Kristen Misiak, MD – Mulago Hospital in Kampala, Uganda

Written by Kristen Misiak, MD – PGY 3 at the Kaiser Permanente OBGYN Residency Program in San Francisco while on rotation at Mulago Hospital in Kampala, Uganda.

As my first global health experience, I knew my eyes would be opened –I knew things would be different—I just never pictured that they could be so drastically different.  I rotated at the largest teaching hospital in Uganda, Mulago Hospital, which has a partnership with the University of California at San Francisco, who graciously allowed my attending and I to participate in an elective there. The reason I chose Mulago was largely due to their high obstetrical volume—they deliver 70-90 (or more!) babies a day, many multiples of my usual. They do this in a hospital that has 1500 beds, but 4000 patients.

The first week, I was assigned to the labor suite. In the US, birth is an individual experience – you have your own room, you have your own nurse at delivery, there is an excess of support for the individual to ensure maternal and neonatal safety.  At Mulago, birth is a community experience, to put it lightly. Walking into labor suite at Mulago, you walk into one big room, with approximately 20 padded tables on which women were laboring. There are curtains at the foot of each table to create a central walkway, but not between beds. There is a small group of midwives and a physician assigned to the area, but there is neither enough space nor providers to provide attentive care. Often, there is a queue of patients on the floor, laboring and waiting patiently for a bed. The Ugandan women were amazing – in the throes of labor you would often not even hear a peep—until they would ask for a “musawo (medical provider)” because they knew that they were about to deliver. These women were grateful for being able to deliver in a hospital – many had made long treks from other clinics to come to Mulago. That first week, I suddenly went from being an obstetrical provider to a neonatal provider—the support for neonatal resuscitation in the labor suite is poor –no neonatal suction catheters, no capability to intubate, no warmers. There are a couple of bag-masks setups and nasal cannula oxygen paired with very few providers, and tempered with hope that the babies are strong and will be able to survive. Seeing the challenges that the neonates face was troubling and I put my NRP training to use as best as I was able, and helped to educate medical students and nursing students on how to help babies transition into the world. In the US, we are able to save so many babies, and this was what I was used to. In Uganda, early preterm babies (before 28-30 weeks or so) most often pass away, and there is a high rate of term birth asphyxia as well– there is not staffing or equipment to monitor fetal heart rates electronically in labor, even for high risk mothers, and the result is pronounced. These things are death sentences for neonates in Uganda, and that was very hard to come to grips with, even knowing that the resources that were available in Mulago were a large step up from those available in smaller regional centers or villages.

The second week I spent on GYN annex (like the GYN emergency department), and saw great successes, and again, some things that were hard to swallow. A CBC could take days to return, ultrasounds were sometimes impossible because patients simply couldn’t pay (imaging costs were not able to be covered by the hospital, generally). There was a low threshold to operate because it was something that you could do—it was either operate or wonder and potentially compromise a patient. Antibiotics were given empirically for the same reason, as was blood. Women lingered for days in the annex because of the time needed for testing, part of which was spent raising funding among relatives to pay for imaging or out of stock medication that needed to be purchased elsewhere. Antibiotics existed—but your choice was limited by what was in stock—endometritis was treated with ampicillin some days, other days the patient got lucky and a broader spectrum antibiotic was available.

I was lucky enough to be traveling with one of our urogynecologists, Dr. Diane Sklar. During our first week she told me the story of a beautiful 20 year old woman she saw in clinic who, when delivering her second baby in an outlying village, ended up with obstructed labor due to macrosomia. Her baby died, and she ended up with one of the worst fistulas my attending had ever seen in her many-decade career. The patient presented leaking stool and urine from her vagina, and walking with a cane due to foot drop. In the OR several days later, I watched agape as, looking into her vagina, I watched efflux from her bilateral ureters through an enormous vesicovaginal fistula. My last week, I had a labor patient who was delivering her 7^th child. She had a fourth degree laceration (complete tear through the perineum into the rectum) with her first child and had not presented for repair, even at Mulago where the procedure would be free. The entire distal end of her vagina was in connection with her rectum, and it had been like that for 16 years.

I saw wonderful things happen too—the hope of mothers as they were handed their baby, after coming to the hospital unsure if they themselves would live, let alone if their baby would. The Ugandan residents—very busy people—were also kind and welcoming. They knew that they were limited in resources, but they did not let that get them down—they carried a lot of hope, and not a lot of cynicism. I was able to perform several deliveries of breech singletons—something that is routinely done in Uganda, but not standard at most US centers, and the development of those skills was invaluable to me. I shared my experience with bedside ultrasound and fetal heart rate monitoring with the Ugandan residents who by and large have little one-on-one training in these technologies, and sharing this knowledge was probably one of the most rewarding aspects of my stay at Mulago.

Lastly, being immersed in the Ugandan culture was a wonderful experience. We were able to take a language course for 2 hours a day for three days of our first week, and learned invaluable phrases to help us communicate (my most commonly used word on labor suite- “sindika,” push!!). I ate a lot of matooke, a steamed green banana which is the most popular food dish in Uganda. Dr. Sklar and I were able to travel to the western Ugandan border to trek gorillas—tourism to do this is what supports and protects the 50% of the world’s mountain gorillas that live in the Bwindi Impenetrable National Park, and the experience was an incredible inter-species connection that I will never forget.

I can’t say that my experience was what I expected—it was so much more mentally and emotionally challenging than I could have anticipated, and so rewarding in ways I never would have expected. I am so grateful that I was allowed this amazing opportunity, and that I was able to share it with Dr. Sklar, as well as the UCSF resident and staff that were present during my stay.