Family Planning in Bumwalukani

Once every other month an international family planning organization visits the Bumwalukani clinic to provide education and various birth control services.  They start their day at the clinic teaching women in a large group about the benefits of planning a family and how different forms of birth control work.  Then the women are checked in, receiving pregnancy tests, blood pressure checks, and discussion about their family situations and which form of birth control might be right for each of them.  We got to observe the nurse injecting about ten Implanons (progesterone-containing birth control implants) in a row; it was like a birth control factory (in a good way).  The system they have is great and allows them to be super efficient. 

We missed most of the individual patient education and discussion, but luckily one woman came later asking for an IUD.  We were very excited to be able to observe this procedure, but the nurses were meticulous about discussing the risks, benefits, and alternatives about the procedure (aka obtaining informed consent).  After getting to know the woman’s story, they decided an IUD was not right for her, and she decided to get an Implanon instead.  It was disappointing to us to not be able to see a different kind of procedure, but it was very reassuring that they were so thorough in their counseling that they were able to discover certain contraindications to the procedure. 

The most exciting part of the day was the tubal ligations.  In the days leading up to the visit from this family planning group, we had heard that they perform tubal ligations in the office in the pavilion down the hill from the clinic.  Just to paint a picture for you, the pavilion is covered, but totally open to the air.  There are some tables and benches set up for various patient groups.  There’s also an 8 x 12 room which transforms from an office for HIV education to a prenatal exam room to an operating theater for the family planning doctor.  Unfortunately on this particular day, we couldn’t rely on Umeme (the power company) to come through with enough electricity to light up the “operating room,” so the doctor decided it would be better to move the surgeries outside of the room, but still under the pavilion.  So we were observing our first open-air surgeries under local anesthesia – yes, LOCAL anesthesia.  In other words, they were doing what would be considered major surgery in the US with only anesthesia to the skin overlying the internal organs they were working on.  So the lidocaine numbed the two-centimeter area of skin that they would be cutting. They carefully sliced through the muscle and peritoneum (the lining of most abdominal organs), reached into the woman’s pelvis with a blunt hook to trace the outline of her uterus so they could follow it across to her fallopian tubes and grab them.  At this point the women would curl their toes or scrunch up their faces in pain.  No one made a peep.  I could look around and in one view see the mountains, a river, a farm, a cow, children playing, and a fallopian tube – probably not a view I will ever have again. They tied off each one, snip-snip, three skin-sutures, and done.  Even more impressive, after performing this major surgery with only anesthesia to the skin, the women were sent on their way to walk through the mountains to their homes with only Panadol (Tylenol), for their post-op pain. 

I thought about all the patients we’ve seen in Flint with medically-enabled addictions to narcotic pain-killers and wondered if either extreme is better.  I wish we could follow up with these patients to see what complications they experience, if their pain is controlled or how that pain might interfere with their lives.  I wonder how the clinicians here compute the risk-benefit equations they are presented with every day.  For example, is it better for these women to suffer the complications of a sixth, seventh, tenth pregnancy or suffer the pain of a hook grabbing the delicate tubes where those pregnancies begin?  Should they have to tolerate the burden of adding another mouth to feed to their over-burdened families or tolerate the risk of an infection that could take them away from those hungry mouths?  I think we are all trying to maintain humble spirits when we confront these dilemmas and think about all the medical and social disparities that contribute to them.  We are learning how to problem-solve in totally new ways and provide care with limited resources.  Almost every day my eyes become (sometimes painfully) more open to a new world of pathology, social inequities, and systemic deficiencies that all contribute to a patient’s health. While I feel stressed at having to think about problems I have never encountered, I am grateful for the skills I am developing and the perspective I am gaining from these experiences.