{"id":156928,"date":"2020-07-08T14:16:46","date_gmt":"2020-07-08T18:16:46","guid":{"rendered":"https:\/\/www.bu.edu\/sph\/?p=156928"},"modified":"2020-09-17T10:32:14","modified_gmt":"2020-09-17T14:32:14","slug":"looking-for-the-mothers-connecting-bereaved-parents-with-grief-counselors-in-zambia","status":"publish","type":"bu-article","link":"https:\/\/www.bu.edu\/sph\/news\/articles\/2020\/looking-for-the-mothers-connecting-bereaved-parents-with-grief-counselors-in-zambia\/","title":{"rendered":"Looking for the Mothers: Grief Counselors in Zambia Trying to Connect with Bereaved Parents"},"content":{"rendered":"
\n\r\nThe back door of the morgue at University Teaching Hospital in Lusaka, Zambia. “BID” stands for “brought in dead.”<\/span>\n<\/div>\n\n

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July 8, 2020<\/div>\n\t\t\n\t\t\t\t
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A version of this article originally appeared in Faculty Opinions Blog<\/a>.<\/em><\/p>\n

\u201cHow many this weekend?\u201d Magda Mwale asks. She is in Lusaka, Zambia, standing in a small lab behind the University Teaching Hospital morgue with her\u00a0colleagues Ruth\u00a0Nakazwe\u00a0and Chilufya Chikoti.\u00a0\u201cNine,\u201d\u00a0Ruth\u00a0responds. Nine babies. It seems like a small number, but not when they are dead.\u00a0Then\u00a0every one\u00a0is a heavy\u00a0and urgently felt\u00a0burden.\u00a0\u201cNine too many,\u201d\u00a0Mwale\u00a0responds.<\/p>\n

A similar conversation occurs\u00a0here daily. You might expect the daily evidence of loss to numb\u00a0Mwale\u00a0and her colleagues,\u00a0build\u00a0a protective shield of compassion fatigue. But the opposite is true. During the brief, solemn pause in the\u00a0conversation,\u00a0everyone gives themselves a mental\u00a0and emotional\u00a0shake.\u00a0A mother and father loved each of these babies. Somewhere in Lusaka,\u00a0they\u00a0are reeling.<\/p>\n

Mwale\u00a0is a grief counselor based in the morgue, offering a service much needed but rarely available in Zambia. She\u00a0also\u00a0leads a team of four other counselors who are collecting data for a post-mortem study focused on infants who die in their first six months of life. The\u00a0Zambia Pertussis\/RSV Infant Mortality Estimation\u00a0Study\u00a0(also known as ZPRIME)\u00a0set out in 2017, with funding from the Bill and Melinda Gates Foundation,\u00a0to swab the nose of\u00a0every infant in Lusaka who dies between the ages of 4 days and 6 months.<\/p>\n

What did they\u00a0die from? That\u2019s the question the Zambia team and Christopher Gill<\/a>, an infectious disease physician and associate professor of global health at the Boston University School of Public Health, are trying to answer. They want to know how many of these babies die with pertussis and respiratory syncytial virus, better known, respectively, as whooping cough and RSV. So far, less than one percent of\u00a0the babies enrolled in the study have\u00a0pertussis. But 10 percent\u00a0have\u00a0tested positive for RSV\u00a0which comes in seasonal waves.<\/p>\n

Enroll 3000 dead babies, swab their noses, and wait for the lab results. The study, according to Gill, is a simple matter of counting. The\u00a0challenges are\u00a0emotional and logistical. \u201cWe have to enroll children and get consent from parents on the worst day of their lives,\u201d he says. \u201cTheir child has just died. This is not a particularly good time to be talking about a research study.\u201d<\/p>\n

Gill,\u00a0Mwale, and the rest of the Zambia team knew they had to put empathy first in their effort to bridge cold science and human compassion. In consultation with Dr. Angel\u00a0Chirwa,\u00a0a psychiatrist based at University Teaching Hospital,\u00a0they developed a detailed grief counseling\u00a0protocol\u00a0and script to structure their conversations with family members.<\/p>\n

