I have encountered many things in my life and in my humanitarian and midwifery career and I am prepared for just about anything because I have learned that I have to be. A lot of it is not easy. Much of it stays with me. Some of it goes down on paper, like this story.
We were called by one of the PHUs about 2 hours away and told of a woman who had had a baby 4 months prior and was at the PHU and was very combative and agitated and they were having to tie her down as she was being violent. They asked us about evaluating her for post-partum psychosis. They understood from family that she had experienced similar episodes to this one after her last birth. I told them I would not be in that PHU for a few days but that I could go and see her when I came at that time. I wasn’t sure what I would be able to do for her but I could assess the situation and make sure her baby was okay and being fed and not in any danger, but without a proper psychiatric evaluation and proper medications, I would not be able to do much. Sierra Leone has one psychiatrist in the entire country and he is in the capitol.
When I arrived in the village, I was taken by one of our outreach nurses to the place where the woman was staying. She was no longer in her own home due to her condition. When we arrived, we were escorted through the dark mud hut and to the backyard where there were a number of people, family members I would guess, several children and a myriad of chickens pecking around – the standard African village scene.
It was there that I first saw Mairy. She was seated on a wooden bench. She looked tired, sad, frail and dejected all at once. She barely looked up when we greeted her. The outreach nurse explained why we were there. I knew that the staff at the PHU had not known how to handle her and in fact that she was not treated very well because psychiatric illnesses were not very well understood here. I knew I would have to try a better strategy than they did in order to figure out what was going on with her. So I sat down next to her on the bench and I asked her how she was doing. The outreach nurse interpreted for me. It was at about that time that I noticed she had one ankle shackled and the shackles were padlocked and nailed to a board.
I have witnessed a lot of things during my times in developing countries – newborns discarded in the bush in black plastic bags along with their placentas, small children dying from cerebral malaria, children with untreated hydrocephalus, woman after woman with type III female genital mutilation, 11 year olds giving birth, women coming into to be surgically repaired after their wedding night – you get the gist – but I have never in my life seen someone shackled for a psychiatric illness in their own backyard. I cannot begin to explain the myriad of emotions that washed over me at the time. I kept my composure and continued to talk to Mairy through the outreach nurse. He explained to me that sometimes she was making sense and sometimes not. I could tell by her rambling responses, even though they were in Mende, that she was confused and not always making sense but she was not at all agitated.
After speaking to her and her father and mother who were also present, I gathered Mairy had had several violent outbursts. She threatened people, was combative and generally out of control. So they shackled her for her own protection and that of others. There really was no other option in their minds.
I learned that Mairy had given birth 8 times. She had 5 living children and 3 that died from fevers, probably malaria – people here generally don’t know cause of death many times. After the birth of her 7th baby, she had a similar episode to this one. The recent birth, 4 months ago, was normal and all was well until a few weeks ago when she had these episodes of violent outbursts.
I told Mairy and her family that I could assist with family planning. I explained that regardless of the cause of her illness, that her high parity put her at risk for maternal death. Also, if her illness was indeed related to pregnancy, family planning would be the best option at this point as well. Mairy’s 5 children were being cared for by her family. Her aunt was caring for the baby and bringing the baby to Mairy for supervised breastfeeding. So Mairy was not able to mother her children at the moment, which further made the case for family planning.
I suggested implants as the best option because they last 5 years. Mairy and her family agreed. We agreed I would come back the following week (the PHU is 2 hours away, one way) and we would put in the implants.
I asked about Mairy’s baby. I wanted to see him and more importantly, I wanted to see her interact with him. The aunt came out with the baby and handed him to Mairy. It was clear he wanted to nurse, so she fed him. I asked his name. Emmanuel. The outreach nurse asked if she knew any songs and if she sang to him. She smiled and replied that she did. Then she began to sing a hymn from church. While she was loving an appropriate with her baby, it seemed to me that she was also doing what was expected of her at the time.
Mairy continued to talk through the outreach nurse. She was explaining something to him and was quite emphatic. He was talking and gesturing towards me and laughing. I asked what they were saying. Mairy explained that because the belief was that there was something ‘wrong with her head’, all of her hair had been shaved off in an effort to cure her. She was very angry about this and felt she was ugly. Her head was wrapped, as most women do here so I did not know her head was shaved. The outreach nurse said he told her, “It is okay, look at Kristine, her head is shaved too!”. I laughed when he told me this and then I turned to her and she took off her scarf revealing a beautifully shaved head. I said, “Look at you! You are beautiful! You are just like me!” She smiled and then we laughed together. I knew then that I had gotten her trust and we would be able to help her.
We made a plan to check in the following week and do the implant for family planning. I informed them that I would also check with the MD for any medication we could give that would help but also not interfere with breastfeeding. Everyone agreed to this plan and Mairy was willing to try medication. My goal was to get her off the chains as soon as possible.
Back at the office, I immediately consulted with the MD and the medical coordinator for the project. Both agreed a low dose of Haloperidol would be the most appropriate thing to give her first. By the following week we had ordered it – a special order had to be placed because we don’t have most medicines on hand, particularly not psychiatric medications.
We went back to do the family planning and Mairy came to the clinic with her baby. She looked good, happy even. She greeted me with a smile. The outreach nurse placed the implants. When Mairy went to leave, she took my hands and she thanked me in Mende. I could see she understood I was trying to help her and she was grateful. I was grateful she seemed better.
The following week Haloperidol was given and Mairy improved. The next time I saw her she was at her own home and no longer shackled. She greeted me with a big smile and her baby on her back. She looked radiant and her baby looked fat and healthy.
Mental illness is a health crisis in Sierra Leone. There is so little understanding about it and it is clearly stigmatized. There is also so much superstition surrounding it. Cursed by devils, married a witch, swallowed an evil snake and so on. People who do seek care generally go to traditional healers. There the evil is cast out, heads are shaved, like in Mairy’s case, herbal medicines are given, spells are cast.
Mairy continues to improve and we are hoping she is through the worst of her illness. She reports feeling much better. We will continue to support and monitor her over the coming months. If indeed her illness is postpartum related, then she should recover completely and this is what we are expecting.
