 1 set of orphaned twins, 2 babies of mothers with severe mental health illness, 1 one baby whose mother left her with the grandmother). Two women were enrolled, both of whom lost their uterus due to birth complications – they are 19 and 20. Nurses conducted 190 visits to mom and babies this month.
Baby Care Story. Hannah’s mother was diagnosed with breast cancer and started chemotherapy but when she unexpectedly became pregnant at 40, she stopped her treatment. She delivered Hannah prematurely. Hannah weighed just over three pounds at birth, but she quickly put on weight with her mother’s breast milk. After two months her mother’s health began to deteriorate at a precipitous rate, and she returned to the cancer treatment center to resume her chemo. Hannah’s grandmother brought Hannah to us, requesting assistance with formula and nursing support.
Mother Care Story. Loveness was just 20 and pregnant with her first baby. Her labor was long and hard. She headed to health center when her labor started and was watched by the clinicians there. But,health centers do not have the facilities to conduct c-sections. By the time she was transferred to the District Hospital, it was too late. Her uterus had ruptured, her baby had died, she was bleeding internally. Loveness lost her baby and her uterus and almost lost her life. At the time of discharge, Loveness was weak and depressed. Joyful Motherhood nurses will visit her at home over the next couple of months, but she is just starting a long road to recovery.
Many times when policy makers, academics, aid organizations, etc. consider maternal mortality and strategize ways to improve statistics the emphasis is placed on receiving prenatal care and delivering within facilities. However, the vast majority of the women we care for, or whose orphan babies are enrolled in our programs, have followed the “rules.” They attended prenatal visits. They made their way to health facilities for delivery. But in the end, they were not protected from excessive suffering or loss. As an organization we stand with the victims, who are often invisible to the larger system. Our support is focused directly on them.
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Tiyamike is 15months old. She was born prematurely on October 19th 2017 weighing just over 4lbs. Her 22 year old mother hemorrhaged after her delivery and died the same day. As her mother’s body was loaded into a vehicle to transport her back to her village, her grandmother was handed a couple tins of formula from hospital nurses. The tins were likely provided as a donation from a kind-hearted individual and stored in the nursey for such events. There was no additional support to the bereaved grandmother, no promise of future donations or follow-up appointments.
Tiyamike’s family live in rural Malawi, they are subsistence farmers and did not have the means to purchase additional formula. Her grandmother is illiterate and does not speak English anyway. She was unable to read the instructions on the formula tin to verify what she understood from the brief instructions provided by the nurse. The day a squall of grief rattled every cell her being, she needed to absorb and process very specific instructions on how to keep her grandchild alive. She did her best.
On November 6th, Tiyamike’s grandmother returned to the local hospital. In the two intervening weeks Tiyamike had lost weight and was now emaciated, significantly below her birth weight. Her grandmother was referred to our program with Joyful Motherhood and our nurses have been visiting them regularly ever since. Life is hard for Tiyamike’s family, their survival rests on their own physical labor and the capriciousness of weather. But, they have love, determination, and support from JM. Now at 15 months, Tiyamike is a normal joyful and busy toddler.
Takindwa’s mom started her labor at the District Hospital in Malawi. She had had a previous cesarean section so it was important that she labor at a hospital with an operating room. Many women in Malawi labor in rural area which are far from any health facility. And even when there is a clinic nearby, many times they lack an operating room and staff capable of performing a C-section. The national C-section rate in Malawi is about 6% this compares with a US C-section rate of about 32% (WHO 2013). According to the World Health Organization, the percentage of women who will require a C-section in order to birth safely is about 15%. This means many Malawian women are not receiving necessary C-sections, which as a result jeopardizes their lives and the lives of their babies.
Takindwa’s mom was in the right place to access emergency obstetric care and after many hours it became apparent that she would again require a C-section in order to deliver safely. Takindwa was born on April 13th by what initially seemed to be an uneventful C-section. However, within a few hours her mother became short of breath, collapsed suddenly and was pronounced dead. There is no capacity to perform an autopsy, so the cause of her death will never be know with certainty. However, considering that her mother was a healthy 19 year-old woman, it is likely that her death was related to a surgical error. Tragically in Malawi, both poor access to care and poor quality of accessibly care threaten the lives of many women.
