Rom i herberget

Alle kjenner historien om Jesu’ fødsel, og hvordan Jomfru Maria og hennes Josef trålet Betlehems gater etter en barselseng, men stadig fikk nei. Stallen og krybben ble redningen, men historien kunne i dag fått en annen vri om de hadde snudd nesen 80 kilometer nordover mot Nablus.

På Rafidia Hospital i Nablus består andreetasjen av en avdeling for obstetrikk og gynekologi, en gynekologisk poliklinikk, og en avdeling for pediatri. Felles for de tre postene er at de vedrører det vi kaller mor-barn-helse.

Fødestuen har et felles rom med fire barselsenger, kun separert av innskutte vegger og plastforheng. Å ligge i barsel her betyr altså at du hører alt som skjer i nabosengene. Mors skrik, barnegråt, sykepleiernes samtaler. Det hele oppleves noe kaotisk, selv om det er tydelig at jordmødre og sykepleiere har rutiner som vedlikeholder systemet. I disse fire sengene fødes det mellom fem- og seks hundre babyer månedlig. Det betyr i snitt litt mer enn 4,5 fødsler i hver seng om dagen.

Fødeavdeling og avdelingssykepleier. Barna tas fra mor like etter fødsel for å varmes under lampen til høyre.

Skulle Jomfru Maria født her, hadde sikkert det effektive helsepersonellet funnet plass til henne, men hun hadde neppe fått hvilt så lenge etterpå. Gjennomsnittlig liggetid for vaginalt fødende mødre er 6-12 timer her, og jeg ser flere ferske mødre som gråter eller skjærer grimaser i det de stotrer seg ned trappene med sin nyfødte. Gynekologen doktor Kaseem ved Rafidia sier at sykehuset er fullstendig klar over at retningslinjene anmoder 1-3 dagers liggetid, i sær for førstegangsfødende, men at pågangen er så stor at dette ikke kan opprettholdes. Derfor sendes mødre hjem så fort man anser det som nogenlunde forsvarlig.  Snittalderen for de førstegangsfødende her er 20-21, og på Vestbredden er fødselsraten 3,27 barn per kvinne.

Her fødes det alltid uten epidural, og familiemedlemmer får ikke være med inn. Flere fødende er redde og har ingen å snakke med om det underveis.

Skulle noen tatt keisersnitt her, ville ikke mors ønske vært tilstrekkelig indikasjon alene for dette. Indikasjoner for keisersnitt her er føtalt stress, tidligere keisersnitt eller vanskelig fødsel, forklarer Dr. Kareem meg. Det gjennomføres 33 keisersnitt på avdelingen månedlig, og kvinner får ligge i snitt 24 timer etter fødsel. Ved denne typen fødsel anbefales en ukes liggetid, grunnet økt risiko for komplikasjoner hos både mor og barn. En spesiell senkomplikasjon vi fikk se, var uttagning av en såkalt Cesarian Scar Pregnancy, der et nytt befruktet egg har vokst i arret fra en tidligere graviditet. Dette er svært sjeldent, men har høy dødelighet grunnet økt blødningsrisiko.

Dagens andre keisersnitt på avdelingen.

Maternal dødelighetsrate for hele Palestina er 42 dødsfall per 100 000 levende fødsler, til sammenligning ligger den på 5/100 000 i både Norge og Israel. WHO-rapporten sitert ovenfor, forklarer også at blant årsakene til den høye mødredødligheten er redusert tilgang på reproduktiv helsehjelp og familieplanleggingshjelp. Dette står også på Norpal sine hjemmesider, og doktor Kaseem bekrefter at tilgangen på helseutstyr er begrenset.

Sykehusdirektøren ved Rafidia, doktor Qasem Daghlas, forklarer at det er økonomiske begrensninger som ligger til grunn for utstyrs- og plassmangel. Rafidia har 200 sengeplasser, og er sentralsykehus for en million mennesker i nord-Palestina. Da er indremedisin ekskludert, som henvises til det andre store sykehuset i Nablus, Watani. Rafidia er et av fem sentralsykehus på Vestbredden. I tillegg er det 175 leger og 350 sykepleiere som arbeider her, som i følge direktøren er et optimalt personaltall gitt situasjonen.

NorPal møter sykehusdirektør Dr. Qasem

Dr Qasem sier at Israel nekter import av PET-scannere grunnet radioaktivt materiale i maskinene, men ellers har man frihet til å hente det meste. Hovedproblemet er at sykehuset ikke har råd til nytt utstyr, og at mange operative maskiner er utdatert.

Eksempelvis er mange av inkubatorene på nyfødt-intensiven gamle og slitte. Her ligger opptil 34 for tidlig fødte barn med pustehjelp, og det er den største avdelingen av sitt slag i Palestina. Turnuslege Dr Abdul Kareem Saymeh forklarer meg at sammen med pediatrisk avdeling sine 30 senger skal disse to avdelingene betjene 150 000 barn på den nordlige Vestbredden. Det vanligste sykdomsbildet er luftveisproblemer og magetrøbbel. Til sistnevnte gruppe gir de ikke antibiotika, men mange mødre kan vise oss utskrivningsnotater med antibiotikaresept for diffuse sykdomsbilder. Dette kan ha sammenheng med at barn skrives ut for tidlig i blant, som turnuslegen vedkjenner at skjer grunnet det høye presset på avdelingen.

Isolat på pediatrisk avdeling. De vanlige rommene har 6 senger.

Så hvilken helsehjelp kunne den hellige jomfruen, eller stylingeksperten forventet seg her? Jeg har møtt svært effektive avdelinger, som gjør mye ut av få ressurser. En konsekvens blir at enkeltpasienten får mindre tid og lever med større risiko for komplikasjoner, antibiotika-assosierte sykdommer og misforståelser. Samtidig opplever jeg leger og pleiere som svært profesjonelt, og tror dette er den største styrken i det palestinske helsevesenet.

Her kan man dessverre ikke stille store krav, men må være takknemlige for den hjelpen man får og høre på faglige råd. Flere leger som arbeider her forklarer meg at de kunne tjent bedre utenlands, men at det ikke gir mening å jobbe andre steder enn i Palestina. De går opp til 30 timers skift, og brenner for pasientene sine.

På vei inn til en ny dag på Rafidia. Morgenmøtet er klokken åtte.

Å få lære om medisin og helsearbeid her, tvinger meg til å se hvor priviligerte vi er som har det norske helsevesenet. Det finnes så klart begrensninger hjemme også, men det er lett å bli flau over debatter om taxipenger ved utskrivning når jeg ser mødre som gråter fordi de må forlate avdelingen seks timer etter å ha født, helt for egen maskin. Jeg er takknemlig for muligheten til å lære på Rafidia og for møtene med tøffe pasienter og hardtarbeidende personale.

Hilsen Audun!

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