A WORLDWIDE JOURNEY FOR MOTHER AND MIDWIFE – DAY 6

Day 6 – Cultural Differences

Late last night, when I was just about ready to check into my bed, Muna arrived! The culture here that the day starts late and ends even later. While that fits in with my current jet lag, it’s hard to get my head around. I still feel terribly guilty getting up at 10.30 when I hardly ever sleep in beyond 8am at home. Can you believe Azaan, Sofia’s estranged husband has just left to go to the dentist and it 9pm?!

 

So, back to Muna’s late arrival, because I just have to mention that once again she arrived with food! This time it was desert. Typical/local delicious sweets made from carrots, honey and nuts – a strange combination but no more so I suppose than our carrot cake. Sofia was in a restless mood and I did allow myself to hope it was the sign of something to come, but it was her 2-year-old Ebo who put paid to that by being unwell and keeping her up all night. Suppress that oxytocin and call in adrenaline!

 

I managed to finish the first series of Game Of Thrones by 2am and then had a bumpy night of sleep awake cycles of 2 hours until 10.30. The culture of servants continues to amaze me. I have learnt in some households it very formal, and the lady of the house would be addressed as Ma’am, however in Sofia and Muna’s house they appear to be more like family and have been employed for many years. Many of them live in and have their own quarters at the back of the house in the basement, although I have yet to see it. Sunia is going home tomorrow as it’s her day off. At seventeen years old, she must go to take her salary home to her family. On Fridays the servants cook food enough for 80 people and take it to the local homeless shelter. I only learnt that last night and, if I am still here next week, that’s something I would like to see!

 

 

Today Muna took us to the sea front (not the beach) where locals fish for crabs. We walked along the sea wall watching the fishermen, all the time being aware of the strange looks we were getting. With no woman other than us around, the sight of 4 in one go consisting of one Pakistani (maid Sunia), one white woman dressed as a Pakistani (Muna), one westerner (me) and one very pregnant woman, made for quite a picture… Literally, as we did see a group of young men taking a picture of us as we headed back to the car. As usual the area was littered with rubbish, but certainly not as bad as the piles of it in other areas of down town Karachi.

 

 

Then it was on to lunch at the golf club and as we entered the grounds you could be forgiven if you thought we had stepped through a time warp back into colonial India in the days of the British rule. Pristine road and beautiful gardens. Only the signs “ladies parking”, “ladies swimming pool” and “ladies gym” gave it away that we were still in segregated Pakistan.

 

 

On the way home they stopped to show me the local supermarket where you could pretty much buy everything you wanted including imported goods with names I recognised. The isles were narrow and the shelves stacked high but the thing that fascinated me the most was the armed guards at the entrance and exit…..yup armed guards at the supermarket!

 

 

Soon it was time for the highlight of my day; I had planned to go to the cinema! Although I was going alone I was driven there and back and Muna came in to show me the ropes. She need not have bothered, it could have been a cinema anywhere with its multi screens, nachos, popcorn and coke, I was well at home. The theatre was large and the seats big and comfy. I settled down to watch my movie but nearly jumped out of my seat when the soundtrack began, why was it so deafeningly loud? I soon realised why…forget the niceties of people being quiet, throughout the film they were arriving late, leaving early, chatting away and using mobile phones…. lucky it was very dark and very loud and I could easily absorb myself in the action.

 

And so another day ends here in Pakistan. I am committed to Sofia and to helping her to achieve her dream birth and they are treating me like royalty, but the homesickness is creeping in around the edges and I am longing for familiar sights and smells of home and the faces and love of my family.

A WORLDWIDE JOURNEY FOR MOTHER AND MIDWIFE – DAY 4

Day 4 – Food, Glorious Food

 

I am not sure if it is jet lag or just insomnia but I managed at most around 5 hours sleep last night and woke this morning feeling very tired, muggy and with a thick headache. I wondered if I could get through the day!