Takindwa’s family was immediately referred to Joyful Motherhood and our nurses have been following her ever since. Today she is a health 7 month-old.
Niya is only 16 years old, but several weeks after the birth of her first baby she had surgery for a total hysterectomy. Niya took care of herself during her pregnancy and grew a 8lb 9oz baby. Unfortunately her baby was too big for her to birth naturally and she ended up with a C-section. C-sections, though common in the US, carry significant risks in Malawi and increase the risk of serious life-threatening infections. Days after giving birth, Niya became increasing ill, her abdomen swelled and she returned to the hospital. Clinicians there did a laparoscopic surgery to determine the cause of her swollen abdomen and found that her uterus was necrotic. The infection was so severe and had continued unchecked for so long that her uterine muscle had completely died as was beginning to decompose inside of her. She had an emergency hysterectomy. Soon after the second surgery she experienced severe nausea and vomiting and was diagnosed with a bowel obstruction. She underwent additional treatment for the bowel obstruction. It was a traumatic and life changing birth experience. She would need to learn to care for her new baby, care for her wounds, and strive to accept the loss of her fertility. Joyful Motherhood nurses have been following her, supporting her as a new teen mom, counseling her about her hysterectomy and encouraging her. Her baby is growing well and she is planning to return to school soon.
Faith was born January 28, 2018. Her birth was uneventful and the next day her 23-year-old mother, Salimba, took her home to meet the rest of the family. On February 14th Salimba became ill. Her family says her face and feet were swollen and she started vomiting. On February 18th they took her to the closest health center. She died there before she was ever evaluated by a clinician. Faith’s grandmother was then directed to Joyful Motherhood. Overwhelmed and grief stricken she told the nurses she didn’t think she would manage. She had five other children at home to raise. With support from Joyful Motherhood nurses, Faith’s grandmother has done a wonderful job; today she glows when talking about her granddaughter.
In the face of this beautiful woman you can see lines of grief, determination, and quiet joy. She is holding her grandson Precious who was born on the day her daughter died. Her daughter delivered Precious and then as she lay back to embrace her new son she began to bleed. The bleeding continued despite efforts of those with her to slow it down. Her life washed away in a sea of red. Her mother clung to her newborn grandson and gave him a name from her heart. She worried about her ability to keep him alive and well, without breast milk and without money for formula. Within the week after telling countless people her story, she was directed to Joyful Motherhood for support. Precious is now 8 months old.
Nineteen year-old Juliet was nearing the end of her pregnancy. She had gone for her prenatal visits at the Mitudu health center, she had taken the antimalarial medications as instructed by the midwife, had the necessary blood work, and regular blood pressure checks. Everything seemed to be going well until the day she collapsed and started seizing.
Pre-eclampsia is one of the most dangerous diseases of pregnancy. Even as our knowledge about it continues to grow, our ability to predict who it will effect remains limited. The onset is often sudden and occurs towards the end of pregnancy. One of the warning signs is a rising blood pressure. Pre-eclampsia can affect all the major organ systems, damaging the liver and kidneys, resulting in bleeding in the brain, seizures and death.
Those around her took Juliet immediately to the health center and from there she was transferred to Bwaila, the district maternity hospital. Without a well organized EMS this process of just getting her to a place where she could be helped took several hours. When she arrived at Bwaila, Juliet was unconscious and still seizing. The midwives – familiar with this presentation – quickly administered magnesium sulfate, the only medication shown to help control and prevent eclamptic seizures. Even with the medication, the only cure for eclampsia is delivery. Once a woman reaches the point of seizing her life is in grave danger and if she is not delivered within a relatively short period, both she and her baby will die. Unfortunately even delivery does not guarantee that the mother’s life will be saved. The clinician at Bwaila delivered her 5lb baby by C-section and Juliet was sent to the ICU, where she remained unconscious for 4 days.
This is where our nurses found Juliet. After talking with her family, she was enrolled in our Mother Care program. Juliet regained consciousness and after a short period she was discharged from the hospital. The nurses planned to visit her six times in her village. During their first visit, nurses found Juliet still swollen and convalescing, still struggling to care for her baby. This picture is from their second visit. As part of her home based care, nurses will counsel her on the disease and help her community members create an emergency plan for such events in the future. They will also provide some education on the care of her baby and help set up an income generating project.