Christmas in Kapsowar

Merry Christmas from Kim, Kris, Dominic and Nala!

Two years ago, I made a promise that someday I would write about Christmas 2021. From a professional perspective, I had endured more difficult periods in Kapsowar than those 48 hours starting at about 7pm on Dec 23. But that Christmas, and the tragedies I bore witness to in the lives of my friends here, are a poignant example of why being a rural doctor - in ANY community, in ANY country - can be so heartbreaking. And why being an OB/Gyn - in ANY community, in ANY country - is a profound privilege, as we walk with families during their moments of greatest joy and deepest sorrow.

There are about 200 employees at AIC Kapsowar Hospital. If I make a conservative estimate, in the 4 years I've been here, I've probably been involved in caring for about 10% of these employees or their spouses during their pregnancies. There are 3 employees who I've cared for during 2 pregnancies each - and two of those delivered their babies on Dec 25 and Dec 26, 2021.

I met the first employee's wife when she presented with a non-OB concern VERY early in her pregnancy. I was consulted to comment on the potential risks of treatment for her non-pregnancy related condition, and found out that she had numerous reasons for a VERY high risk pregnancy- including prior stillbirth, a prior very preterm delivery due to a serious pregnancy complication, and two significant medical conditions despite appearing to be a very healthy young woman. In North America, she would have been extensively worked up by a High-Risk OB doctor before pregnancy, and been followed weekly or every other week until a likely early delivery.

However, our options for Rachel's pregnancy were limited (not her real name, of course). She was returning to her job about 8 hrs away, where she would be living for most of her pregnancy. Her medical conditions required close monitoring as they would likely worsen during pregnancy, but she wasn't able to perform the monitoring from home due to lack of proper testing supplies/equipment. Ultimately the couple decided to continue antenatal care with a specialist close to her work, but running his recommendations through me before implementing them. Things were going okay- she saw me for a growth ultrasound a checkup around 20 weeks, and there were no signs of poor health in mom or baby. But we had quite a while to go before this baby would be "viable" - have any chance to survive outside the womb. In Kapsowar,  "viability" is 28 weeks or 1kg, but babies born that early have a LONG fight ahead of them.

Fast forward to the week before Christmas. Aaron (not his real name), still working in Kapsowar, told me that Rachel had had an ultrasound at the specialist's office because the baby wasn't moving well. The specialist said the baby was smaller than expected. No big deal, we'll just change your due date, he told Rachel. I was speechless. We had the best possible dating for Rachel's pregnancy - a first trimester ultrasound that agreed with her last menstrual period. Rachel had at least 5 good reasons for her baby to be small or "growth-restricted," all of which were reasons for significant concern and further testing, NOT reassurance and changing her due date. I told Aaron that I was  worried, and that I recommended that Rachel either find a doctor in her area who could perform proper antenatal testing, or return to Kapsowar as soon as possible so that I could assess the baby myself.

The next day -the night before Christmas Eve - our family was at home watching a Christmas movie in the evening. I got a call from Aaron. Rachel had returned to the specialist- she had not felt the baby move for over 24 hours. The specialist was gone - traveling for Christmas holidays - but the person filling in for him had performed another ultrasound and diagnosed stillbirth, now Rachel's second. He recommended emergency c-section to remove the baby, because Rachel had had a c-section for delivery of their only living child. I asked some follow-up questions- was Rachel okay? Were her blood pressures normal? Was there any reason why she couldn't travel to Kapsowar? And then recommended that she leave her local hospital and travel here so that I could safely induce her labor and spare her a major surgery if possible. Aaron agreed.

All through Christmas Eve, Aaron and I waited for Rachel to arrive via public transport. Meanwhile at home, I tried to carry on with our Advent celebrations - but awaiting the birth of the Christ child, and anticipating the birth of my friend's demised baby, produced a sobering contrast of emotions. When Rachel finally arrived, I confirmed her diagnosis, explained the induction process to the couple, and prayed with them for a quick and uncomplicated delivery. Through that Christmas Eve night, Rachel labored, knowing that this Christmas baby wouldn't be the gift she has waited for.

On Christmas morning, Rachel was able to deliver safely and quickly, and I was even able to be there for the delivery (I don't often make it for normal deliveries since all our moms are unmedicated and can't wait for the doctor!). I went home, mourning but thankful that the worst part of the day was now over, and ready to celebrate Christmas.

A few hours later I got a call from maternity. Sharon - another employee at the hospital, pregnant with her first child after years of trying, and Aaron's next-door neighbour - had just arrived at maternity. She hadn't felt her 34-week baby move in 24 hrs. The nurse had listened, and listened, and listened for the baby's heartbeat, but couldn't locate it. Could I come in and do an ultrasound to find the heartbeat for them? Sharon was starting to get anxious.

I grabbed my things and walked in to the hospital with a sinking feeling. My nurses almost NEVER fail to find a heartbeat. But maybe these were inexperienced nurses, on call on Christmas Day. Maybe the baby was in a funny position, making it difficult to find the heartbeat. Maybe it was just fetal distress - maybe the heartbeat was low, but we could still get the baby out in time with an emergency c-section. Lots of maybes, and prayers, and pleading during that 5 minute walk to the hospital - but the ultrasound was clear. Sharon's baby had also died.

Two years later. Did it really take me that much time to recover emotionally from that Christmas, to tell their stories? Well, yes and no. This Christmas, Aaron and Rachel will celebrate Christmas with their infant twins, born last fall after a VERY closely monitored pregnancy (between me and a real High Risk Pregnancy Specialist in Eldoret). Sharon and her husband will celebrate their daughter's first Christmas - after receiving a diagnosis of diabetes and starting treatment, Sharon was able to carry her pregnancy to term and went home with her healthy baby in September. We've all talked about sadness that we experienced that Christmas, and that we remember every holiday season, and about what a blessing it is to have something (someone) to celebrate this year. And those tiny someones give me the courage to share their families' stories.

BUT. Sharing their stories is something I also do with caution. There are a lot of heartbreaking and amazing and unbelievable stories to tell in our community and in this area of the world, and I want to tell those stories with the gravity and respect they deserve, because these are real people, my real friends and neighbors, not statistics or tragic characters designed to stir up sympathy and donations. We're really excited to have a videographer on our team who is helping us to navigate that balance. Here is a recent short video that she put together about the hospital. We hope this video helps explain why we are here and why we do what we do!

If you are interested in donating to the "Needy Patient Fund," please follow this link to donate through African Mission Healthcare, an organization who supports our hospital in a variety of ways.