I still think of abortion when I cut into papaya. I learned to do aspiration abortions on the mature fruit while working in Congo. The little black seeds representing bits of products-of-conception would march down the cannula towards the barrel of the vacuum syringe.
And because this is Congo, and because abortion is illegal in all circumstances, aspiration abortion is just called aspiration and not abortion. And it’s only done in the case of miscarriage, to save the woman’s life.
For some miscarriages, the incomplete ones, only a bit of placenta comes off the inner wall of the uterus, and the uterus remains in a quandary—unable to fully contract to staunch the bleeding, unable to fully relax to eject the contents of the uterus. You can start with medication, a bit of misoprostol, to contract the uterus enough to get the rest of the placenta to shear off the wall. If you’re too patient with the misoprostol, the woman could lose too much blood. If her heart starts to beat faster to make up for the lost blood, then you need to move along quickly to an aspiration.
Aspiration can save a woman’s life. And that’s what Médecins Sans Frontièrs (MSF) tells the staff at the Ministry of Health. Because here in Congo, there is a high risk of death from illegal abortion, and there is a high risk of death from just being pregnant and giving birth. So it’s one of my first extended competencies added to my Canadian midwifery scope of practice—but first, I must show my dexterity on papaya.
Celine, a midwife from West Africa, shows me how to construct a teaching model. In the office, we find a cardboard box that held reams of A4 sheets of copy paper. The Spanish administrator had been saving it for the calico cat in our compound that looks to be about ready to drop her third litter this year. He’s been here a while and knows the cat’s value of keeping the rats from taking over our pantry.
With the box at the end of our kitchen table, the narrow end becomes the woman’s buttocks, poised at the edge of the exam table. With a scalpel (for lack of an X-Acto knife), Celine cuts the top and shoulders off a small water bottle. The scalpel slices easily through the thin plastic. Then she slices strips lengthwise and pushes them back, so the top of the bottle now resembles a translucent flower in bloom. She slices off the bottom of the bottle and holds it up to me, claiming the petals represent the labia and the length of the bottle represents the vaginal walls. Then she turns to the box and slices a circle for the vaginal opening, and jimmies the plastic bottle through until the petals come to rest.
“Voilà,” she says, pointing to the petal labia on the outside. I look through the hole, and sure enough, the sides of the bottle somehow resemble the walls of the vagina. “Now for the cervix.”
With a machete from our pantry, she slices the small end of the papaya off and turns the cut side to me.
“The cervical os.” With her finger, she circles the air around the revealed pink flesh and in its center is a single black papaya seed. That’s brilliant, I think.
“Now, get your instruments ready,” she says, looking at the roll of green surgical cloth. I tear the tape and open the collection of metal and plastic. She points to the 60 mL syringe and a cannula as thick as a McDonald’s milkshake straw. “Attach the cannula, turn the lock here,” she points to the ring around one end of the syringe, “now pull back and turn it again to lock it, so there’s a vacuum inside of the syringe.” I nod.
She tells me to sit at the edge of the table as if I’m sitting at the foot of a gynecological exam table as I have done a thousand times before. She removes the lid of the box and cradles the papaya in both hands.
“Can you see okay?” I peer through the hole and can see the papaya cervix at the end. I raise my eyebrows, indicating the affirmative. I pick up the speculum and, turning it on its side, place the duckbill beak into the vaginal opening, rotating as it goes in, then depress the handle and screw the nut down so that it stays open. “Now paint the cervix with the sponges soaked in iodine. Then take the lidocaine syringe, and inject freezing at 2, 4, 8 and 10 o’clock. Do not exceed 20mL in total.” I pretend to do these steps so we can eat the papaya after.
“Now the tenaculum to hold the cervix in place.” She motions with her chin to the instruments laid out on the green cloth. This long clamp ends with two needle-like points that can pinch flesh. “Place it at 12 o’clock, close one tooth only.” I tilt the tenaculum slightly to the left to lift and prick the pink flesh of the papaya and move slightly to the right to puncture the flesh with the other side. I close the tenaculum with one click.
