Cause of death

While Americans are busy marching for women's rights and holding out hope for their universal health care, small stories from the people between the lines are unfolding every day. Yesterday (ok, sometime last week, it's taken days to finish this post) I was riding to see a tailor on the other side of town (forever in search of a skilled and talented tailor...although at this point, I'll take capable.) Part of our drive passed through a section of town that I can only describe by saying I was reminded that some people are leading dismal lives. Dirt, poverty, frustration and anger. The sun shining doesn't bring light or happiness here - just plain heat.

In Abidjan it can be all too easy to forget that the difficulties are just as dire as in any developing country. There are plenty of highways, bridges and roundabouts connecting malls, shopping centers and restaurants. There are plenty of clean storefronts and bright neon advertising. Neighborhoods are spread out in such a way that you might never need to leave the confines of your area. Those that do leave residential cartiers are most likely on their way to commercial ones and so the poverty stricken neighborhoods end up being isolated and out of view. But they make the news often enough. And just because they aren't as visible, doesn't mean they don't exist, along with all of the problems that take root there.

While American women are marching, Ivorian women are having babies. There have been a lot of new babies since I've arrived. Aside from several neighbors, the nounou at my house had a baby and both the nounous who work for my friend gave birth.

The first was a younger woman, young enough that I think of her as a girl. She has her own family now, and was sequestered by her 'husband's' family during the birth, nothing too remarkable, both baby and mom healthy. The second woman, however, did not fare so well.

She already has a child and apparently the first birth was not easy. She appeared swollen about halfway through her pregnancy and we advised her to put her feet up, see her doctor and all sorts of other things pregnant women are always getting advice about.

Eventually it came to a point of increased concern. Her hands were so swollen she couldn't close them enough to pick anything up. We wanted to send her to the hospital right away. We tried to let her know how dangerous it could be. The problem was, the nurses weren't expressing the same message. One nurse told her she was going to bleed a lot, supposedly a warning that she should start saving money for medicines and treatment for a complicated birth. Her blood pressure was elevated, but the only council she received was to stay away from salt and oily foods.

I know that Abidjan has better care to offer, the problem is affordability. Many Ivorians have health insurance. But I think a whole lot more don't. And there was the doctor strike. She'd had plans to go to the village to have her baby, the ever elusive 'village'- home to family and traditional rememdies that cure all ills (being able to relax and have someone take care of you surely one of the most traditional of cures.)

However, one afternoon found her in an ambulance, touring the city in search of a hospital that would take her. She was turned away by several. She cites the strike or no room as reasons for this. We wonder if the severity of her condition and the light pocketbook weren't an influencing factor. Finally, she ended up in a clinic in Adjame. She had an emergency c-section and was still in pain when I talked to her a day later. She'd barely seen the baby but told me he was 'under covers'- the phrase for the care premature babies receive.

She'd racked up a hefty hospital bill and they weren't giving her any post natal care until she paid. During that first phone call, she told me they would keep the baby until the bill was settled. With Kinshasa flashbacks, I wondered how long the baby was expected to stay in the hospital. Preemies usually require more care, and I wasn't really sure how early he was.

News came later from her sister that the baby 'didn't stay'- their phrase meaning he'd passed away. She hadn't informed the mother yet. There is no way to know if it was because he simply came too early, or because, as rumored, the clinic didn't even treat him for the first 24hrs to see if he would, in fact, 'stay.' Or if it was a not having money for the required medicines.

I can't know the real answers, and I don't want to. It's bad enough to know that better pre-natal care might have saved him (or possibly not.) My thoughts were focused on the mom. She was clearly suffering, not only from her surgery but from the pre-eclampsia that'd gotten her there and the news of her baby's death. She needed money.

We scraped together what we could, my contribution much less than I felt good about, and she eventually received some medicines and was released in a day or two. But there remains that frustration of the 'holding the patient prisoner' model. There is the frustration of the patient needing to purchase the medicines (most often a relative must be there to get the prescription and then go to a pharmacy to purchase the medicine and bring it back.)

I couldn't, and still can't, have never been able to, wrap my mind around this. The hospital staff will work around this woman, watching her deteriorate and possibly pass away herself, because she can't purchase the required after birth medicine? It smells awfully close to murder. My memories invaded with images of another patient, languishing on a hospital bed, head split open, in and out of consciousness while hospital staff waited for the all important dollar. And even my own birth story, suffering malaria, pleading for a bag of glucose, anything to get the treatment started, while those around me negotiated the cost of my impending delivery.

Somewhere along the way, we humans decided money holds the most value, pieces of printed paper and imprinted coins worth more than our lives. It's better that I don't know the real cause of the baby's death. It's hard enough to sleep at night.

Insurance, Assurance, Never Sure

I ve been having contractions for awhile now- months really, but its only the ones in the last few weeks that have got me thinking. They re still the Braxton-Hicks variety but as I reach the 36 week mark I am all too aware that could change at any time.

My first thoughts- worries- have always been about the need to take a cab to the hospital. What if it is the middle of the night? What if its pouring buckets of Abidjan rain? Will there even be a taxi?

My next worries were about the 10 minute walk it takes to get to the main road. In labor? Really? A friend put this into perspective by pointing out that walking is part of labor- it will be good for me. Since this is baby no.5 however, I m just worried she s going to pop out in a matter of minutes right there on the dirt road in the middle of the rain with no taxi in sight. It would make for an interesting birth story.

Then we found out the little princess is in seige- sitting down- in the wrong position. Though I keep imagining her able to kick off the side and flip around like an astronaut in space, both the doctor and the sonogram technician have pretty much ruled that out. There just isn t much room in there.

I ve been thinking a c-section takes care of some of my other worries. They re usually planned, right? And don t necessarily happen in the middle of the night. Except now I have to pay for it. Despite extending my "global" health insurance, the clinic here refuses to work with them. Pay first, get reimbursed later. Luckily, African medical costs mean I actually can pay for a c-section out of pocket.

Banking practices make it a little more of a challenge however. Once my last school paycheck is deposited in my American bank account, I ll need to make numerous trips to the ATM- once per day over the course of several days- trying to amass the amount I need. Its a result of negotiating my own banks cash withdrawal limits and the ATM s ability to spit out enough bills.

Now I am hoping to gather all that cash before any real contractions start, assuming I ll need to pay up front before they admit me. In Kinshasa, they are known to keep new mothers prisoners-in effect- patients of the hospital long after necessary in order to recupe payment. I m not really sure what the policy is here but I have been told the price is all inclusive-medicines, food, doctor, 3 days rest and care. Its a bargain at 800,000FCFA.

I m planning to tour the maternity section next week and be prepared with my list of questions for the doctor. While my insurance company hasnt provided the ease and comfort they promised, its hardly their fault. Once I have my little cushion of cash I should feel slightly more assured.