Coming into the World

The Birthing Room

Way back when, I wrote an explanation of the work I do in Cambodia. The big picture. The assignment that I was given by Peace Corps. "As a Community Health Education Volunteer in Cambodia, I have five target areas to focus on: 1) Antenatal Care (ANC) and Delivery; 2) Nutrition; 3) Water, Sanitation & Hygiene (WASH); 4) Sexual and Reproductive Health; and 5) Non-communicable Diseases (NCDs)."

Or at least I thought that I did... now looking back I seem to have missed that and have been trying to describe my work without acknowledge the framework that I operate within... whoops. So now I will. Let's start with 1) ANC and Delivery.

When I first arrived (September 2012) my health center was re-evaluating day-to-day patient flow. A newly built delivery and post-delivery recovery two-room building set just slightly off the side and back in a perpendicular L-shape from the main section was being used, but yes not fully functioning. The wing was funded entirely by the Reproductive and Child Health Alliance (RACHA) and the United States Agency for International Development (USAID). (Unfortunately recently RACHA was audited by USAID and accused of corruption in the higher management...) In October 2012 the midwives began regular use of the wing and since then I have been on hand for 11 births. While many CHE volunteers I talk to steer clear of the birthing room, when I see the midwives (Ee Chhat, Kim Heang, Chantee, or Nu) heading to the wing, I always follow. At first I thought it would be awkward, weird, and/or an invasion of privacy to have me observing the deliveries, but as is common in Cambodia, especially in regards to healthcare, confidentiality and privacy do not exist, at least in the way that I define them.

In 2013 there were a total of 63 deliveries in my health center, 2 delivered at home by traditional midwives (a practice that is highly discouraged in my area as this typical does not denote any level of training), and an unknown (but significant) number of deliveries at the referral hospital in Siem Reap. A lot of the deliveries happen at night or early in the morning when I am not at the health center (there is a 24-hour rotating duty schedule for the staff of which I am not a part...). Over the course of a year and a half, 11 births does not seem like a lot, but they each have been powerful and memorable in their own way.

If you came across a Khmer woman in labor, you may not know it. (This is a gross generalization, but hear me out.) I have missed a fair number of births even while I am at the health center, because I just didn't know they were happening... 10 feet away from me. And no the walls are not soundproof. The Khmer women I have seen give birth, are extremely composed and stoic. When I used to think of birth, I would picture Katherine Higel's character screaming profanities in Knocked Up. (I have never seen a live birth in the States, so I don't know if that is a realistic depiction...) Since being in Cambodia, I associate deliveries with midwives chatting about the changing market prices of fruits, an encouraging (maybe strict or vicious) grandmother/mother/mother-in-law/sister/aunt, and a screaming (maybe, most are pretty quiet too) infant. Maybe a grimace, grunt or one tear from the woman in labor. One time, a woman named Srey Rath asked politely if she could please take a few seconds to rest after her aunt told her to push harder, and then apologized(!). The one time I saw a woman make an unusual scene, (she was getting up, yelling, laying on the floor, crying, and generally being disobedient) Thea produced the largest baby I have seen yet at 3.6kg (7.9lbs) with an elongated head because he had been stuck in the birth canal for a long time. I have seen 2 sets of twins be born, 3 breach (feet first exit - this is not a water slide babies go head first please!) deliveries, 1 with unbelievably excessive bleeding, 1 birth with a husband present in the room (very unusual to have men in the room... little boys is okay... oh and husbands clean up after...) and 2 women in labor for under 30 minutes. I have only been on the verge of fainting once (a breach delivery of twins) and the overwhelming warmth I feel inside watching a being enter the world and take he/r first breath, hiccuping or screaming or silently observing, makes me think that I could be a midwife. Truly a miracle of life.