We move through the rest of the steps until I’ve filled the vacuum syringe with papaya seeds. We review antibiotics, pain medications, and how to know when you’ve emptied the uterus.
She doesn’t, however, prepare me for the politics.
“Email me any time,” she says as she stands on a scale wearing her backpack before climbing into the small Cessna. One pilot records her weight on the load list. The other pilot has already started the single prop engine—they make their stops here as brief as possible.
MSF gave me training on Congo’s employment rules and the forms I would need to complete to order medical supplies from the capital. I recall several security briefings explaining the military and militia players, a patter of acronyms that I simplify as Men With Guns. I was briefed on MSF’s obstetric protocols and the training the staff have already received over the past year. And I recall, or maybe my bias makes me misremember, but I recall being instructed that while in Congo, I should provide abortion on request.
The first couple of times I perform an aspiration, I’m called into maternity by one of the midwives, who gives me a history of heavy bleeding, amenorrhea of twelve weeks, and a physical exam indicating eight weeks gestation. I do the aspiration, ensuring that each of the midwives gets a chance to assist so we can follow the tested pedagogic model of see-one-do-one-teach-one. I then document in the patient register aspiration for incomplete miscarriage complicated by obstetric hemorrhage. But the word is out. Any woman who reports that she has had substantial bleeding and her uterus feels no bigger than a grapefruit is given pills followed by aspiration if needed. Since my arrival, all the midwives are now trained, and the maternity unit stats show that we’ve provided ten times more aspirations than any previous month. The Coordinateur de Terrain, or Charlie Tango in radio lingo, calls me into his office one late afternoon to explain this increase.
Even though we are members of the same organization and live in the same compound, I work at the hospital, and he works at the base’s office, so we have not become particularly familiar with one another. I usually work through the midday meal, and he doesn’t socialize with the team in the evening. So when I enter his office, there is an awkward formality, compounded, I suspect, by my age. I’m the only one on the team older than him.
“Are you conducting …a-vor-tee-ments?” Charlie Tango seems to have difficulty saying the word. We’re speaking French, a second language for both of us. But his trouble isn’t related to pronunciation—it’s more from a bitter taste the word gives him. I can’t tell whether this stems from his discomfort discussing gynecology or a robust moral opinion about abortion.
I explain incomplete miscarriage complicated by heavy bleeding. I keep it simple, knowing he may have to repeat these points with confidence when talking to a representative of Congo’s Ministry of Health. I keep the explanation squarely in the realm of God’s hands and leave out the woman’s agency in the story.
“So the baby is dead already?”
“The pregnancy won’t continue if the placenta is no longer working. In the meantime, the woman can lose a lot of blood. It causes one in five maternal deaths.”
“I don’t know, this sounds like a security risk.” He leans his elbows on his desk and narrows his eyes in thought. He brings his palms together and rests them to his lips in pensive prayer. The beginning of the evening light slants into his office and gives him a beatific halo, which, for someone with less conviction than me, could be mistaken for a sign.
“Reducing maternal deaths from obstetric hemorrhage,” I say, “is a priority of the Ministry of Health.” I scroll to Congo’s Action Plan on my phone and turn it to him, but he dismisses it.
“No no,” he says, pursing his lips. “I’m thinking of an angry husband showing up accusing you of killing babies.”
I had not thought of that. I think of most women accompanied by female family members, but of the few husbands coming with their wives, I imagine only concern in their faces. Concern about the “situation.”
“I want you to call me when you need to do this procedure, every time,” he says. “Then I’ll consult with the capital, and we’ll determine how to proceed.” I interpret this to mean some foreign white guys playing cowboys will make medical decisions and determine whether I can do my fucking job.
“I’m not okay with that. You’re tying my hands.” I immediately regret speaking. Dispassionate would have been the preferred strategy in this situation. He’s already up and walking to the door.
“Call me any time,” he says as he waves me out.
