Prishtina Hostpital is a dodgy place to be, especially if you´re sick. But for Kosova´s prematurely born babies a regular checkups at the hospital after discharge may well be the singlemost important factor for increased chances of survival.
Prishtina hospital is the biggest in the rural region known as Kosova to the Albanians and Kosovo to the Serbs. The two ethnic groups lead an uneasy coexistence. While 90% of the population is ethnically Albanian, the administrators and heads of public institutions like the hospital are Serbian. Rumours circulate about Albanian patients being mistreated at the hands of Serbian doctors and nurses. While they are most likely all unfounded, they nevertheless add to the mutual distrust and suspiciousness permeating local society. The Albanians have created their own parallel health and social services system called “Mother Theresa,” but the clinics are poorly funded and cannot offer much in the way of eg. nenonatal care.
Together with a general boycott of the hosptails by the Albanians, the fear of the Serbian medical proessionals keeps the Albanian mothers away, though a quick look at the hospital itself would be reason enough. The most basic facilities at the run-down facility are lacking (parts of the hospital are regularly without water or electricity), medical supplies are inadequate, the sanitation disgusting and the temperature in most wards not above 55 degrees. “Equal opportunity neglect,” as one American midwife aptly describes it.
The infant mortality rate in Kosova is the highest in Europe, and so is the birth rate. Children are born either at home, at the Mother Theresa birth centres or at the region´s state-run clinics. Once born, the children are whisked away to their village, and that may be the last any doctor see of the baby. For the frail premature and SGA (small for gestational age) children this lack of doctor´s care can lead to the tragic neglect of otherwise curable medical conditions. “This is the single largest problem facing us: they don´t show up for the scheduled check-ups, so we don´t know how the baby is doing,” explains neo-natologist Dr. Besa. “We can´t force the parents to bring the kids in for controls, only pursuade them and teach them the value of follow-up after birth.”
Dr. Agim, who is in charge of neonatal care at Prishtina hospital, is quick to point out that people in the villages er intelligent enough. The problem is that the parents just don´t know the right things to do. “If we had these control visists, we wouldn´t be seing as many cases of anemia, poor growth etc,” he points out. “I have seen the most incredible things. A perfectly healthy baby left this clinic; after two weeks, he came back, skinny and weak, in terrible condition. Two days later, he died. It turns out the mother had only fed him water skimmed from boiled fruit, nothing else. As she herself put it, ‘well, he didn´t seem to care much for milk.´ Other mothers will wash their children with eggs, because it allegedly ‘gives them such smooth and soft skin,´” Dr. Agim says with a shrug and sighs.
“A lot of the mothers make the strangest mistakes with the best of intentions, and it is very hard to convince them to do things differently. If you question their methods of child rearing they will respond with a sense of hurt pride: ‘well, that´s how my mother taught me to do it.´” We have to get out there, into their houses, so we can see what the family setting is like, he concludes.
To boldly go where no nurse has gone before
This year, maternity and neonatal wards from both the Albanian and state-run Serbian institutions are taking part in an irc project providing comprehensive follow-up for those particularly vulnerable newborns after they are discharged from the clinics. The main goal of the IRC program is three-fold: 1) to watch the health of the babies as they return to their new home, 2) to encourage the mother to take her newborn to see the doctor for regular check-ups and vaccinations, and 3) to monitor the mother´s state of health when and if she becomes pregnant again, for her own sake as well as for the sake of the next child.
The work of providing the on-site follow-up will be done by a team of hand-picked, experienced nurses. All but one them were fired from the medical system in the ´91 purge of Albanians; the exception is the one Serbian nurse attached to the project in order to make it “politically correct” in the current Kosova setting and thus acceptable to the powers that be. These nurses will head off to the villages throughout Kosova and pay home visits to the families whose babies are part of the program target group.
It is important, the nurses are told during the first of their three preparatory lessons, not only to watch the health of the new-born that has recently come home, but also to check on the health of the mother. She will most likely be having another baby, and it is the nurse´s job to make sure that the next one doesn´t become a “problem baby.” Although the first baby may suffer from a medical condition, there´s a good chance of preventing that from happening with the next one.
The nurses should take notice of the hygiene conditions they encounter on their visits to the homes in the villages. They have the opportunity to observe the circumstances under which the newborn is growing up and the mother is living, and this may also be the setting for the birth of her next baby. They should make the parents aware of nutritional requirements , not only for her baby, but also for her as an expectant mother. This includes the taking of vitamines to prevent ao. spina bifida, avoiding drugs during pregnancy and so on.
As they gain the trust of the parents it is hoped that the family will confide in the nurses and listen to the advice they give. If so, the nurses can offer some pre-conceptual information, including the suggestion that the family space the children by at least two years. “So, the next time a mother tells you that she´s expecting, you should be the one to tell her how happy you are for her, but also that she should go see the doctor to avoid, for example, having a big baby or small baby or premature baby due to complications from diabetes or other medical conditions,” explains one of the American doctors who are training the nurses in preparation for the project.
The nurses are urged to give the mothers an explanation for the things that are happening to them, ie. explain to them why it is vitally important for them and their baby to go see a doctor at the hospital, even though they may be quite reluctant to do so.
Dr. Besa explains that it is hard for the parents to find the time to take proper care of the newborn once they get him or her home because there are so many other kids to look after, and so much that needs to be done in the daily life of a villager. Besides, she points out, they lack almost everything required to give their offspring a decent start in life water, electricity, decent roads and phones that work.
At the clinics themselves the project will provide the means to collect and store the data from the follow-up. It is hoped that statistically significant results may be achieved through the completion of the project, showing the true value of this kind of follow-up care.