One year on: grief, guilt and thoughts of maternal mortality

One year ago today, my coworker and friend, our steadfast headteacher, Immaculate, died while giving birth.

And it's not fair.

In all my grief and angst at the time I said, it's not fair. And now, while calm, while able to breathe, while no longer consumed by horror and guilt and panic, no able to see the path ahead I still say, IT'S NOT FAIR.

At the time of Immaculate's passing I was in the UK on maternity leave, myself 38 weeks pregnant. Immaculate and I had planned to see our children grown together, perfect age mates to be perfect playmates.

Almost immediately people started to panic about my health - mental and maternal. That I might begin to panic and become "weak" and that this might have an impact on my own birthing outcome. They kept telling me don't be scared, be strong, don't be scared.

But I didn't feel scared. Instead I felt guilt. Immense amounts of gut wrenching guilt.  As I attending my weekly midwife appointments, heard my baby's heartbeat, cooed over my additional growth scans, I knew that I was safe in the arms of the NHS.

That is not to say that things do not go wrong and that mothers and babies make it through that passage unscathed, whole and with beating hearts. But the likelihood of a preventable error affecting me and my baby was so wholly diminished by own privilege.

According to Save the Children's 2015 Mother's Index the risk of a British mother dying in childbirth in her lifetime is 1 in 6900.  In Uganda it is 1 in 44. I find this figure staggering. I had read this document when it came out and been astounded and outraged. I had seen and heard of mother's dying multiple times in the 6 years I'd been in Uganda. But until it was confronted with it being my friend, it was just part of the harsh reality of life here.

When you read figures like that, you think of women in remote villages, giving birth alone or with aging birth attendants, in poorly lit huts on banana fiber mats. You think of war zones and refugees forced into inescapable circumstances. You think of poverty and of destitution.

You don't think of my dear, smartly dressed, educated, articulate, empowered Immaculate. Who went took prenatal vitamins, went to every antenatal appointment and paid for additional private scans just for the reassurance all expectant mother's yearn. Who had a bright pink family sized suitcase stuffed fully of beautiful baby clothes and a custom made crib waiting for collection. When you think you think of preventable maternal death, that is not the image you see.


For Immaculate it did not matter that she did everything right. That she interrogated obstetricians, that she ate her greens or that she slept under a mosquito net. At the end of the day my friend lost her life because of poor medical practice, lack of adequate care and a frankly nonchalant attitude unfitting of a medical practitioner.

We will never know her exact cause of death, other than it is presumed she bled to death after a caesarean section. Had the doctors in the first hospital identified the baby was in distress earlier, the outcome might have been different. Had she have been transferred to the main (government) hospital for a caesarean earlier, the outcome might have been different. Had the doctor on call been ready and willing to operate rather than waiting for his dinner or a bribe, the outcome might have been different. And when Immaculate's sister ran after the doctor and said "She's not okay" had he attended to her rather than shrugging his shoulders and saying "she'll be fine" and walking away, the outcome might have been different.

Accidents and malpractice happen everywhere. But this is routine. And it's not fair.
 
This is not just about poverty, or locality, or literacy or a preference for cultural practices over modern medicine. It is about the pervasive lack of access to well trained, well resourced medical professionals and resources. It is about enforcing protocols, such as after hours care and on call systems. It is about the lack of standardization of medical training and practice.

There are not enough doctors, even fewer good ones, and barely any who do not accept bribes or slip away from their workplace to perform private work leaving wards and emergencies unattended. And this is not necessarily because they are mercenaries (I'm sure there are a few) but because they are underpaid and undervalued and jaded and worried about their own future and that of their children.

And not least it is about a culture of acceptance from Ugandan patients who never question their care, their prescriptions or their outcomes. I have never even heard of a malpractice case or inquest into a maternal death or any other case for that matter. It is just accepted.
    
All Immaculate ever wanted was to be a mother. She longed for it and yearned for it and planned every aspect as so many of us do. There is not all the much that differentiates Immaculate and I, especially not in our journey to motherhood. Other than an "accident of birth" that meant I had the odds stacked in my favour and she had them stacked against her in what should be the most joyous, wondrous experience of any mother's life. 

Immaculate loved my daughter and longed for her own

For me, the panic of being without her has subsided and the veil of grief has slowly risen. But when I cradle my sweet baby boy, stroke his soft skin and tickle my chin with his hair I feel so profoundly privileged and so, so, so guilty that my roulette wheel had 6900 spaces on it and hers had only 44. 


The only saving grace in this sickening affair, is of course the beautiful baby girl, named after her mother but known as Accurate, who turned 1 today. And we will hold her up and we will shower her in love and we will do all that we can do to make sure she has the life her mother would have envisaged and that she grows up to be the strong, formidable, hilarious, kind and stubborn her mother was.

Accurate loves her Grandmother, Mary, who is her primary care giver

As for us, at Small Steps Foundation and Glory Be Nursery, life goes, of course. This is Uganda. And 1 in 44 women will die giving birth so how long can you pause the clock for just one? The children are in classes, singing, playing, chanting, writing. We have appointed a new management team, to spread the load of this irreplaceable woman to three: Lead Teacher, Business Manager and Special Needs Manager, all of whom are proving themselves capable and willing to live by their predecessors example.

Yet there is, and will always be, a void that cannot be filled. At every turn we find hurdles: favours that were done for Immaculate and Immaculate alone; mate's rates; personal belonging on semi permanent loan to the school now gone and; hoards of information stored in her head and her head alone. Moreover, it was her pure passion and drive and spirit. It would see her carry a disabled child around the Jinja Show, just so they could go; have her walking around the village at 9 o'clock at night knocking on doors asking why a child was absent from school or why they attended with no shoes today; and saw the best primary schools in town reserve places for our village children out of pure respect for Immaculate and the educational standards she upheld.

Our children will still grow together 💜

As for me, personally, my dear friend, I miss your smile, your laugh, your dramatic moods, your annoying ring tones, your hilarious selfie calanders and finding you lying on the office floor because... why sit at the desk?

I will love your daughter and I will love your school and each and every step of the way I will be thinking "What would Immaculate do?"