 

 

Sunia served me a lovely mushroom and cheese omelette, fresh orange, and peppermint tea in my room, which went a long way to reviving me before Sofia came in to have a girly chat. Sofia has a lot of life’s difficulties to bear right now, and although she does not want me to go into detail, due to personal circumstances her husband and she are estranged and he lives elsewhere with his aunt. Sofia has a deep sadness about her situation, but wears her pain with a quiet and mature dignity. She never raises her voice or lets her pain turn to bitter nastiness. My admiration for her and how she is dealing with her situation knows no bounds.

 

So, full of my lovely breakfast and following our chat, Sofia informs me that Grandmother (who was born in the caul) had said it was important that I had a meal to make me feel at home, so later this morning we are off to Munas’ house for a roast chicken lunch! Oh my goodness, lunch? Breakfast has not even gone down. I also knew that the plan for the evening was to go out for an evening meal with the whole extended family. At this rate I will be going home needing bigger clothes.

 

So to Munas’ for lunch, and following the delicious roast chicken with many different traditional accompaniments, I could easily have slept for a week. To keep awake instead I asked to be shown a hairdresser to get a blow dry. Typically, all the plug sockets in my bedroom were nowhere near any mirrors, and blow drying my own hair is not one of my few accomplished girly tasks let alone doing it without a visual guidance.

 

 

Like most “nice” shops, restaurants etc. the hairdresser shop was hidden behind high walls and greenery rather than being on the typical streets with shop fronts. It had everything you would expect of a beauty parlour and superficially was clean, although like most buildings I had been in, with the exception of the very western shopping mall, was a little battered, grubby and rough round the edges. However, the experience was great and the prices dirt cheap. I had a full pedicure and blow dry for the amazing price of 3800 Rupees (£18).

 

 

Muna had left me in the hairdresser with assurances that Sharif the driver would be waiting for me outside when I was ready to come home. He wasn’t, and for a few minutes I had a few cold feelings of dread; here I was alone in Karachi, a very unsafe city, it was dark, I was a westerner (so stood out like a sore thumb) and I was alone! Dark thoughts of kidnap had, once again, just started to creep in around the edges.

 

But a few minutes later the lovely Sharif pulled to halt right next to me. At this point I realised that the doorman, who were ever present at all establishments, had been keeping an eye on me and rushed forward to where I was standing next to the road, and opened the door for me with a reassuring nod of his head. My fundamental belief that most people are good was restored.

 

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Unable to communicate with Sharif I sat and watched the night lights of Karachi pass by. With the dark of the night hiding the dirt, rubbish and decaying buildings it actually looked pretty and just like any other city in the world. We drove through wide brightly lit streets and then onto the sea front road, where vibrant coloured lights lit up the fun fair, and the night hid the appalling lack of safety precautions!

 

Now back home to get ready for the night out and yet another meal. Into my lovely Pakistani outfit, with my brightly painted toes and a preened hairstyle. The only thing missing to make me feel like a queen was my king by my side.

 

 

The restaurant we went to was a typical Pakistan meat feast establishment. Huge and over 4 floors it was obviously very popular with the locals. Alcohol is banned in Pakistan, which is a shame, because the varieties of meat consisting of chicken, lamb and goat in varying degrees of hot spice were so delicious that a glass of red would have complimented it no end. With many women covered up in Burkas and the rest in traditional dress I was glad of my outfit, because this was not a restaurant with western attitudes. Although I felt I blended in well my white skin and red hair still afforded me many a curious glance.

 

Finally home to bed, well fed well socialised but a little culturally shocked. Maybe a baby will come tonight!

A WORLDWIDE JOURNEY FOR MOTHER AND MIDWIFE – DAY 3

Day 3 – A Trip to the Shop

 

Thinking I had escaped it, jet lag hit hard last night and, following a period of insomnia, I struggled to wake this morning at 10.30 and did so with a muggy head. Mornings in this household are late and unhurried, so it compliments my current cycle and, after a lazy cup of peppermint tea and some freshly squeezed orange juice served to me of course by one of the maids (I could get used to this), I felt a little better. Sunea and Rumi the maids are so lovely. Sofia has explained to me that they would otherwise live a very poor existence. Suneas’ family live in one room and without her salary and extra benefits (toiletries, education, food and clothes) life would be very different. That aside I find it very strange indeed to be waited on!

