IT NEVER RAINS BUT IT POURS

Its rainy season here in Malawi. It rains nearly everyday and pours nearly every night. The beautiful tropical trees, plants and flowers are thriving , the mountains look glorious, the river is full, has even burst its banks rushing frantically through the old centre of Lilongwe.No one can remember seeing the river quite like this. Everywhere is muddy, unbelievably muddy. It is almost better to go without shoes and just wash your feet.Well at least that's what Lucas thinks!

There is water everywhere. Huge muddy puddles . Suprisingly deep potholes in the road that appear in the most unexpected places..I'm sure that wasn't there yesterday? (Unfortunately I don't have a large 4 wheel drive car) Slippery slidey paths and umbrellas by the score.Have you ever seen a town full of people riding their bicycles protecting themselves from the rain with vast and highly coloured umbrellas?



But at Bwaila hospital we have now been 36hours without a drop of water. Now that really is hard to imagine, especially for those of you who work in the hospital service.

No water for drinking.. most of our women will not be able to afford to buy bottled water.No water for washing. After having a baby there is no way to clean the mother nor in the postnatal period. No water for staff hygiene. How to protect oneself? How to protect the women?

We have been cleaning our hands as best we can with white spirit or meths. No water for washing floors .No water for washing beds between patients. Birthing a baby can be a pretty messy business without suitable materiales ..blood, faeces, urine, amniotic liquid, all manner of bodily fluids and no means of clearing it up. The few sheets that are provided by the hospital are all used up and of course no clothes washing can be done. This is smelly and uncomfortable. But this afternoon our operating theatre closed indefinitly. This is desperate.There are no clean or sterilised drapes or theatre clothes, instruments cannot be washed for sterilising, it cannot function. This means that all c.sections, haemorrages or any other emergencies will be transferred to the nearest hospital which is 4km away with just one ambulance if it works, if its available and weather and traffic permitting. Women will die today, tonight and untill normal water services can be resumed.We have not been told when that will be.



This morning I arrived at Bwaila as usual at 7.15am. I enter the labour ward with the usual feeling of dread as to what will await me this morning after the long and busy night shift. What needs to be attended to first, to be sorted out when day staff arrive? What and who? for these are women and babies.

Oh no! not another fetal death! Alive on admission at 3.30am... no fetal heart heard at 6.30 am.

Whatever happened in that time? Why has this baby died?

I look at her labour chart and once again it springs to my mind what they say in our favourite film..Pirates of the Carribean... THESE ARE NOT RULES THEY ARE GUIDELINES

Guidelines means thought and assesment.

Guidelines means each women is different and individual and should be treated that way

Guidelines means taking responsibility

Guidelines means being interested in outcome

Guidelines means caring

RULES are easy to follow...blindly, religiously, without thought, with no sense nor common sense, no ability to see the wider picture, just obey the rules and if it goes wrong its not my fault!

So the rules were obeyed and the baby died.

I cried, I cry now as I write this .

Such a sensless loss.That was a mothers baby, a fathers child , a grannies grandchild, that child was loved. That child is no more and all because of rules... OK the rules aren't to blame. So some one please help these poor overworked, underpaid, exhausted , well meaning" carers " to use them as guidelines...........

I PROMISE I WILL TRY..................



Her first baby had beeen born by c.section. I found her fully dilated and ready to push. "Please let her birth this dead baby without more surgery" She had little or no contractions, without help it would not work. The rules are.. no drugs for labour enhancement with a uterine scar, (this can be potencially dangerous but is widely used in western hospitals under close supervision.) I approached the senior obstetrician. I asked her under what circumstances would she be prepared to use this drug on a previous c.section? She replied that if I was to take care and responsibilty for this woman, at no time passing her care to anyone else she would permit this. YES ! Now we were working with guidelines!
This poor, lovely woman went on to birth her stillborn infant with Oxytocin and without surgery. I recieved her little girl onto the bed , dried her off and wrapped her in her brand new 'chitenge'(This is the colourful material that the women use for everything.Skirts, dresses, wraps for babies and children, for carrying them on thier backs and many other uses.) Even the poorest manage to buy or be given a special new one for their new baby. She cried and I cried as she held the little one in her arms and said goodbye.

