Chad: Tiny Hands

Lanice is a doctor from Canada, currently using her skills in the maternity department of the MSF hospital in Am Timan, Chad... 

One month into my work in Chad, I am haunted by the memory of tiny hands, folded in repose. 

Tiny hands, perfectly formed, opalescent nails smaller than a pencil tip, fingers softly curved toward the palms, tiny wrists reaching, reaching out of the most private area of a women’s body, tiny hands resting where fetal hands should never be. 

I had just arrived to start the morning in the maternity department and the agitation was palpable. “Caesarean,” I was informed by the staff who were just completing their night shift.  “Accouchement à domicile, gémellaire.” 

Women wait outside the maternity unit at the MSF hospital in Am Timan. Photo: Sarah Creta / MSF

A home birth, with twins. I brushed aside the pink drape separating the birthing room to assess the woman who had been brought in moments before I arrived.  She lay on our birthing bed, knees drawn up, two tiny hands emerging from her birth canal. Our newly obtained ultrasound machine was beside her, the ultrasound scan done by the on-call doctor, confirming the lack of a fetal heart; the second twin had died. 

The first twin had arrived at the home birth without incident; I imagined the second twin, diving headlong out of the womb, urgent in the flood of amniotic fluid not to be left behind, determined to catch up to her sibling.  However, birthing canals are not designed for the passage of arms, the head trapped behind the pelvic brim, and thus, the second twin had perished before arriving at our hospital. 

The caesarean section proceeded without incident, the lifeless cherub brought out of the abdominal incision, perfectly formed but so very small, the unfortunate result of a twin-twin transfusion where the first-born received most of the placental blood flow, starving the second from her share. She was wrapped in an MSF receiving blanket and delivered to the awaiting family. 

The mother and surviving twin recovered well, the firstborn greedily suckling and thriving

Over the week that the mother remained with us, the mother and surviving twin recovered well, the firstborn greedily suckling and thriving.  I couldn’t read grief or relief on the mother’s face, only the stoic determination to give this child, this firstborn, the chance to live. 

In Canada, such a high-risk pregnancy would have been followed every two weeks and eventually every week by an obstetrician.  Here, a woman might arrive with no prenatal care, with no idea she was carrying twins.  MSF does provide prenatal care through our outreach clinics and our referral clinic in the hospital, but with the recent return of the transient nomad population, women still present with no previous prenatal care. 

MSF has been working in Am Timan, Chad, in partnership with the Ministry of Health for over six years, providing a full-service birthing unit capable of caesarean sections.  Overall, Chad has many challenges to overcome in healthcare, but being able to provide safe and timely caesarean sections saves the lives of mothers, and of infants as well. 

Saving the life of the mother also has a tremendous knock-on effect of saving the lives of her children 

Chad remains the third highest country in the world for mothers dying in childbirth, as would likely have been the case for this mother, as this infant would not have delivered through the birth canal, ultimately resulting in infection and death for the mother.  Should a mother die, the health and wellbeing of all of her children is gravely at risk; saving the life of the mother has a tremendous knock-on effect of saving the lives of her children. 

I have been grateful again and again for the work the midwives and doctor team does.  Working with the Chadian midwives I have had the chance to deliver other healthy twins, as well as breech deliveries (foot or buttocks coming down the canal, rather than head-first). These are scary births for me, as a family doctor or midwife at home does not undertake these deliveries, however here the midwives have built up their skills, and have been excellent role-models and teachers, sharing their knowledge in technically difficult deliveries.  I share my knowledge in preventative medicine, instructing the team to educate women on steps they can take to help prevent dangerous eclampsia (high blood pressure and seizures) or placenta previa, where the placenta covers the opening of the womb, potentially causing massive and often fatal bleeding at birth. 

The work has been challenging, and with each challenge I whisper to myself my mantra ‘this is what you wanted, this is what you asked for’.  There are days when I wish it didn’t come all at once, such as the forty-eight hours when we had four caesarean sections back to back, an amount that we might normally do spread over a month.  The woman who arrived with one living and one deceased twin, little hands reaching out of her body was one of those four caesarean deliveries.  The sweeping tide of work, of other deliveries, all these memories blur into a montage of colour, sound, fatigue, but in quiet moments of reflection, it is the image of the tiny nails, fingers softly curving, one hand against the other, where hands should never be; this is the image that will forever define my first month in Am Timan, Chad.