The painted sign over the morgue intake door is unflinching: BID, Brought in Dead. Families come to the low-slung concrete building to make funeral arrangements and lovingly wash the\u00a0bodies of their dead.\u00a0Huddled groups\u00a0of women wearing white\u00a0support relatives sagging from the blow of loss. The air vibrates with emotion and activity. Wailing, singing, praying, drumming, laughing. Lives\u00a0celebrated and mourned. Halfway up the long driveway lined with flower merchants and funeral kiosks someone has painted \u201csuffering tree\u201d in black on the stone wall. Extended families on their way to burials wait in the beds of white pick-up trucks for a coffin to slide into their midst. Everything about the place defies euphemism.<\/p>\n

\u201cHe\u00a0didn\u2019t want to come in,\u201d\u00a0Mwale\u00a0says,\u00a0describing\u00a0a conversation\u00a0she just had with a father\u00a0whose baby died the day before. \u201cThe grandparents were here to collect the baby and he was waiting\u00a0by the truck.\u00a0I\u00a0convinced him to come\u00a0see\u00a0her\u00a0one last time. He took\u00a0her\u00a0in his arms and started to cry.\u201d<\/p>\n

Funerals in Zambia are important. Typically,\u00a0they\u00a0last up to a week and are a primary means of processing grief. Relatives travel long distances to close in around those left\u00a0behind and carry them through. But support for parents who lose\u00a0very young\u00a0babies is muted and pragmatic. No one gathers.\u00a0No\u00a0church service\u00a0precedes the\u00a0burial. Mothers are kept away.\u00a0Couples temporarily separate. Mothers often return to their parents\u2019 home for cleansing rituals that can last weeks.<\/p>\n

Fathers\u00a0also stay on the periphery. Those who come to the morgue tend to\u00a0linger\u00a0outside. \u201cI encourage them to come in to say goodbye,\u201d\u00a0Mwale\u00a0says, \u201cto even touch the foot or hand.\u201d Mothers are rarely afforded such opportunities<\/p>\n

Families are distraught,\u00a0rushing\u00a0to pick up the body, prepare it, and get to the graveyard. Sometimes they are angry. They blame the hospital or suspect malfeasance. Sometimes\u00a0they\u00a0lash out at\u00a0the person in a white coat asking to talk to them.<\/p>\n

\u201cOur role is to bring empathy and remain neutral,\u201d\u00a0explains Charles\u00a0Chimoga,\u00a0who has\u00a0many years of experience doing post-mortem studies. \u201cSometimes grieving family members are angry and\u00a0blame\u00a0medical staff for the death,\u201d he says. \u201cThey sometimes say that we are just sitting there waiting for dead babies to test. That what we are doing now should have been done when the baby was still alive. We\u00a0do not\u00a0react\u00a0or get defensive. We listen,\u00a0empathize, and\u00a0explain\u00a0that\u00a0what we are doing is unconnected to\u00a0the child\u2019s death. If they don\u2019t believe us we don\u2019t push. We continue to offer\u00a0emotional support.\u201d<\/p>\n

Approaching families to offer condolences and explain the study is a delicate, intricate interaction.\u00a0If the family agrees to participate, the counsellors ask for consent\u00a0to swab their baby\u2019s nose.\u00a0For infants who die at home or\u00a0en\u00a0route to the hospital, they\u00a0also record death narratives,\u00a0known as verbal autopsies, about the events leading up to the\u00a0final breath.\u00a0Mostly families\u00a0are willing to participate as long as the process doesn\u2019t take more than a few minutes. (The consent rate hovers around 85 percent.)\u00a0If a family does not\u00a0consent, counselors continue the conversation\u00a0as long\u00a0relatives want to talk.<\/p>\n