There is a combined 32 years of birthing experience in my health center between the 4 midwives. I have seen them perform complicated deliveries and deal with post-delivery issues and babies not breathing. Infants are put to the breast within the first hour and skin to skin contact is initiated immediately. I have heard horror stories of energy drinks (think RedBull) being put into IV bags (always on hand) and pumped into the woman in labor at other health centers where PCVs work. I am lucky to be at a health center where there are extremely competent and experienced professionals and where I just worry that nobody watches the newborn swaddled in a sarong on the tabletop post-delivery (typically for no more than a few minutes... I have become the baby-watcher.).

I am not birthing children. I observe. I ask questions. I throw in some education prenatal and postnatal. I talk with the parents about breastfeeding and nutrition. And that is great. The general care is improving. A lot of money is pumped into maternal and newborn health around the world, because who wouldn't want to save the babies and women?? What I see that needs to be addressed is what I scientifically call "Baby Mamas" - the women under 22 years of age giving birth. Normal development for women is said to continue until 22-24 years of age. This means that the pelvis is not ready to accommodate for the head of a normal sized newborn. So while the birthing room is an important piece of the Peace Corps target area of ANC & Delivery (I mean delivery is in the name...) my work remains crucial to the stages before those women arrive- that and baby-watching of course.

My 24th Birthday

So I was a newborn once. I know. Hard to believe that I didn't come out of the womb as the sophisticated Meghan that you all know and love. Jokes. Every year on my birthday (1/20 - this year MLK Jr. Day was the same day) my mom likes to retell the story of my "quick" labor and how I "was born ready." Which sounds a bit ridiculous now that I have seen 30 minute labors... 2 hours is a long one. Anywho, this year I turned 24 or started the 25th year of my life and in Cambodia since people count the day 1 as 1 year old, here I would be 25 (so you were right Mom!) or turning 26 in April since many people count from Khmer New Year... no wonder age is confusing and people born in 1992 and 1993 say they are older than me. I have stopped arguing that point. The hardest part about turning older is... remembering to say the new age. It usually takes me about a month to get it down packed and in a different language (!) gosh life is hard. 

I had the chance to celebrate with some other PCVs with January birthdays and some more friends in Phnom Penh. Plans to go swimming or to the water park were cancelled on account of the cold weather (75 degrees), but I can say that it was quite a better birthday than my last one when I celebrated with amoebic dysentery in the hospital... Let's see what this 25th year of life brings me!

Photos to follow next time I have internet. 

A Look Back. A Look Forward. A Bit Belated.

I made New Years resolutions like the average sucker, but one of those did NOT include being better about blogging about relevant things as they occur. Sorry I am not sorry. Can't snap your fingers at 12:01 AM January 1st and make magic happen. Instead I will try and be better - a more realistic goal I think. So here I am attempting to summarize all that has happened recently. I am backtracking and this is quite belated so apologies for absurd length and for inevitably leaving things out. 

NATION WIDE VACCINATION CAMPAIGN - December 1st - 18th

Back in October, the Ministry of Health announced a nationwide measles-rubella vaccination campaign that would vaccinate 4 million children between the ages of 9 months to 15 years, by the end of 2013. To accomplish this goal, "local staff of the provincial health departments had to vaccinate hundreds to thousands of children per day in each commune." What did this look like on the ground? When I arrived back to site from my parents' visit I was thrust into the middle of this campaign, tagging along with two of my HC staff (Om Phanna and Ee Chaat) for two full days of vaccinations in remote villages across the Pouk operational district. Each of the 23 HC's across the district sent 2 of their staff out each day to that day's designated target commune. Everyone would meet at 7:30am at the district hospital to gather the necessary vaccinations, syringes, syringe disposal boxes, coolers, etc. and they set off on their way. The first day I went, we only ended up vaccinating  96 children and had plenty of time for other things like learning to make oam bok (flattened rice) and go to a local palm reader. 

getting a lesson in the foot pedal to flatten rice

the palm reader told me... married by 27. dead by 74. get livin'!