Last night I couldn't sleep.
I was wondering if water services had been resumed ? How had they managed during the rest of the afternoon ? Had there been any disasters ? When I left we were running out of clean instruments in labour ward.The last birth I attended before going off duty had been with one plastic cord clamp, one piece of wide cotton thread and a razor blade.

Today is my day off. I needed to call in this morning to find out if the water supply was back on. I was not sure what I could do or how I could help if not, but was unable to go off for the day knowing how terrible the situation could be. The water supply had been resumed sometime during the night.
Thankyou, thankyou, thankyou.
But it had not been without incidence. As they were getting three women ready to transfer to another hospital for c.sections,for various reasons, all with some degree of urgency, the breech baby started coming.There was no stopping things, no time for the ambulance. The head got stuck, as they had rightly diagnosed it would and with a snap of the neck the baby died.
Just one more casuality at Bwaila.
Why ? Because they are poor, very, very poor and they are women.They have no voice.
WE MUST BE THEIR VOICE.

WE ARE HAPPY HERE.

We are happy here. There are some very difficult moments, which tend to be connected to work.. but life in Malawi is all that I expected it to be and more. There is an underlying British feeling from those not so distant colonial days and although any show of superiorism on our part is totally unacceptable to me it does make me feel there is something familiar here, something I understand and in general feel liked and accepted.

Lucas has settled well into the European school. The system is very different from Spain but it seems to suit him well. For the first time in his life he actually enjoys reading. He has made many friends and will go anywhere, with anyone.....especially if they have a treehouse in their garden!

Last week I received a mail from wonderful couple who I had accompanied throughout their whole pregnancy. Monthly antenatal visits, then weekly ante natal classes . One day they arrived at the hospital where I was working in Spain ... just one week past the due date ...just for a check up...I could not hear the baby's heartbeat. Their little girl had died before she had been born. Such a heart breaking moment, such pain, tears, questions, such loss. Loss of a child, loss of a dream, loss of a future with that little one.How to explain with no explanation.
They still have that pain, they still feel that loss....I still feel sad.

Babies are dying daily at Bwaila. I am attending births and deaths. I can't even remember the face or the name of every mother who has lost her baby during my short time here. Does she grieve less? Is her pain any less? Does she really accept that loss more easily than my European mums ? Is that baby really less precious because it was born at Bwaila? I think not.... Babies that are born prem, babies from mothers that have not had adequate care. Babies that would have lived if they had been born in Spain , in UK, in the developed world. Just to be born in Malawi means you only have a chance if things go well if you're in the right place. Bwaila hospital is the referral hospital for the poorest of the community, Bwaila is the right place in Lilongwe, in this part of Malawi, but weak, prem,distressed, uncared for babies, have little chance.

Without entering into all the details.. on Tuesday a very young mother lost her baby due to birth asphyxia. One hour later I heard the most awful wailing as another mother, having left her baby on the bed whilst showering, returned to find her baby gone..disappeared! The child was found ..she had been taken by the one whose baby had died. The police ,the recriminations, such a terrible thing to do... BUT maybe in her desperate grief she looked for another to love, to care for, her mind was confused with grief, she did a terrible thing to steal anothers child BUT where is the counselling, the psycological help, the understanding? For her just a police cell only 2 hours after loosing her first child.

My 28 week prem died 5 days later. I thought it was too good to be true. No neonatal unit to help him on his way, just a mum sitting on the floor of the nursery manually expressing her milk and dripping it into his open mouth as he got weaker and weaker. A few..very few.. caring nurses ...no neonatologists....who with no equipment and little materiales, could only stand by helplessly and watch. I call into the nursery every day to see how the babies that I have sent are getting on. Some days the news is good, they have been discharged home. At least for now . Other days I find out that the little one has not survived . It makes me sad. I dont want to "get used" to this. This is not acceptable.