 

 

So today our first adventure was lunch in a French restaurant. I cannot say it was ‘posh’ by western ‘posh’ standards, but it was nice, clean and the food was absolutely delicious. I had a Rocket, strawberry and feta cheese salad and found lots more besides those ingredients in it to make it scrummy….. Muna and Sofia said we always need to keep fingers crossed about Deli belly, but so far so good.

 

I couldn’t help but to take more pictures of the shocking and amazing things I saw on the journey; like the spaghetti junction electrical wires and the children begging at the car as we stopped. Sofia always gives them Rupees and as she handed out hundreds of them to a gaggle of around 20 beggar children she did a quick calculation and converted the money to sterling for my information. Each child was receiving 80 pence which would feed each kid for a week. I couldn’t help but join in and spent a massive 200 Rupees myself to those grubby little hands.

 

 

Next, a trip to the local shopping Mall where, guarded by gun wielding security men, I felt safe and at home, especially when I saw shops that had home written all over them: Debenhams, Body Shop, Mango, Mothercare, not to mention all the normal food chains. I was not really interested in those shops, however, because (when in Rome and all that) I just wanted a Pakistani outfit. So bought a beautiful outfit consisting of silk trousers, a long floaty top and a scarf to finish off the look. Everyone speaks perfect English with a Pakistani singing accent, (except Sofia and her family who look and sound completely western) and so I was delighted when trying on my outfit two young women told me I looked lovely in it!

 

 

Home from the shopping Mall we followed the route along the sea front and I saw the beach. Although it was crowded with locals, camels, food sellers and even people swimming in the sea, it didn’t look very inviting for, as like the rest of Karachi, a day out at the beach would mean fighting with the rubbish for sand space. We were not close enough to see it but Sofia informed me that the romantic sounding Arabian sea was in fact black with pollution.

 

“A woman’s life and decisions here are run by committee.”

 

Home for the evening and I thought to relax and rest but, oh no, I had a difficult night ahead. Remember I said a Pakistani woman marries the family? Well a woman’s life and decisions here are run by committee, and the whole family came around for a discussion about Sofia’s plans for the birth of her baby. They are not party to the home birth plan, and rather they think Sofia will be staying home “for as long as possible”. So that we could even persuade them that was safe I sat them down to a showing of “The Business of Being Born”. Poor Sofia, I just want to pick her up and run for the hills.

A WORLDWIDE JOURNEY FOR MOTHER AND MIDWIFE – DAY 2

Day 2- Birth Plans

I woke up this morning wondering what the day ahead would hold as I was going with Sofia to consult with a doctor. Sofia wants a home VBAC but her extended family are not supportive due to worries about safety. Pakistanis, no matter how westernised, are very patriarchal, and when a woman marries into a family she becomes a daughter of the in laws, to the extent that official and medical forms often ask her to document her husband’s father's name. The family were causing Sofia, and indeed themselves, quite a lot of stress due to Sofia’s birth choices. It appeared that the worry had little to do with the previous caesarean section, and more due just to them being ill informed about birth in general and knowing Sofia did not have a doctor involved. I was keen, for obvious reasons, to know the procedure should a problem occur in labour, and where we would head to. So Sofia found a female obstetrician who said she would like to meet me and supported Sofia in her plan for a VBAC.

 

The system in Pakistan is archaic to say the least. There is no simply turning up at a hospital, because if she is not booked with a doctor the administration would turn a woman away even in an emergency! One hospital even turned away an unmarried women. Later the baby died, but their view was that at least their reputation remained intact, because they had maintained honour in not condoning pregnancy outside of marriage.