The following day however we vaccinated 234 kids (whew!). No time for pictures of screaming children held down by willing mothers, aunts, grandmothers, and village health volunteers (VHVs). This campaign went on for 18 days in my district. So was it successful? For all account yes. The last reported case of measles (a serious infectious disease that can cause severe illness and complications like pneumonia and blindness especially in infants and children) was in November of 2011. But Cambodia is not certified by the World Health Organization (WHO) as measles free until the country can prove no more cases in the next 2 years. However, Cambodia is well on its way thanks to this large scale vaccination campaign (modeled after the polio eradication campaign in 1996), initiative to give two doses for every child before 2 years of age, and targeting rural areas. This is a recent article about the campaign's success. 

Something that this widespread public health effort brought up for me was what I see day-in and day-out at the health center and in my community: lack of informed consent and decision-making. Doctors and health professionals are seen as having the knowledge and you do as they say, whether you know why you are prescribed something, what it's side effects could be, what your alternatives are or not. More likely patients are not provided this information and their only power is in the decision to take and when to take the meds or not at all. The focus of this vaccination campaign was not to educate the general public about the horrors of measles or rubella or the benefits of vaccines. It was more of a production line operation. "Right arm. No your other right. Open your mouth. Hold still. Now you are protected." In essence: this is for your own good. I am not saying that this type of campaign should not be done. On the contrary, I am thrilled that Cambodia is taking big steps to improve public health. However, I think this raises questions of patient rights and power to make informed decisions about one's own body and health. Discussions that are rare here in my experience. 

CELEBRATING MY HOLIDAY TRADITIONS... KHMER STYLE. 

I got really into X-mas this year. I celebrated 2 times. Once with my host family and once in Siem Reap with a bunch of volunteers. With all the little munchkins around the house we spent evenings leading up to X-mas day making paper snowflakes and setting up "presents" (empty product boxes tied with ribbon) under a "tree" (a branch pulled off a mango tree in the front yard) and making paper ornaments. On the actual day I was able to skype home to the states and in the afternoon I found eager little kids sitting around our tree excited to open actual presents that I had placed there the night before. X-mas with the host family meant that I got a present from each person I gave a present to - none of them exchanged gifts with each other. 

my presents :)

our tree :)

In Siem Reap, the celebrating was a bit different. The weekend after X-mas was spent eating Western food and chocolate drinks of all kinds, playing group games and doing a hilarious "white elephant" gift exchange (everyone makes a gift, wraps it, puts it in the present pile, everyone picks a number, then goes around picking a gift from the pile and deciding to keep it or steal from a previous picker). I made a candle holder from my old bike parts (which I had to get replaced because of wear and tear the result of 2,206km logged on for 11 months!), and I ended up with a lot of chocolate. Before heading back to site, I strapped on some rollerblades with 2 other PCVs at a skatepark and completely Khmer teenager hangout hotspot. A couple of swollen and bruised sitbones and elbows are still with me weeks later. 

just like the 90's :)

swollen elbows :(

Compared to the way I rang in the New Year last year (with Cori at a monk blessing ceremony and dancing in the streets of Siem Reap) this year was quite calm. My host family went to Siem Reap and left me behind so I spent the evening watching the sunset and darkness roll in while reflecting on 2013 and looking ahead to 2014. I made a wish, lit it with a match and watched the wish float heavenward. It would have been nice to have toasted the new year with a flute of champagne in hand and hearing it clink against another, but there will be such occasions in the future I am sure. I don't really like New Years resolutions as I think that each new day should be a time to improve self and strive toward goals, but I found myself making some anyway. But this time around they have taken a different focus. I wrote weekly and monthly goals relevant to my life in Cambodia: go to the market, do laundry, go for a run, finish a book, etc. Realistic and achievable. Small steps. But all for Cambodia. The year 2014 brings with it my close of service (COS) only a few months off. And with that is a major transition that will call for new resolutions. Before I know it I will be writing entirely different expectations for life post-Peace Corps which is something that 2014 will bring, for better or for worse. Here's to new adventures, smooth transitions and staying in touch throughout it all. Happy 2014.  

sending a wish on the wind.