I know I should check with my immediate medical supervisor. He’s experienced and approachable but swamped at the moment with what looks like a measles epidemic ramping up. The Ministry of Health received money from GAVI for the measles vaccine last year, but it would appear that no child actually received the vaccine; hence, it’s a delicate situation.
Instead, I decide to have a frank discussion with Bernadette, the mid wife in charge of family planning. We’ve learned we share a birthday, and when I let her try my reading glasses, we discovered we share the same prescription.
She keeps her hair brushed back into a tight bun at the nape of her neck, even though she could choose to brush a lock of hair to the front. This lock could cover the upside-down smile of a keloid scar that stretches across her forehead.
“Is abortion possible?” I want to avoid the word illegal.
“Why do you ask?”
“Just curious. Do some women …” and then I add, “and their husbands, do they request abortions sometimes?”
“Yes, but we tell them it is illegal and to go speak to the doctor.” She nods as she’s speaking, then raises her eyebrows to ask if I understand. I may understand.
“There are doctors who do abortions?”
“I don’t think so.” She raises her eyebrows again and her scar winks at me. She turns to her desk to stack files.
“Could the doctors charge a fee?” I continue.
“I don’t think so,” she says without looking at me. I had heard that a few of the doctors would bully patients for additional cash before starting any care, to top-up their Ministry of Health salaries.
“Maybe women without the means, maybe they don’t go to see the doctor?” I only recently noticed that this hospital serves a varied demographic. For births, there is a mix of women. Some wear tailored dresses and carry new vinyl-zip square sacs containing matching layettes for the baby. They smell like Dove soap and barbeque charcoal. Others arrive just in wrap skirts and thin torn t-shirts. They smell like road dust and wood smoke. But for aspiration, most women make up the second group.
“Women without the means go to the midwives,” she says in a whisper, looking down.
This new revelation just emboldens me.
My simple life goal is to “Stay Above My Personal Scum Line.” I can keep my head up by following three rules. The first is to “leap, and the net will appear,” so I can act in situations of uncertainty and not paralytically wait for a well-laid plan. The second is “better to ask forgiveness than beg for permission,” which has its roots in my white privilege and my trust issues with authority. And finally, I pay close attention to any situation in which I feel that I need to lie in order to navigate it to my moral satisfaction. I know the lying one, in particular, is habituating me to a life below my personal scum line.
I decide I’ll call Charlie Tango every time I do an aspiration. I’ll document the stats as usual. And the goal is the same: to ensure discrete, uninterrupted service.
As serendipity would have it, I get a break. I get malaria. It was inevitable. My daily pill, while unable to prevent malaria in a place like this, will at least reduce my chance of dying.
Charlie Tango passes me in the compound as I return to my room after a bucket-shower. I am wearing only a damp sarong. My cheeks are burning with fever, and I want to be back in bed before the cycle of chills starts. He stops me to ask for any “developments.” Usually, we give our teammates privacy when we pass from shower to room and wait for them to emerge fully dressed before starting any conversation. I tell him that I can talk later, but I’m going to bed early because of malaria. My medical supervisor knows, and I assumed Charlie Tango knew, too. He looks doubtful and asks whether I have had any exposure.
“Exposure to mosquitoes?” I ask. He hesitates, then nods while crossing his arms. “Yes,” I say. “I believe I have had exposure.”
For the next few days, I’m quite unconscious under my mosquito net. I have LSD-like dreams that feel so real. I dream of drinking a piña colada with crushed ice that soothes my burning throat. In occasional moments of lucidity and functioning cell service, I respond to the midwives’ text messages on my little red Nokia phone. I cheer them on and promise them I’ll bring them all cold Fanta when I return.
When I can get up and eat, I move to the couch in the gazebo in our compound. I sift through files on the medical team’s ancient laptop. The cat trots along the walkway between my room and the gazebo, her belly dangling just above the ground. I wonder if she’s installed herself yet in the papaya abortion box I left under the rear overhang of our shower. I enlarged the vaginal entrance so she can get in, and put in two old towels as a mattress.
