Maternal Healthcare in Kashikishi, Zambia Carrie Malcom, MS4

International Educational Experience

1/27/19-2/24/19

Kashikishi, Zambia

• Zambia is a country in South-Central Africa

• Population of ~16.5 million(1)

• Former British colony: gained independence in 1964(1)

• Kashikishi is located in the Luapula Province, on the northern border of the country, lying on Lake Mweru

• Many residents of Kashikishi are farmers and fisherman

Kashikishi

(2)

Rotation Site: St. Paul’s Hospital, Kashikishi

• Regional hospital: many referrals from surrounding villages and clinics

• School of Nursing and Midwifery at hospital

• Hospital mainly staffed by nurses, and clinical officers (similar to nurse practitioner/physician assistant)

• 200 bed hospital staffed by 4 doctors, but only worked with 3 of them

• Rotated mostly on Maternity and Surgery wards, spent some time on Pediatric and Medical wards

Maternity Ward• Easily the busiest ward at St. Paul’s

• As St. Paul’s is a regional referral center, many pregnant women transferred from local clinics for:

• arrest of labor

• antepartum bleeding and anemia

• intrauterine fetal demises

• infections

• planned, repeat C-sections

• Many women receive prenatal care at local clinics

• Some women arrive to St. Paul’s in labor, having had no prenatal care

Pregnancy Norms• No epidurals for pain management!

• Not even for C-sections→ do spinal blocks with bupivacaine

• No IV or oral pain medications other than Tylenol

• Average age of 1st pregnancy: 14-16• sometimes as young as 7th grade

• Average # of pregnancies a woman has in her lifetime: 8-12

• Youngest gestational age of infant survival at St. Paul’s : >33 weeks• >23 weeks in USA

• No neonatal intubations or oxygen available at St. Paul’s

Maternal Death• Maternal death rate in Zambia:

398 per 100,000 live births• *per an obstetrician from Mansa,

a larger town and referral center for St. Paul’s

• 1 maternal death at St. Paul’s during my rotation, due to anemia• Patient had a placental abruption

• Transferred to St. Paul’s from clinic

• St. Paul’s did not have any blood for transfusion

(3, 4)

Intrauterine Fetal Demise (IUFD)Case Report:

• Female in early 20 arrives with intense, rapid contractions

• No fetal heart rate auscultated with fetoscope, no heart motion seen on ultrasound

• Mother developed fever, concerning for sepsis

• C-section performed: • Fetus had died days earlier

Culture:

• Very common for women from nearby villages to drink special “teas” to induce labor• Teas made of leaves, herbs, tree bark,

roots, that have oxytocin-like properties

• Teas induce contractions, but toxic to fetus

• Doctor we worked with said he sees IUFDs all the time, and women later admit to drinking these home-made brews

Fetoscopes

Maternal & Neonatal Infections

• Syphilis, HIV, genital herpes very common infections in pregnant women in Kashikishi

• Diseases can be transferred to infants during pregnancy and delivery

• Many babies born with abscesses→ often due to syphilis

• Treatments given at St. Paul’s

• Adult Syphilis: benzathine penicillin

• Neonatal Syphilis: benzyl penicillin

• Genital herpes: acyclovir

• Many women with infected C-section incisions• Due to poor patient hygiene or lack of antibiotics

C-Section Operating

Room

Maternity Care Conclusions

• Kashikishi is a very difficult place to practice medicine due to limited resources

• Many patients die of preventable causes • infection, insufficient blood supplies, having to

walk for hours to reach a clinic

• Doctors also struggle with patients’ tendencies to follow traditional medicine practices over modern, scientific medical advice• Example: drinking local teas to induce labor

• Often to patient’s detriment

Most Profound Clinical Experience

• Pregnant 19yo F at 24 weeks gestational age (full term = 40 weeks), arrived at hospital having constant abdominal pain• Patient found to be in active labor• Baby expelled 2 minutes later, moving and crying• Baby passed an hour later, as hospital does not have

NICU, ability to intubate babies, or give oxygen

• Preterm baby (at 35 weeks gestational age) with jaundice and trouble breathing passed that afternoon as well

• Both of these babies, especially the 35-week old, likely would have lived had they been born in the US

• Doctors at St. Paul’s are very knowledgeable, just insufficient resources The ultrasound at St. Paul’s

Most Profound Cultural Experience

• Zambians have very different attitudes towards pain management• No epidurals or other pain medications during and

after labor• Women in labor who were making too much noise

(due to pain) were criticized for being too sensitive

• When a midwife from Switzerland questioned why laboring women were not given any pain medication, a Zambian midwife stated “that’s the culture here”

• We suggested the doctor inject lidocaine into a patient’s wound before cutting on it (as patient was screaming in pain): doctor said, “you can’t be too sensitive…you’ll kill your patient”

Repairing Baby’s Club Foot

I pet a Cheetah!!!!!

Zambian Food

Ntumbachushi Falls

References

1) “Zambia.” Wikipedia, Wikimedia Foundation, 21 Mar. 2019, en.wikipedia.org/wiki/Zambia.

2)https://www.bing.com/images/search?view=detailV2&id=3536E503D86B42A7E8DB86CF420DBE01B2B22DA7&thid=OIP.aZuIsfinVMm4PwkCKovOvQHaG-&exph=565&expw=600&q=Zambia+Africa+Map+Location&selectedindex=6&ajaxhist=0&vt=0&eim=1,2,6

3) Nina Martin, ProPublica, and Renee Montagne. “U.S. Has The Worst Rate Of Maternal Deaths In The Developed World.” NPR, NPR, 12 May 2017, www.npr.org/2017/05/12/528098789/u-s-has-the-worst-rate-of-maternal-deaths-in-the-developed-world.

4) “Global, regional, and national levels of maternal mortality, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015,” The Lancet.