Thursday, 4 July 2013

There’s Something about Mary

Warning. This one is sad, and the photos aren't in the right order. sorry.

I first heard mention of Mary when I had just arrived here at FreMO. She had attended for antenatal care, but when the time came to birth, she either couldn’t make it to FreMo, or she decided that she couldn’t afford our fee of 4800KSH and went somewhere closer, and cheaper.

Now here’s the thing. They were talking about her because it turned out that Mary was carrying twins. She went to this other medical centre where she was put in a room, and promptly left alone. This isn’t her first labour, she has a 4 year old ‘senior child’, so it didn’t take long for a baby to be born. She didn’t get any help from the staff at this centre. When the first baby came, she called out for help, and everyone was surprised to find that another one was on the way!!! Twins, now that certainly complicated things for Mary.

Welcome to Angela and Cecile! Hold onto your hats, because here is the clanger. The other medical centre charged Mary DOUBLE fees because there were two babies. Never mind that they didn’t do anything for the first one! But wait, there is more. They sent her home within the hour. Can you imagine? Both of the girls weighed around 3000gms so I guess they figured everything would be alright.
Mary and the girls the first time I met her.

Well it wasn’t. Vicki was still here at the time so they went to Mary’s place to do a postnatal check when they heard that Mary had delivered. Bless Mary but the twins weren’t doing so well and Vicki had concerns about their weight, justly so. Mary came back to FreMo for a postnatal check after Vicki left, but for some reason, the twins weren’t weighed.

This is where I come in. Vicki left me a parting message that she was concerned about the twins and thought that they needed further follow up. It wasn’t until a Friday afternoon that we managed to visit Mary to check on everyone. One look at the girls and I was concerned. They were pale with dark circles around their eyes. Their fontanelles were sunken. Their lips and mouths were dry. They were drowsy and didn’t really move much when I undressed them to weigh them naked. I asked how often they were being fed, and mum said she woke them twice a day. I don’t know how long it had been since they had a decent feed. We weighed them and they were 2800gms and 2900gms. I thought that was ok, but later I found out that there is a known discrepancy with the scale of around 300gms. I didn’t know that at the time, being the new kid on the block. And I didn’t want to be the one to walk into a new work environment and be all bossy. I was still learning how things worked.
Your's truly weighing the girls.

The postnatal check was performed partly in English and partly in Swahili and I wasn’t party to all the information. We tried to get the girls onto the breast. One was better than the other, and Mary confessed she didn’t know how to feed them simultaneously. As she fed one, I weighed the other, and while it was vaguely awake, we put it to the other breast. I took a photo of Mary, in her house, breastfeeding both her twins together for the first time. She looks happy! We took our leave but there was no real plan in place to do anything further apart from telling mum to wake them and feed them more often!
The scales on the floor to have it even.

Once we were around the corner I spoke up. I voiced my concerns for those two babies, and so did magdalen. I think she was waiting for me to take the lead, but I’m not sure why that was? We decided to leave Mary with a bottle of clean water that I had in my pack and instruct her to give each baby a capful every half hour, hoping that we could slowly rehydrate them to the point they might wake up and get hungry!
The sleep over night when we intensively fed the girls

On our return to FreMo we spoke to the boss. We voiced our concerns about the twins. I knew their condition was extremely poor. I still hadn’t figured out the true weight loss. Moffat, who is not a clinician but an administrator with a lot of experience and knowledge, put it back onto us. He asked us what we wanted to do. I thought about it and said that in a hospital situation, the babies would be admitted for observation and rehydration, either IV or NG tube or both. He just said do it. Bless you Moff.
Syringe feeding

We called Mary and explained what we wanted to do and invited her to come in. She did. She was there by the end of the afternoon and we settled her into our postnatal room. We started with oral 10% glucose and I syringe fed them small amounts as they could tolerate to give them an initial boost. We syringe fed, because we couldn’t find an NG tube. Plus, they were in such poor shape that we didn’t want to traumatise their oesophagus at all. Then we started to express mums milk so that they could have that too.
Mary was a trooper. She let me express her, but the milk just started to flow. Then the other breast started of it’s own accord and she just sat their holding specimen pots under her breasts catching the liquid gold. We kept syringe feeding for a while, but then when the girls got their energy back we started to cup feed. Cecille was bigger and better than Angela but they were both going OK. Soon Cecille decided she didn’t want to bother with the cup and was back at the breast. Angela was a little more of a concern.
The first time Mary twin fed. This is at her house
the first time we went there.

We had started with half hourly small amounts, then hourly and I gradually lengthened the space between feeds as they had more and more. They were cold and their temperatures were down. I wanted to put the electric heater on but there was no power point in the postnatal room, and no extension cord available. Needless to say there is a power point there now. We continued in this way over night with me popping back in at 3 hourly intervals. By morning the girls were doing much better. We wanted to keep Mary in all weekend, at our own expense, but Mary had problems at home. There was no one to care for the senior child at home. So by morning tea time she was ready to up and off.
Weighing the girls the last time I saw them
before they went up country

Change of plans. I gave Mary the feed charts that I had made up for the twins, and showed her how to continue filling it in. We made arrangements to visit her on Sunday to check and weigh the babies. She was agreeable to this.
Same day, both together.
Mary's hand for perspective

Sunday came and we went off to visit Mary in the afternoon. It was later in the day because of a labouring mumma we had been looking after. Mary had continued with the feed chart up until 9pm the night before. I asked why she had stopped. Her simple answer was that the next door neighbour who had a clock had gone to sleep and couldn’t tell her the time anymore. To find out the time, they called out to each other through the corrugated iron walls. That made me stop and think about the things we take for granted.

