Not to culturally generalize, but Ugandan women are pretty much badasses.
I thought I'd write this post about my last day today in the hospital - the everyday chaos, tragedies, and swimming against the tide - but the more I thought about it, the more I decided I'd rather write about my growing admiration for the women I've met and treated and delivered and dined and danced with here.
You can guess at their badassness just by people-watching on the streets here. Whatever their income, Ugandan ladies dress just spectacularly. The wealthier young ones wear immaculately tailored dresses, modest in terms of shoulder and knee exposure but specifically cut to emphasize butt curvatures. Respect. Older women go for more coverage but still impressive, with blooms of perfectly matching bright fabric cut to form billowing sleeves and swishy skirts. Even the women patients of Mulago, who sleep on the floor and eat only rice for dinner, are still bringing their A-game. Their only skirt is colorful and as clean as possible, and occasionally you'll spot one sporting what is clearly a second (third?)-hand American prom dress, shiny and floor-length and all. No sweatpants or old Tshirts here. Personal standards to be upheld. And this is to say nothing of the amazing variations in, cost of, and time spent maintaining beautiful hairdos.
So they look good. But they're also constantly rising to the high (and unfair, I'd say) demands Ugandan culture puts on them. Family life is essentially entirely on their shoulders. I've met many women like Juliet (mentioned two posts below), who house/cook for/raise the children of a man who always has his foot halfway out the door. Many men here, especially those wanting a son, will openly father kids with other women; Juliet's husband has seven children, exactly one of which is hers also. She cooks for them all while he watches TV. And the more well-educated women - or at least the female faculty and house officers of Mulago I met - get no breaks. All of the childrearing and food preparation and hostessing duties go on unabated, just squeezed into smaller time frames. Dr. Namulindwa, one of the Mulago faculty training with Dr. Ueda, told me about one of her recent Fridays: she started doing hours of oral exams with medical students, followed by a complicated multi-hour surgery in the OR, then spent the night of running all over town preparing food for the 100 people who were coming for her husband's Catholic prayer group the next morning. (Dr. Namulwinda herself is Anglican.)
The pressure on Ugandan women to have children, preferably lots of children, sometimes looks crushingly intense. The stigma for infertile women here is dramatic. Until recently, though it's now officially discouraged, Ugandan women who died childless were actually buried in different, less respectful manner than mothers, carried out the back or side door rather than the front one. This manifests itself in different ways in womens' health care here: women often fear and avoid birth control, and medical professionals often contribute to that (I was looked at with amazement here when I asked if a patient having her fifth complicated C-section might be interested in having her tubes tied. The house officers thought it was crazy to even offer it after "only" five.) It's not necessarily true that the woman herself wants more children (we see plenty of complications of illegal abortions to attest to that), but rather seems to be a fear of being known to be sterile. Sadder still was a patient I met at Herbert's clinic, who'd lost six - six - pregnancies in the second trimester (even one loss at that stage is very rare), and just went right on getting pregnant again as soon as possible, desperate to have a child despite the mental and physical toll.
So out of all that background comes the scene at the Labour Ward itself. Sweet sassy molassy, these women are tough. Imagine 20-ish beds (cots, really) side by side, with thin curtains separating them, each occupied by a patient who brings her own plastic half-sheet on which to deliver her baby. No men are present, including fathers. No anesthesia whatsoever, including for stitching vaginal tears (ow). An occasional yell or heavy fast breathing may come from one section of curtains, maybe right around the time of delivery, but mostly women labor stoically, gritting their teeth as contractions pass and then going about their business in between. Even if things eventually end up going towards a C-section, women obligingly fold up their plastic half-sheets and walk themselves to the OR, hopping up on the table despite being 9 months pregnant and actively laboring. Badasses. (I cringe a bit to think of coming back to UCSF and the American women who insist on their vision of a "natural" birth: surrounded by candles, a birth doula (or two), a whirlpool tub, a husband giving back massages, moaning for hours with soft Enya music in the background. I thought they were a little ridiculous before, honestly, and I'm really not going to be able to take them seriously now. I'll give you natural, lady.*)
So that all seems like the right thing to say, the right thing to write, as I wrap up here in Kampala. The systems that serve women here are often crazy and broken. But the women themselves are resilient to the point of awe. I hope that if they stick it out long enough, eventually the Ugandan systems will prove themselves a bit more worthy.
*I realize this statement may make me a big, bad, birth-medicalizing ObGyn. I respect the desire for minimal intervention, I do. But if you've seen patients die for lack of an intervention that a wealthy patient then actively chooses to decline, it rearranges your perspective.