But all is not sad, all is not terrible, maybe you just need to bear with me for a few weeks untill this need I have to talk about these injusticies, to make you all realize what is going on, is not so strong.....or maybe I should never loose that need? Maybe I don't want to loose it? Because that would mean I accept it and I will never accept this.

Today I looked after a young mum ..they are nearly all young...first baby. It was a lovely birth she was so happy she smiled , she thanked me .. " zicomo, zicomo kwambiri" she so loved her baby and she showed it.
It is unusual for the mothers show their emotions when they receive their babies , so when it happens it is really rather special. I also "caught" two more babies. It is not unusual to turn round from the woman you are attending to see a baby's head emerging in the bed opposite! Just a quick change of gloves and another little one is born.

Iwas able to bring a number of nurses/doctors uniforms and white coats from Spain that had been donated to me . I am now well sought after as staff arrive from all over the hospital to be fitted.
Unfortunately there are many rather portly midwives ..I call them "GRAND LADIES" who just dont fit in . I am actually trying to give only to the labour ward midwives in the hope that a pair of trousers will enable to get down to the woman's level even if it is on the floor and attend vertical birth....but that might take a little more time yet!!!!

I'M TIRED, MY LEGS ACHE, MY HEART ACHES

I have spent most of the past 4 days in Bwaila hospital on the labour ward. Starting at 7.15 in the morning and continuing until 5 or 6 o'clock in the evening almost without a break. Drinking fruit juice to keep going and wondering how to slow down.

So many women to attend, so few of us to care for them. I want... I need... to give them of my best but how can I give more? How can I give what is needed? It is every one of those women´s right to be given the very best of care but we just can't physically do it. How can I divide myself into so many parts? How can I attend them all? I have no answer. I am trying to learn what to do, how to cope, what are my priorities? If I give more to one, if I give the right amount to one, then others will have little or nothing. So what will it be? A little here and a little there just the minimum so as to keep them safe and healthy... if I am lucky or if they are lucky.

There is an overwhelming amount of work, more than when I was here 14 months ago and such a huge lack of midwives, of trained and particularly, experienced staff.

Most days I will attend 5 or 6 births as well as helping out other midwives and students. They are not easy. Many complications such as prem babies, unhealthy mothers, difficult labour, too long or often too short. Born in the parking area, in the ambulance bringing them from the villages. They are already high risk pregnancies, already problematic. I have often been called to receive babies in theatre who have been born by cesarean section. That has been particularly traumatic for me as most women arrive in the operating room very late when all else has failed. This generally means that the baby will be born in poor condition and needing resuscitation. This is the job of the midwife. The delay in getting them born, for all sorts of reasons (only one theatre, the aneathetist may not be on site, the already overworked doctors are not available) means many of these babies will need to be very stong and determined if they are to pull through. I have been amazed at their strength, their will to live and have also been saddened when despite all efforts it just doesn't work.

At the end of my first shift on Monday a young mother was wheeled into the labour room. Very few arrive in this way, most will walk in even if " pushing." There was blood running down here legs and onto the floor. I took her to an empty bed so she could lie down. Wrapped up in coloured cloths held in her lap was a timy prem baby. The cord was still not cut, the placenta was still inside and she was bleeding. I ran to find a delivery pack (which if you are lucky consists of 2 clamps and some rusty scissors... though more often than not there are no scissors) and called to a colleague to attend the mother whilst I took the baby. I could see that it was not more than 28 or 30 weeks gestation. I cut the cord and rushed to the resusitating cot. There was no heart beat no signs of breathing. When had this baby been born? How long had it been in this state? I had no idea... so I gave it a go. Cardiac massage, inflating its little lungs with oxygen, drying it off and warming it up. It started to give a few gasps, little by little showing signs of breathing so I carried on. How long for? Could it really make it? I had no idea. One of the Malawi midwives came to see. She said it was a fighter, that it would make it! I couldn't believe it. I took the little one to the nursery and went back to labour ward to care for the mum and tell her that the little one was waiting for her. Does it really have a chance? It still has a long way to go. And back to what? Two days later I called in to the nursery. Yes it was a fighter and is doing ok... not well just ok. The baby has no name but his mum Soflet gave me hug and we said we would keep in touch.