On the laptop, I find a guide to a legal context analysis for abortion. It’s quite dated, with no clear directives—essentially an instructional list of trip wires to consider. It articulates potential eugenic evil, abuse for monetary gains, and the threat of unintended consequences such as the incarceration of clinician and client. I feel my arrogance sober, and then I just feel fear.
My first morning back at work is quiet, and I bring cold orange Fanta for each of us. The heat of the day is already oppressive. While I usually find cold Fanta to be deliciously restorative, post-malaria I feel like there’s a bottomless pit of restorative-need to be filled.
We sit around on stools and tables in the delivery room, and the midwives update me on what I missed. Even though there were some hairy cases, everything turned out well, and they all seem relaxed. They laugh easily when I tell them it is my first time having malaria, and they find it cute that I took it so seriously and stayed home from work. I don’t tell them that I am worried that the feeling of having lead in my limbs will never go away. I don’t tell them that I’m worried I’ve taught them a skill that could lead to prison.
When I raise it with her in private, Bernadette dismisses my concern. Not because it’s invalid but because she’s too practical to dwell on anything that has no immediate solution. She had asked me to come to her office to go over the statistics, but really it’s to discuss a rape case she managed the day before. The teenager arrived with her mother, multiple Men With Guns involved, any wounds were healed already, and it was too late for the morning-after pill.
“I gave her misoprostol,” she says. “I didn’t document it. She’ll come this afternoon for aspiration. She will ask for you.” I nod. Her words tumble out quickly so we can pretend they were never said.
As expected, the girl and her mother arrive. The mother asks Felicité, one of the young midwives, for the mwa-zungo midwife, telling her that her daughter had heavy bleeding through the night. I’m too tired to walk Fecilité through doing the assessment herself. Instead, I ask her to translate for me while I lead the woman into the delivery room.
The room has two tables side-by-side, and efforts to erect a divider to give two women giving birth some privacy is underway. There is no one else in the room, but at any moment a woman could arrive pushing, so I quickly pat the table and then help the woman climb up.
She’s a teenager, lanky, having not yet grown into her limbs. Her thin t-shirt is worn through at the bony points of her shoulders, and she keeps her long arms wrapped around her waist. Her blood pressure and temperature are normal but her pulse is 120 beats per minute. She looks pale and spent and makes a clicking sound in the back of her throat in the moments when a sudden cramp takes over her.
I put on gloves and help her hike up her wrap skirt. Several rivulets of blood streak down her legs. I help her slip off her underwear and catch a large clot in the palm of my hand, pressing on it with my thumb to separate it, looking for tissue. It’s just a clot. She continues to bleed, and droplets that form at the edge of the bed begin to tap on the toe of my shoes. I ask Felicité to start an IV and to call for another midwife to come help us. I kick an empty bucket from under the bed to catch some of the blood and drop the clot into the bucket. I carefully lay her underwear over its edge for the cleaning staff to wash and return to her after.
On the shelf, above the delivery sets, I take down an aspiration kit and unroll the wrapped green cloth on the Mayo table. I drop in gloves, a syringe, and a needle on the sterile field. I explain to the woman that I’m going to feel inside with my fingers first, and then I’ll look inside with the speculum. It’ll be uncomfortable, I add, but if we work together, we can be done quicker. Felicité is next to her, translating quietly. I have to remove more clots that have pooled in her vagina, and reaching back, I can feel her cervix as if I’ve just put my two fingers into a jar of set jam. It’s soft and open, and I can feel little firm bits of fetal parts poking out of the cervix. With my other hand on her belly, I bob her uterus back and forth between my fingers inside and my hand outside and guess her uterus is about the size of a grapefruit. I then explain to the woman that the pregnancy stopped and everything is starting to come out.
“I’m going to help take it out, so she doesn’t continue losing blood,” I explain to the woman’s mother. Felicité follows every word I say and translates.
And without prompting, she asks the woman for permission to proceed. This is something we just started working on—getting consent—I’m so proud of her.
“Go,” she translates.