Nine babies this weekend. Four on Monday. Two on Tuesday. Three on Wednesday. Five on Thursday. Twenty to thirty dead babies each week. As the\u00a0number of samples clicks\u00a0unrelentingly\u00a0upward, these grief\u00a0counselors-cum-researchers\u00a0feel compelled to do more.<\/p>\n

\"AThe few moments of comforting talk\u00a0with extended family members\u00a0under a shady canopy behind the BID\u00a0are\u00a0not enough.\u00a0The team knows parents ache out of sight,\u00a0just beyond their reach. Culture and pragmatic resignation create formidable impediments to connecting with bereaved mothers and fathers.<\/p>\n

Zambian cultural traditions prohibit parents from openly mourning very young babies, this is especially true for young, first-time mothers.\u00a0Nothing good, mothers are told, will come of dwelling too long and too openly on the baby who has died. Showing and holding too much sorrow for the\u00a0one\u00a0who has left\u00a0can\u00a0block another from coming. \u201cWe have an inner belting that allows us to not be expressive,\u201d\u00a0Mwale\u00a0says.<\/p>\n

Infant mortality statistics hint\u00a0at the reason for this learned emotional restraint.\u00a0Forty-five of every 1000 babies born alive<\/a>\u00a0in Zambia die before their first birthday. Forty-five is an ongoing travesty, especially when compared to\u00a06 in 1000 in the US or 0.7 in Iceland<\/a>. But it\u2019s also an achievement, down from 109 in 1996.<\/p>\n

Despite the progress, the unfair truth remains:\u00a0Zambian women cannot be surprised when their babies die. But grim statistics\u00a0do not\u00a0reduce the pain. On the contrary, the death of a child adds grief to the mountain of other stressors created by poverty. Vulnerability begets\u00a0vulnerability. The parents of the babies enrolled in the ZPRIME study are often young, many just teenagers\u00a0from the poorest parts of Lusaka. Some mothers are already experiencing\u00a0post-partum\u00a0depression, compounded by grief and,\u00a0possibly,\u00a0feelings of guilt.<\/p>\n

The grandmothers and aunties who come to the BID assure the counseling team that the bereaved mother will get over her loss quickly with family support. The team expects this answer, but they know\u00a0emotional responses are being stifled by well-meaning elders. Young mothers who show their devastation are quickly hushed by older women who buried their own babies long\u00a0ago. Who had even more reason to expect death to come in the night in the form of diarrhea, pneumonia, malaria, or for no apparent reason at all.<\/p>\n

These traditions likely began as a form of protection, a sanctuary from grief,\u00a0and a road map for moving on. But they also isolate young mothers and fathers and\u00a0can\u00a0deepen pain rather than healing it.<\/p>\n

\u201cFor the mother, the story behind the pregnancy,\u00a0emotions,\u00a0and feelings of attachment to her child are ignored,\u201d\u00a0says\u00a0Chirwa.\u00a0\u201cThe mother must move on very quickly.\u00a0She must not expose herself and her misfortune to the world. The father is often also lost in the equation. It\u2019s life and these things happen.\u201d<\/p>\n

Gertrude\u00a0Munanjala, another member of the counseling team, describes the compound\u00a0trauma of being forced to\u00a0move on too quickly:\u00a0\u201cA baby is a baby. In maternal and child health we start\u00a0counting a baby from the time you conceive.\u00a0You\u2019re pregnant, you\u2019re talking to your baby in the tummy because you believe you are going to have that baby.\u00a0This baby came out, breathed, cried, and you breastfed. That\u2019s a baby. So nothing should stop you from grieving over something you have held in your hand. Something that was growing in me. I have held it in my hands and then it goes away. Please allow me some time to grieve.\u201d<\/p>\n

The team recently started reaching out to parents after the\u00a0child\u2019s burial. Their goal is to give parents an opportunity to express emotions their friends and family have been telling them to hide.\u00a0The counselors understand that the symptoms of complex grief and depression are expressed in many ways. When asked what formal grief counseling offers that the community\u00a0cannot, each counselor\u00a0emphasizes\u00a0the importance of asking bereaved parents specific questions about their sleep, their dreams, whether or not they are eating, their social interactions, and relationship with their spouse.<\/p>\n

