By Tisha Titus, MD, MPH
After several hours of rapid fire pregnant women in search of their first, and potentially only, prenatal visit, there is one patient for this day that stands out in my mind. I will wonder what has happened to her for months and maybe even years after returning home. I would like to say that this remembrance is due to the stellar care that I was able to provide to her and her baby or my great clinical skills that caught the often missed rare diagnosis, but this is not the case. She stands out in my mind for what I was not able to do for her.
She was in her early twenties and had come in the first trimester of her first pregnancy with the usual complaints of fatigue and lower abdominal pain. As it is not uncommon for dates to be off by several months, I began to feel her belly and watched as she winced when I pressed near her pelvis. Through the interpreter I asked her to tell me about the pain – where was it, how bad was it, did it hurt all of the time? She pointed to her left side and I apologized as I began to feel that area to sort out what I was dealing with. A mass that caused considerable discomfort. With her positive pregnancy test, my options quickly all converged to an ectopic pregnancy.
I know what to for an ectopic, but I had no idea how to get it accomplished in the environment of a bush clinic with nearly no resources an absolutely no capability for urgent surgery. After some quick discussion we found the referral form to send her to the nearest hospital and a second local interpreter to discuss this with her. She had come to the clinic with other family and her children were at home being tended to, but before she was willing to go to the hospital, she needed to find her sister and the children that had come with them and then head home to make arrangements to have all of the children watched. Transportation was another issue – she was going to walk home and then to get back to a main road to try to find a ride to the hospital.
The urgency of the situation was explained several times by the interpreter, but she held firm that her family needed to be tended to first and her looming medical crisis would have to wait. I had no other option but to hand her the hospital referral slip and beg to her to go as soon as possible knowing very well that she may not go at all, or may rupture and die on the way.
This was the only ectopic pregnancy, but definitely not the only concerning encounter regarding prenatal care. Many of the women were having their first prenatal visit well into their third trimester and a fair number of them also had a sexually transmitted infection or urinary tract infection requiring treatment. Many of them were planning on have a midwife assisted home birth, but in a number of instances this was not appropriate because of the high risk for complications due to fetal presentation or previous c-section.
The medical documentation system was a bit surprising and a significant hindrance to the continuity of care. Previous experiences in rural underdeveloped countries had provided previous exposure to the most simplistic systems of record keeping – a small booklet or stack of papers that the patients carried with them. There was no such record here; each patient was documented on a color coded sheet with only the current problems at hand. For prenatal care, this proves to be problematic in that there is insufficient time to take a detailed history of pregnancies and any unmentioned existing problems must be rediscovered. It is essentially starting from scratch at each visit for each patient.
Although delivering care in this setting can be very frustrating, it is also tremendously rewarding. Patient after pregnant patient smiled and their face lit up when they heard the thump-thump of the baby’s heartbeat from the doppler. Some of them giggled as the baby kicked us while trying to feel for position. All of these women allowed the students to repeat exams. Each patiently waited in turn and each was thankful to receive a quick exam and a small bottle of Tylenol. Despite all of our efforts, there is still that nagging feeling that more could have been done followed by the “what if” and the “but” that comes out as we analyze the situation.
I am happy to say that more is being is being done. On one of our last days we stopped by a construction site of the new Maternal Health Center which will give women in the nearby area access to prenatal care. The two buildings seem to be a fair bit off the beaten path, but will be able to offer many aspects of care that I (or the rest of the team) was not able to provide – care that is needed and will be appreciated.
After leaving Haiti I still wonder about the young woman with the ectopic pregnancy as well as several others. I may not be privy to what has happened since our brief patient encounter, but I do cherish those brief moments where I was able to make a difference, no matter how small that difference was – sometimes it is the smallest and simplest acts that have the greatest effect.