I sit down between the woman’s legs and reposition the bucket on the floor between my feet. I ask the woman to lift her bum a bit so I can drape a rubber sheet at the end of the bed and flop its bottom corners into the bucket like a downspout for the blood. I guess we’re at 400 mL.
“Felicité, can you get me some iodine and lidocaine?” I turn and Bernadette is there with a vial of lidocaine, holding it steady, so I can puncture the top with the syringe and draw up the lidocaine. I place the speculum in her vagina and my whole visual field fills with blood.
I ask Bernadette for sponges. She opens a stack of 4×4 gauze and lets them fall next to the forceps. She sprays a few with iodine. I fold the gauze and clamp it between the forceps’ rings and use it to reach into the vagina to mop up the blood, sweeping out more clots. The field fills again, and I work faster. Bernadette is putting on sterile gloves, and I can hear her assembling the vacuum. She asks Felicité to take the woman’s vital signs. Her pulse is still 120, but her blood pressure has now dropped to 90/40. We’re at 800 mL.
“Oral misoprostol?” Bernadette asks. I nod. Bernadette hands Felcité a small paper cup with three misoprostol tablets, and Felicité instructs the woman to keep them under her tongue. I keep dabbing and sweeping out blood, dropping the saturated gauze into the bucket between my legs. They each land with a soft hollow tap next to the collections of plum clots. Minutes go by, and the bleeding slows enough for me to see the cervix. I quickly let the woman know she’ll feel a sharp poke. Felicité translates and adds something to the effect of: keep your bum on the table.
I turn, and Bernadette is ready to take the syringe from me as she hands me the tenaculum, and once placed, she gives me the vacuum syringe. I feel sweat rolling down my back and my left hand holding up the tenaculum shakes and my shoulder aches. I adjust my wrist so this poor woman’s pubic bone can take the weight of my arm. I look to place the cannula of the aspiration syringe, and I can’t see the cervix again. I ask Bernadette to use the ring forceps and clear the speculum. From behind me, looking over my shoulder, she places the ring forceps into the vagina and drags out another large clot and coaxes it off the ledge of the speculum into the bucket, making another soft tap sound. Is that 900 now, maybe 1000 mL?
I can see enough to guide the cannula through the cervix, and once in, holding the syringe, I release the vacuum lock. I start maneuvering the vacuum through my 3D image of the inside of the uterus, beginning at the top and scraping down each side. Deep red bits of tissue move through the cannula to the syringe, and I need to empty the syringe in the bucket two more times before I see pink froth that signals I’m done.
“Vitals?” Her pulse is now 140, but her blood pressure hasn’t dropped lower. Felicité has the woman’s head supported in her arms. “She’s conscious?” Felicité nods. “Can you call the lab to come to arrange for blood?”
“Listen, I didn’t have time to call you, but I just did a procedure.” It isn’t until I am standing in the vestibule entrance of the delivery room hosing blood off my shoes that I remember I was supposed to call Charlie Tango. He asks me to come to his office to give him a full report, and before hanging up on me, he adds he’s disappointed that I was unable to follow this simple order. I look at the screen of my little red Nokia phone, and then I look down at my MSF t-shirt. It is flecked with blood, and my scrub pants have a smattering of blood at each of the knees. Fatigue pours into me like concrete.
In the shower stall, I get a text from Bernadette telling me the patient is stable. We’ll re-evaluate for transfusion in the morning. Then I get a text from Charlie Tango. I don’t respond. I’ll tell him I had no cell service since this afternoon when we got “cut off.”
Wearing my wet sarong and using my shower bucket for support, I slowly crouch low and peer into the papaya abortion box under the overhang in the back of our shower stall. The late afternoon light makes the red brick wall of our compound look lit from within and casts a glow on the vagina door. Inside the box, I can just make out the outline of the mother cat lying on her side, and I catch a glint from her eyes as she lifts her head. I count about six kittens lined up at her belly nursing.
“Cheers girl.” I raise my cold orange Fanta and take a sip.