\u201cThose institutions like the church, the old women, the uncles,\u00a0the grandmas will not see,\u201d says\u00a0Benard\u00a0Ngoma. \u201cWe see families breaking down. Others where, since the death of the child, the husband and wife are no longer together because they are blaming each other.\u201d Grief counseling, he explains, brings all of this to the surface before it festers and causes greater damage.<\/p>\n

Sometimes opening up is enough. In other situations, counselors\u00a0can\u00a0provide medical referrals.\u00a0This happened in one of\u00a0Munanjala\u2019s\u00a0sessions with a couple who told her that\u00a0they wanted to wait before trying for another baby. She\u00a0referred them to\u00a0a clinic where they could learn about family\u00a0planning options and suggested they go\u00a0together.<\/p>\n

Counseling has been available in a limited way for decades in Zambian healthcare facilities, according to\u00a0Chimoga, who specialized in psychiatry when he was training to become a clinical officer in the 1970s.\u00a0But over the last 20 years HIV care absorbed many\u00a0trained counselors.\u00a0In a context where counselors, psychiatrists, and resources for mental health care are few, helping people move through grief has never been a health system priority.<\/p>\n

The team recently set up a comfortable, quiet counseling room in their office across Nationalist Road from the morgue. And they have begun distributing pamphlets\u00a0about grief counseling describing what it is, how it is useful,\u00a0and\u00a0how to get help. They\u00a0put\u00a0a stack in the neonatal intensive care unit, where half of the babies enrolled in the study die (the other half die at home or on the way to the hospital). In the morgue, they ask family members to take the pamphlet home and let\u00a0bereaved\u00a0parents know that someone will be contacting them. Within a week, the counselors\u00a0call\u00a0parents and invite them to come in for a conversation, on their own or with their\u00a0spouse. The session is free and transportation is reimbursed.<\/p>\n

So far, they have held five counseling sessions. Every week they schedule more, but they have recently had a number of\u00a0clients\u00a0not\u00a0show up, even after confirming\u00a0the appointment.\u00a0The team\u00a0is disappointed, but they are not\u00a0surprised. They\u00a0know\u00a0they are offering a service that can appear culturally counter-intuitive.\u00a0Asking grieving parents to travel to talk about their feelings\u00a0with strangers, they all acknowledge, goes against the grain of quiet fortitude and\u00a0family connection. \u201cIt would be better if the parents met us,\u201d says\u00a0Chimoga.\u00a0\u201cAn emotional bond and trust could be established.\u201d<\/p>\n

Timing is critical. \u201cIf the mother has gone off to her parents\u2019\u00a0house for a month,\u201d\u00a0Chimoga\u00a0says, \u201cand comes back feeling better, we should not interfere.\u201d Offering counseling too late, he explains, runs the risk of reopening wounds that will be even more difficult to heal a second time.\u00a0\u201cIf we can reach the parents within the first week after the baby has died,\u201d he says, \u201cthen we can offer useful support.\u201d<\/p>\n

It\u2019s a fragile balance:\u00a0offering therapy when it can be beneficial,\u00a0recognizing early signs of recovery or\u00a0complex grief, and navigating deeply engrained cultural practices.\u00a0\u201cWe\u00a0are all learning as we go,\u201d says Lawrence\u00a0Mwananyanda,\u00a0ZPRIME\u00a0co-principal\u00a0investigator, who\u00a0oversees the Zambia field operations.<\/p>\n

So\u00a0far\u00a0the team has enrolled over 1500\u00a0infants in the study. Each tiny nose they swab, jolts their sense of urgency. Three\u00a0thousand devastated mothers and fathers\u00a0grieve\u00a0silently. \u201cLooking at the few families or couples I have met at the BID,\u201d says Ngoma, \u201cI can see that a father or mother is going into depression. I will see this mother is not really attended to. You can see that they need help. They don\u2019t come back but we know if they had we could have helped.\u201d<\/p>\n