 

Ok, so birth plan A) is that Sofia has a home VBAC with no problems, and then following the birth, she tells the family if need be that baby came too soon to get to the hospital. Plan B) is that, in case she changes her mind at any point, she needs to book a doctor who will be supportive of a physiological VBAC in hospital as well as being on hand for plan C) which is an emergency trip to the hospital should we need help. We are accompanied by Sofia’s mother Muna, who is in fact a Dutch woman married to a Pakistani. Muna knows the system very well and is fully supportive of her daughter, and the only other person in the household who knows about plan A (other than the two maids Sunea and Rumi who I will bring into the story a bit later).

 

Before heading off to the hospital we went to Muna’s house for lunch, and while there I was introduced to Sofia’s grandmother who is 88 years old. While frail of body her mind is sharp and we began to share a few stories. I told her about one of my clients in UK who has had 10 babies, and I told the story of the biggest baby whose birth I attended who weighed 12 lbs 120z and was born at home, and she shared stories back with me.

She told stories of German doctors who were prisoners of of war in WWII and working in the military hospital near to where she was living with her soldier husband. She told me about her year-old first born son, who had died during the migration from India to the new country of Pakistan after the war. Finally, she told the story of her own birth, which she had heard being told many times when she was a child. When she was born she was contained in the membrane sac and the midwives of the village were scared of what they could see. They had never encountered such a thing, presumed it to be some sort of deformity and thought the baby was dead. You can just imagine that the baby may have not been initially moving and was not yet breathing. One midwife apparently wanted to throw the baby in the garbage, but another midwife who they all knew as being the brave one came forward and said they should investigate further. She pulled a reed from the roof and proceeded to pierce the sac with the sharp pointed end. Of course lo and behold a healthy baby girl was within, who instantly breathed and lived long healthy life to now be telling me this story. I was delighted to hear it, and told her that was known as being born in the caul and is very rare. It is said by fisherman folk lore that those born thus would not experience death by drowning.

 

After this fascinating insight we went off to the hospital though down-town Karachi. We had deliberately chosen the busiest rush hour time of day and we told Sharif to put his foot down. I wanted to know how fast we could reasonably expect to get to the hospital in an emergency.

 

 

Past all the colourful buses, swerving and horn-tooting through traffic like you have never seen it before we drove. Past shanti towns and crowded streets, past schools and other official buildings only just visible behind high walls with barbed wire atop, and closely guarded by armed men outside. Shops all crowded together, their wares spilling onto the streets, and high poles dotted everywhere with so many electrical and telephone wires attached, spiraling up and around, that it was impossible to see where one ended and the next one began. But most fascinating of all about this diverse and strange place was the huge wide piles and piles of rotting, stinking and decaying rubbish left absolutely anywhere and everywhere. I don’t think I will ever complain about UK streets again because of a few empty water bottles and crisp bags.

 

 

We finally arrived at the private hospital in well under 30 minutes, which was perfectly acceptable to me. There are ambulance services but really they are no more than taxis, as the drivers are not medically trained and the culture of hooting and tooting that goes on gets largely ignored so, Muna informed me, no one gets out of the way for ambulances. I reasoned, therefore, that I trusted Sharif to drive us in an emergency rather than wait around for a dubious ambulance.

 

The hospital was a bit like an old, scruffy NHS one, only dustier. Everywhere there was a brownish yellow décor with an atmospheric sense that a smoking ban had not long been enforced. This was not the hospital Sofia had used for the birth of her first baby, nor was it the doctor who had given the advice which led to the resulting caesarean section, but a female obstetrician who Sofia knew to be more woman-centred. Sofia’s story was that, at 38 weeks pregnant, her doctor had concluded the baby was not growing and advised induction of labour. Sofia had not put up any objection as she was not fully informed and had absolute trust in the advice she had received. The induction had failed, because of course at 38 weeks her baby and body were not ready, and after many hours of pain and distress and no progress into active labour, fetal distress had been diagnosed and a caesarean section performed. Her baby boy was born well, healthy and a whopping 7lbs! Sofia was traumatised and distraught. It does not take an expert to know something did not quite add up!

