Health-E: When a child gives birth, who failed her?

There's an awkward tension in the operating theatre as the nurses and doctors prepare for the caesarean section. They go about the usual business of unpacking equipment and switching on theatre lights, but occasionally someone stops what they are doing, looks at the patient on the table and shakes their head in disbelief.

The intern doctor nervously rubs his gloved hands together, shifting his weight from one foot to the other. Today marks the first time he'll perform a caesarean section as the surgeon and not an assistant, but this isn't the reason the theatre atmosphere is tense.

We are all uncomfortable because our patient is a 12-year-old girl. I'll let that sink in a bit. At 12 years old, Mbali (not her real name) is about to have a baby and we are performing her caesarean section.

Caesarean sections are only recommended for women for whom pregnancy or a vaginal delivery poses a risk to them or, secondly, their child. It's better for women without risk factors to try giving birth naturally before making the decision to undergo a caesarean section.

In a public hospital setting, delivering naturally usually means sharing a small space with other women in labour with limited privacy and family visits. It also means repeated vaginal examinations by medical staff trying to assess a patient's progress during labour. Most women have no choice but to accept this reality, and some are more cooperative than others.

Innocent and seemingly unprepared, Mbali was completely out of place in our labour ward. She screamed violently and refused to let anyone near her whenever nurses approached to exam her pelvis. After efforts to explain to Mbali that examinations were part of the process failed, a senior doctor made the decision to deliver her by caesarean section and spare her further trauma.

Mbali was alone in the hospital and didn't have anyone who could consent to the procedure for her so our hospital manager did it on her behalf. As we prepared her for theatre, we tried to explain what the surgery would entail by using words a child would understand. She appeared unphased as we described that an injection in her back would make her lose feeling in her legs for a few hours while we cut open her abdomen to take out the baby.

Mbali kept quiet throughout the procedure, responding only in monosyllables to our questions. Afterwards, the familiar practice of showing the baby to the mother upon delivery and joyfully shouting, "It's a girl/boy!" just felt strange.

Everyone who encountered Mbali in our ward wanted to know what happened to her and how she got there. Mbali lives with her father and stepmother, and her biological mother was not part of her life.

The father of her baby is her 14-year-old boyfriend who attends the same rural primary school as she does. His mother had agreed to care for the baby. They were just kids having sex and now they were going to be parents.

Trying to figure out how Mbali, the child, and her full term pregnancy came to be lying naked and alone on the operating table depends on how far back you're willing to go. Did it start with her family dynamics and the absence of a strong female role model? Is it because of her rural upbringing with all its associated problems relating to poor quality education and access to services, especially for young women? Don’t think it’s because she's black because we also did a caesarean section on a 14- year-old white girl, except she had her father in theatre during the operation.

We certainly shouldn't blame the 14-year-old boyfriend because he's also a child and a victim of circumstances, but where did they learn about sex without learning about condoms, HIV, sexually transmitted infections and pregnancy?

The sad reality for many rural girls like Mbali is that many only get access to proper contraception and counselling when they arrive at hospital during their first pregnancy - and it's not always to deliver. Sometimes they come to us bleeding from a miscarriage, suffering from a life-threatening condition like eclampsia or septic from a failed abortion by an illegal provider.

Nationally, health facilities are seeing a decrease in the percentage of babies born to mothers under the age of 18 years, but teen pregnancy rates are still high. About one in every 14 births in our health facilities involve underage mums, according to Health Systems Trust's latest District Health Barometer. The barometer notes that rates of teen pregnancies are highest among the country's poorest districts, and that the gap between these rates and those in the country's wealthiest districts continues to grow.

Judging by Mbali's naivety, I can only imagine that she didn't know what was happening to her until she felt something moving inside her. We can be thankful that she finally made it to our hospital where she was treated by qualified staff in a safe environment and that she didn't end up in the hands of someone providing backstreet abortions or being given the herbal concoction known as "isihlambezo" used to induce labour at home.

When I think about Mbali, I still feel uncomfortable. I doubt any of us who were present that day could rationalise a child having a baby. No child should ever have to do that.

Mbali's life will never be the same, her childhood is over and even if she does for a moment manage to forget the memory of carrying a baby to term, her scarred abdomen will be a constant reminder.

As long as children in the country’s poorest areas are the last in line get access to contraception and condoms and policies aimed at increasing access to safer sex, health care workers and the system, in general, must be better prepared to deal with "paediatric deliveries". DM

Photo: Children's dolls lie on a bed at a pre-school in Cape Town's Khayelitsha township February 17, 2010. REUTERS/Finbarr O'Reilly.