"She was just too little"

I was called to the maternity ward to help assess and manage an infant delivered at 28 weeks by dates after premature rupture of membranes. The mother had had some abdominal pains earlier in the week and had been hospitalized for possible preterm labor. Everything had been done that could be done to prevent delivery and to prepare for it at the same time; antibiotics for possible urinary tract infection even though the urinalysis was normal, steroids to try to mature the babies lungs and drugs to attempt to stop contractions. The parents had been waiting, hoping and praying for a child for eight years and the mother was now 38 years old. Mercy Oduyoye, Bridget Ben-Naimah  and other African women theologians have described reproduction from the traditional African perspective as a woman's religious duty and the most important factor governing marriages. They report African woman are disempowered and shamed by childlessness even in the church community. One of the students from Ohio doing a rotation asked me if people think about children the way we do. It is clear by the names given to children, they are desired and cherished; patients with names in Chichewa meaning Accomplishment, Remembrance, We are thankful, Love, Faith, Gift, and Fruition were all on the ward this month.

I saw the breath go out of this medically educated mother when I told her the baby weighed just 720gms. We spoke of the next 24 hours as the most critical for her baby's survival. Being able to breathe alone would be the telling factor. I tried to instill hope even when I had none. It was less than an hour after birth when the baby began to have episodes of apnea (failing to breathe) and bradycardia (low heart rate) with concomitant drops in oxygenation. Apnea and bradycardia are seen in nearly 100% of babies born under 1000gms.  In Neonatal ICU's  in the US we have surfactant and ventilators to help premature lungs and children survive. We did not have a catheter, an endotracheal tube or even a nasogastric tube small enough to use in this infant. Through a miniscule butterfly IV introduced into a vein barely visible through the translucent skin, we gave antibiotics and dextrose.

When the baby failed to breathe we began giving extra breathes with an ambu bag. The oxygen saturation continued to fall slowly and inexorably. Despite drugs to stimulate the heart, respiratory distress persisted and progressed. In a final effort to try anything that might help I called the lab to come and assess for anemia and then contacted the missionary surgeon with O- blood to give 15ml (3 teaspoons) of blood in the unlikely event that this would improve the course of events. Shortly before her death,her mother began asking questions every mother asks, "Was there anything I did to cause this? Was there anything I could have done to prevent this?" When a child is sick mothers the world over blame themselves wondering if there was anything done or not done that led to their child's illness. I have done it myself. At a deeper often unspoken level in Africa people often wonder if there is a curse or an evil force conjured by someone to cause illness and death. Five hours after her birth this beloved and cherished child died. "I am so sorry. She was just too little."

In the late afternoon, when the relatives had gathered, a group of 30 women proceeded in single file out from the hospital gate carrying a small bundle. The mother and father were not among the group which included women friends, staff, patients and myself. Three different women took turns carrying the baby, wrapped in a pink blanket, in their arms. A cloth which covered their chests was tied at the back hiding their precious bundle. Twice on the journey the group stopped while the baby was taken and placed in another's arms, retying the cloth. Each of the three women bore the burden of their friend's child a relatively short distance on the way to the forest but there was solidarity in the act - a sharing of the loss. It was getting toward dusk, the breeze was picking up and the clouds in the sky were changing to pinks and oranges. There was a good chance of rain and only one of us had an umbrella. We marched on across the field, across the road, through the school yard and into the graveyard. Without a word women broke away from the line and began picking up large rocks from the sides of the path. I moved into the grass and found two sizeable moss covered rocks. Rocks in hand we proceeded on past fresh graves strewn with withered and faded flowers into the quiet of the surrounding forest. We followed a narrow dirt path further into the forest till the group stopped by a large tree. After some discussion one of the women began digging with a khasu, a wooden handled hoe whose blade can be turned and used as an axe or a shovel. Women took turns beating the earth and shoveling it aside. Each worked digging the grave deeper and deeper while others stood in a semicircle watching. When one woman paused another would take the handle and begin again pounding the earth with renewed vigor. The vigorous hammering seemed cathartic. Eventually the depth of the grave reached mid-thigh. Still the beating and shoveling continued until everyone was satisfied it was deep enough so that this tiny infant would not become prey for the wild dogs. Finally a woman on her knees in the soft earth at the edge of the grave shoveled out the last bit of earth and all were satisfied. As we stood in the darkening forest watching the proceedings, the laughter of children playing in a field nearby moved through the trees and we could feel the coming of rain. Nearby saplings were quickly hacked down and leaves stripped off the branches, creating a bed of leaves on which to place the infant. Then the patter of rain drops began as if the Lord himself were weeping and the infant was gently lowered into the grave and covered with white plastic. Sticks were positioned lengthwise over the body followed by a layer of rocks and dirt. The remaining dirt was mounded up a foot high above the level of the ground and rocks arranged on top. A simple prayer was said and we slowly filed back out of the forest past many, many, many other small unmarked mounds.

Psalm 139 "....All the days ordained for me were written in your book before one of them came to be..."