 

 

The Sofia of today is a whole lot different; she is educated in birth issues and is strong in her determination to do things different and retain control. The evening before Sofia showed me a birth plan she had written. It was a typical birth plan to be found on many an advisory birth internet site, with references about no CTG monitoring required and no cutting cords, amongst other issues, but it had lots of “unless necessary” written everywhere in it, so I encouraged her to re-write it in a firmer way. “I do not consent to …” gives less leeway to anything being done without consent because it was deemed “necessary” at that time.

 

When we were finally shown into the doctor’s office and the birth plan was being read I wondered if my suggestions or a firmer birth plan would be met with hostility. Once she had read the plan Dr Azra slid the piece of A4 paper back across the desk to Sofia, and basically said there was nothing in it that she had a problem with.

“There is nothing in there that can’t be found in text books or good evidence papers” she said and I slowly let out my tightly held breath.

 

She went on to say that as long as Sofia was taking responsibility for her own decisions she was supportive of her choices. Whilst Sofia did not tell Dr Azra directly she planned a home birth, she did say she was planning on staying home for as long as possible with me as her home support, and may come in at the end of the labour. Muna did not say much, and I was aware that she was uncomfortable not discussing plan A with the doctor. Muna had already spoken to Sofia’s previous doctor from her last pregnancy and so was well aware that support for a home VBAC was virtually impossible. I felt that this lovely doctor was truly supportive. We discussed a plan should Sofia require a repeat caesarean section and we discussed how we could achieve all Sofia’s wishes including me going into theatre. I sometimes have to fight to achieve such continuity in the UK, and yet here was this doctor offering it to me as a professional courtesy and in Sofia’s best interest.

 

We were finally shown the labour rooms, which were an exact replica of UK labour rooms (except with more pillows). It was almost time to leave, but not before Dr Azra asked me if I would like to come and speak to the doctors and nurses (and Alvera, the one midwife at the hospital) about practice in the UK. She told me she had trained in the UK, and she certainly appeared to be aware of all current evidence. She explained that Pakistani women still demanded their enemas and shaves, and would freak out at being given their baby for skin to skin without it being cleaned and wrapped. I responded with my usual response when women are blamed for the current poor practices which continue in childbirth: “We professionals introduced all these procedures, so now we must find a way to undo the status quo… never blame women”.

 

I think Dr Azra liked me!

 

I felt comfortable and reassured as I could possibly be with the safe birth plans we had put into place.

Once home, Sofia and I discussed with her two maids how her labour and plan A) must remain a secret from the rest of the family and from her mother in law, who lives in an apartment upstairs, to save stress and worry all round. The maids are loyal to Sofia (there is rivalry between the upstairs staff and downstairs staff) so they were delighted to be in on the secret and be part of such excitement. Rumi told us that she had two of her four babies at home and that she loved being at home. She told us about a special plant that is used in labour. It is called Bibi Maryam ka phool, and consists of a bundle of closed knot roots that are put into water. The flower is a help to the labouring women, and once the baby is about to be born the flower opens up.

 

“When the pains get fast the Dai must go and sit down in the corner and be quiet.”

 

I told Rumi, being the knowledgeable midwife I am, that it is important a woman is not disturbed in labour. However, it seems I am not the only one with knowledge because speaking in Urdu and Sofia translating she replied that when the pains get fast the Dai (village lay midwife who has been taught her trade through the generations) must go and sit down in the corner and be quiet! Yes, that told me!

 

Following such a fascinating day, when I thought nothing more could happen, I was served a delicious meal cooked by Rumi. However, I didn’t look close and proceeded to eat what I thought was a green bean atop some tasty buttered chicken. What happened next invited looks of astonishment as they all watched me run to the fridge, grab yoghurt, and greedily pour it into my inferno of a mouth, while Sofia laughed her head off at me. I had eaten a very hot chilli!

 

So no baby yet and feelings of homesickness coming on. But I was also feeling that this place was growing on me, and these wonderful people were a long lost family.