The team is now looking into the possibility of visiting mourning parents\u00a0at home.\u00a0They think home visits\u00a0will\u00a0inspire trust and willingness to open up.\u00a0As\u00a0evening draws in,\u00a0Chimoga\u00a0and Ngoma walk away from the BID,\u00a0past the suffering tree and the coffin and flower vendors. They are convinced\u00a0that visiting bereaved parents in their homes\u00a0is\u00a0the most culturally appropriate way.\u00a0\u201cAs Africans,\u201d\u00a0Ngoma says, \u201cthis is what we should be doing.\u201d<\/p>\n

Jennifer Beard<\/a> is a clinical associate professor of global health at the School of Public Health and associate editor of Public Health Post<\/a><\/span>.<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

Collecting data at a morgue in Lusaka, the Zambia Pertussis\/RSV Infant Mortality Estimation Study team developed a detailed grief counseling protocol and script to structure their conversations with family members.<\/p>\n","protected":false},"author":14852,"featured_media":169234,"comment_status":"closed","ping_status":"open","template":"","meta":{"bu_prepress_billboard":"","_bu_prepress_primary_term":"","_bu_prepress_primary_term_manual":""},"tags":[2488,2562,3189,1721,506,2166,1871,2530,2305,2536,2529],"bu-publication":[3516],"sphnews-article-category":[3519,3531,3532,3539,3540],"sphnews-topic":[],"bu_edition":[],"media_type":[],"profile_tax":[460],"_links":{"self":[{"href":"https:\/\/www.bu.edu\/sph\/wp-json\/wp\/v2\/bu-article\/156928"}],"collection":[{"href":"https:\/\/www.bu.edu\/sph\/wp-json\/wp\/v2\/bu-article"}],"about":[{"href":"https:\/\/www.bu.edu\/sph\/wp-json\/wp\/v2\/types\/bu-article"}],"author":[{"embeddable":true,"href":"https:\/\/www.bu.edu\/sph\/wp-json\/wp\/v2\/users\/14852"}],"replies":[{"embeddable":true,"href":"https:\/\/www.bu.edu\/sph\/wp-json\/wp\/v2\/comments?post=156928"}],"version-history":[{"count":11,"href":"https:\/\/www.bu.edu\/sph\/wp-json\/wp\/v2\/bu-article\/156928\/revisions"}],"predecessor-version":[{"id":175126,"href":"https:\/\/www.bu.edu\/sph\/wp-json\/wp\/v2\/bu-article\/156928\/revisions\/175126"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.bu.edu\/sph\/wp-json\/wp\/v2\/media\/169234"}],"wp:attachment":[{"href":"https:\/\/www.bu.edu\/sph\/wp-json\/wp\/v2\/media?parent=156928"}],"wp:term":[{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.bu.edu\/sph\/wp-json\/wp\/v2\/tags?post=156928"},{"taxonomy":"bu-publication","embeddable":true,"href":"https:\/\/www.bu.edu\/sph\/wp-json\/wp\/v2\/bu-publication?post=156928"},{"taxonomy":"sphnews-article-category","embeddable":true,"href":"https:\/\/www.bu.edu\/sph\/wp-json\/wp\/v2\/sphnews-article-category?post=156928"},{"taxonomy":"sphnews-topic","embeddable":true,"href":"https:\/\/www.bu.edu\/sph\/wp-json\/wp\/v2\/sphnews-topic?post=156928"},{"taxonomy":"bu_edition","embeddable":true,"href":"https:\/\/www.bu.edu\/sph\/wp-json\/wp\/v2\/bu_edition?post=156928"},{"taxonomy":"media_type","embeddable":true,"href":"https:\/\/www.bu.edu\/sph\/wp-json\/wp\/v2\/media_type?post=156928"},{"taxonomy":"profile_tax","embeddable":true,"href":"https:\/\/www.bu.edu\/sph\/wp-json\/wp\/v2\/profile_tax?post=156928"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}