At work in tension.

Abstract

(…) Generations have trod, have trod, have trod; And all is seared with trade; bleared, smeared with toil; And wears man's smudge and shares man's smell: the soil Is bare now, nor can foot feel, being shod. And for all this, nature is never spent; There lives the dearest freshness deep down things; And though the last lights off the black West went Oh, morning, at the brown brink eastward, springs (…) Hopkins describes a bleak world, but the hope of ‘deep down things’ promises to spring. A thoughtful reader must consider how these opposing truths coexist within the same structure – both the literal structure of the poem and the metaphorical structure of our experience. As I reflect on my clinical work in Malawi, tension abounds. Women have greater access to caesarean deliveries in the setting of obstructed labour than ever before but the surgical delivery leaves them at greater risk of severe puerperal infection, which may lead to hysterectomy or even death. The number of Malawi-trained obstetrician–gynaecologists is increasing, but in our tertiary hospital with specialists on call, we care for women with ruptured uteri and intrapartum fetal deaths, transferred from rural hospitals too remote from our emergency, skilled care daily. We can repair severe obstetric fistulas with tissue transpositions and vaginal reconstruction but our patients may continue to suffer from significant stress incontinence due to irreversible urethral injury. In Malawi, evidenced-based, accepted management often cannot apply. How do we treat severe puerperal infection without adequate antibiotics? How do we respond to postpartum haemorrhage without adequate blood products? How do we counsel a young woman about options for future fertility after performing a life-saving hysterectomy to remove a necrotic, infected uterus? Limited resources and delayed care defeat us. Yet, we also progress; a trainee learns to perform a caesarean delivery safely, to prevent obstetric fistula after obstructed labour by recognition of risk and prolonged catheterisation, to spare fertility by diagnosis and treatment of endometritis before puerperal sepsis ensues. As happened while analysing poetry in college, I have again become comfortable with an uncomfortable tension. Practising medicine in this humbling grey zone requires a constant reassessment of setting, skills, and resources to save or improve a life. A reader of a poem will struggle to reconcile the tension within, but one side must inevitably triumph. In his poem, Hopkins gives a hint at the stronger side, ‘And for all this, nature is never spent; There lives the dearest freshness deep down things’. As an obstetrician–gynaecologist, I can see fresh hope with each birth or a maternal life preserved; we remain the stronger side. None declared. Completed disclosure of interests form available to view online as supporting information. The author wishes to thank Dr Rachel Pope, Dr Bakari Rajab, and Dr Jeffrey Wilkinson for their mentorship and support. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.