We weighed the babies. They were the same. BUT, they were hydrated, they were peeing and pooing and they were waking for feeds. They were moving their skinny little arms and legs and I was happy with all of these things. We made arrangements to come back in two days. But Mary had a problem.

Her father was very ill in a remote area of Kenya, and had been calling her back to see him before he dies. What do you do? It’s a 12 hour or more, depending on what’s happening on the roads, bus trip. She would have to keep the two babies on her lap and possibly not have a seat for the senior child either. How do you breastfed twins on an African bus, that would typically be shoved full of people, animals and stuff to the very limits? We advised her for the interests of the babies not to go. She asked us to call her father and explain the situation. We did. But it was only a temporary reprieve.

We came back in two days. The babies could have been the same weight, but the scale isn’t that accurate. It measures in 100gm increments. They could have even lost a little weight; from where tho I had no idea. There were already skin and bone. Why weren’t they gaining weight? Mary had milk, she was feeding them regularly. It was time to feed the mumma. We bought greens and bananas and avocadoes. Well I did. When we returned the husband had turned up. Mercy advised him that Mary needed more nourishment and described a bone marrow soup that he was to procure the ingredients for and to make. He agreed and left straight away to do it.

I asked Mary if there was anything else that she needed. She said yes, that she needed Pampers (any disposable nappy here is a Pamper). Now what to do? I am here to support FreMo, not to sponsor any single family. I graciously declined and pointed out that the traditional cloth (flannel) nappy that she had been using was sufficient. She said that their skin was suffering from the urine. I pointed out that their skin had looked fine when I undressed them. I gently suggested that a little barrier cream like Vaseline (which she already had) would be perfect, and to not let them sit in a wet nappy for an extended length of time. I didn’t want to start Mary using Pampers because they often leave them on for very extended time frames, and then dry them out and reuse them if they aren’t ‘dirty’. Plus who will then buy them when I leave. I thought that changing to Pampers would be worse than her current system. She accepted this, what else could she do? Then she came out with it.

Her neighbours were giving her a hard time. They thought that she had a sponsor. Why else would Mzungu’s be visiting her in her home so often? They were putting pressure on Mary to ask for Pampers, and probably lots of other things. What a predicament for her to be in. And to think that I was responsible for it. I was simply doing what I had come to Kawangware to do. I explained it to Mary in this way, and suggested that she could use the same explanation to her neighbours. I am not rich in money where I come from but I have lots of knowledge, skills and the time to share it with others. I have come to Africa to support FreMo, so that they can continue to support their community in ways that are needed. Like helping Mary free of charge when we are essentially a private organisation. She said something in Swahili that I didn’t catch. Mercy said she was embarrassed because we were helping her even after she went somewhere else to birth because it was cheaper. We arranged the next meeting to be at the clinic, so that I wouldn’t cause Mary any more trouble than necessary.
We wanted to see her a few days later in an effort to give the twins time to gain weight. Mary didn’t come. We called her and she said she had no one to help her carry the second twin. We waited. We called. I worried.  Finally a week later she came in. We went through the usual process assessing the girls, but they still weren’t gaining weight. They were still under their birth weight and they were nearly a month old. They were certainly in better condition than before, but I think that they were using all their energy to actually feed. I spent some time with Mary and her friends talking about the first milk and the behind milk. We spoke about patterns of feeding and allocating one breast to one baby for each feed. If that was too hard to remember, then maybe one breast per baby per day. Either way, they both needed to have the first milk and the behind milk. It seemed that Angela was still the one that was struggling, so I suggested that every time Cecille fed she needed to wake Angela and feed her. Since Mary had done such a good job of syringe feeding and expressing before, I also suggested that she express milk for Angela during the day and cup feed every second feed to give her a rest. We talked about hygiene so that the girls wouldn’t get food poisoning.

I had been dwelling on Mary’s inability to move around easily. You see traditionally, mothers of twins stay at home until the babies are big enough to be slung onto her back. She will then have one on her back and one on her front. When babies are small, they are bundled up into great big loose cocoons of blankets and carried in the arms of the mother. Once they can tolerate it, they are then strapped to their mummas backs. But when there are two babies, it’s hard to carry them. There are no pram, they can’t afford them and the paths are well, not paths! I had been trying to figure out how to tie the lessu’s around Mary so that she could carry them both. That way she would be a little more independent. I suggested we try to find a way. Mercy was doubtful. Mary was tolerant. I tried a couple of different ways in an attempt to mimic a sling, but it didn’t work. Peninah laughed. I guess if there was a way, someone would have figured it out by now!
Mary being very tolerant of my attempts to
tie her up in knots

That was the last time I saw Mary. I don’t know if I will see her again. We rang when she didn’t come to the next appointment, but she had gone up country to her family. I’m happy with that idea as I think some nurturing by the women of her family and village is exactly what she needs. We rang her last night. She said that she was fine, and the babies were fat. Let’s hope so.

PS. Mary  turned up today. She came to weight the babies. I also asked if she needed immunizations but she said that she had them done that morning. I did think it was odd as the babies would have been weighed at that point, but we were all so excited to see the girls that I didn’t think more about it. As you can see, the girls a gaining weight, plump and ‘bonnie’. Mary is also very happy. When I was left alone with them, Mary asked me for some money for her friend who was ‘helping’ her. It seems that this is why they came to FreMo, to see me, to ask for money. It’s a difficult position to be in. Mary’s husband has a job, and I am here to support FreMo. I’m very happy that the babies are doing well.
One is still bigger than the other
but at 3600gms and 3400gms
we are happy.

No they don't look happy but they are fatter!

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