It is early days still. I have some good stories and some bad ones. But SO REAL, JUST SO REAL.

This is life at its most basic. They say that the moment of birth is a moment that hovers between life and death but never so much as here in Bwaila hospital... in Malawi.

WE´VE ARRIVED

I really did try to find time before we left to write, but it proved to be impossible. There was so much to do in the weeks leading up to our departure and then with Christmas, saying goodbyes, and trying to leave things more or less organized... well here I am now and we have arrived!

My reasons for choosing to fly with Kenya Airways through Nairobi were good. Apart from it being a fairly direct route and a good price Kenya has been considered one of the more stable... polictically speaking... countries of Africa. That was up until a week or so before we left when as you know it all changed. The last days were rather tense, family and friends feared for our safety I tried to remain calm and confident. We would be fine, the airline would not put us in a high risk situation and so it was on Saturday 5th we flew from Valencia to London , Nairobo, Lusaka and finally arrived in Lilongwe at luchtime on Sunday.

Saying goodbye to my children was the hardest. They are great and supportive and I am confident in their love.

It was a long tiring journey we ate, slept and made friends. Lucas was great... he arrived with so much pent up energy my first stop was to find open space to run, to jump, to shout we had arrived !
It was not difficult. Malawi is a land of open spaces, lush and green at this time of year... just beautiful. We have arrived in the rainy season, warm temperatures but not too hot... humidity but not too wet.

A chance meeting on the plane provided us and our luggage with a
lift from the airport into Lilongwe, to Tareks house, where we had stayed on our previous visit. Lucas jumped out of the car at the gate a threw his arms around Peter, the security guy. He obviously has good memories. He ran down the garden to find Kela his young Malawian friend a whilst I was warmly received by Tarek and Lara he went off to explore. As I sat at the table exchanging news I felt as if I had never been away.

Later Tarek took us to what was to be our new house. This was important for me, for us both, a place we could really call home. I needn´t have worried, it is perfect. Small but adequate, just 2 bedrooms, lounge, kitchen and bathroom but it has a spacious feeling about it. Clean and simple we immediatly felt good and started to unpack. Tarek and Lara had supplied us with a huge basket of groceries. This was an amazing gesture and greatly appreciated. The compound consists of 8 small dwellings with garden. It is walled with security guys 24hours. It is not a dangerous country but with such huge poverty, is it suprising that men may rob or attack to feed themselves or their children?
We feel safe, protected and cared for. Our washing, ironing, cleaning, is all part of this and this morning I came out to find my car had been cleaned too!! It takes a bit of getting used to but we dont take things for granted and having learnt our first words of Chichewa we are able to say : zicomo : thankyou for everything.

This first week has been spent sorting ourselves out.We now have a hire car... very important as the distances from one side of town to the other are too great to walk. Well at least for us the local oeople have no choice. There has been no petrol to be bought since I arrived so I have tried to be careful in fear of running out in the middle of nowhere! I now have a working mobile phone. Well at least it works locally I have not had much success phoning home. The land lines are either not working or maybe you just get lucky and get through. They tell me this is normal in the rainy season... help this could go on till March! I would like to hear my childrens voices.

Lucas started school on Thursday. He loved it! He came home the first day with a birthday party invitation. Mums are allowed to go too! The English is will not be a problem they will give him extra help. He bought home library books yesterday. It was the first time in his life he enjoyed reading.

I popped into the hospital twice to make contact. I will start work on Monday. I am pleased that Doreen the wife of Tareks home help will look after Lucas after school until I get home. School hours are 7.15 till 12.15 ... mornings. She is a lovely lady I trust her and she will bring Kela with her to play with Lucas.

Nothing much had changed in the hospital.
As I walked along the corridors to the labour ward, avoiding standing on the women and children sitting on the floor filling every small space. Waiting to be seen. Labouring quietly until there became a free bed. I realized that I had already accepted that this is how it is, it didnt suprise me, I wasnt upset.

THIS IS NOT HOW IT SHOULD BE .....THIS IS NOT ACCEPTABLE.