Thursday, 28 February 2008


As I walked out of the nursery today I wondered how many more tiny lifeless babies would pass through my hands ? How many more mothers I would have to call to tell them that their child had died? Despite the limited care we had given, the time they had spent squeezing their empty breasts for the last drop of milk, their little one just hadn't been strong enough, just didn't have what was necessary. Today it was a young 20 year old mother. Her second pregnancy, her second baby, but nothing to show for it. The first had not survived either. Very tiny, very prem, he didn't really have a chance. The impression is that life is cheap, expectations are low or non existent and another little mound of earth in the village cemetry was was all she had left.

I am amazed each day as I learn more of Malawi, of their ways and of their customs but especially of what they don't have and would never expect. Most of the births will not be registered officially. This means that when they die nor will it be necessary to register the death. Procedure is that the baby's body is wrapped, labelled and put in the hospital fridge. (on labour ward and its generally full) The family will arrange their own funeral with very specific rituals that the older women will pass down to the younger ones. I believe it is for women only, that the men are not present. The child will be collected and a procession will make its way to the cementry, the women carry branches of leafy trees to signify the loss and respectfully all will make way to let them pass. The cementries are easy to recognize as there will be a large number of trees growing there. Each village will have its own area. The baby will be laid to rest with no official recognition that it ever existed.

So this past week has been dominated by the loss of little lives. A baby born with kidney problems lasted just 24 hours. One with a congenital heart defect whom we found impossible to wean off oxygen after more than 10 days just needed a pediatric heart specialist .. in Malawi there are none. (and they certainly dont have the money to be treated elsewhere) Premature babies sometimes weighing less than 1kg. or 1- 1.5kg would survive and thrive in UK, in Spain, in many other countries, but here in Bwaila nursery they have little chance.

40 babies in the nursery. One of the nurses I know has worked more than three 24 hours shifts this week, at night on her own, plus a day shift. The nurses are paid (relatively) well for working extra shifts.Who can blame them for wanting to supplement their meagre earnings. I joke with her that Bwaila nursery is her home that she really doesn't have a home to go to ! I tell her that I don't know how she stays awake to care for the babies. I know she doesn't stay awake. I know their care is minimum and I want her to realize that I know that too. But what will that change? The nurses have to rest but if the babies are not cared for they will die. The matron came to see how they could cover for a nurse who is sick. She must know the situation. Is it really only important to cover the shift without taking into consideration the level of care? I have no answer and the problem is throughout the hospital, throughout health care in Malawi. Today is my day off and I cannot get them out of my head. I know I will have to pass by to see them sometime during today. Who will check if they are feeding ? Who will support the mums and ensure they have enough milk? Who will take the c/section babies to their mothers breast then bring them back? Who will make sure they start antibiotics when necessary or feed the tiny ones regularly through the tube?

As I write I am wondering whether the last remaining triplet born on Monday is still alive. They were born in a health clinic...supposedly a twin pregnancy . Mother and babies were transferred to us several hours later when the placenta had not been expelled. The ambulance took 5 hours to arrive..this is normal, but she arrived in good condition and delivered the placenta without hemorraging. The babies each weighing 1.250g were in good condition, just cold. I warmed them up and gave a litle glucose. The next day...what had happened during the night? It was so sad to see the first one go and then the 2nd one the following day. The mother cried when I placed the 2nd one in her arms. I gave her a hug and told I was sorry, that now she must work hard to express her milk to save her remaining child. I put her on the breast pump twice that day and was pleased to see that by day 3 she had plenty of milk. I hope I made her understand that she must feed her baby every 2-3 hours that she must give it warmth and love. Yesterday as I left she was doing well and the little girl looked strong. The nursery is ripe for cross infection. So many babies in such a small area. The nursery room is like a large incubator with temperatures unbearably high for working in but it is the only way to ensure the babies are kept warm. Sometimes the nurses find it too much and turn off the heaters. Sometimes they forget to turn the heaters back on. I arrive in the morning to find several hypothermic babies. This is definitely not good for these tiny things.

I walked to my car yesterday afternoon to go home, my heart was so heavy, I felt a heaviness throughout my whole body that I did not no how to shift. I felt so helpless, so useless, so hopeless. I could do so much in those 8 hours in nursery, never stopping, never tiring, doing all I could and now what? I saw the grieving mother, I went to her and gave her another hug. There was a cry from the distance and one of my mums came running up to me " see you tomorrow nursey " and gave me a big hug . How could I tell her it is a bank holiday weekend, I need to spend some time with Lucas, with friends, enjoy a trip out ? How can I tell I'm not coming tomorrow?

" Yes nursey see you tomorrow"

Yes I will go by. Yes she will see me today.

My spirits were lifted, I felt some of the heaviness leave me. So that's what Malawi is all about.. those tiny little things that mean so much. It doesn't have to be big, it doesn't have to be clever, it may not move mountains, I can't move mountains but I can feel love, and love will get me by once again. Love of my children, my family, my friends and love of those mothers that come into my care that have so little but give me their love.

Friday, 22 February 2008


I have spent this week working in the Bwaila nursery. It is the referral neonatal care unit for most of Lilongwe and surrounding areas. That means it receives all the sick, premature and low birth weight babies from the largest part of Malawis capital city. There is no neonatal specialist.There is no permanent medical cover. The care is overseen by a very small team of extremely overworked pediatricians covering more than one hospital and not necessarily specializing in neonates. We may receive a short visit from one of them during the morning ..or they just dont come. It is therefore the nurses/midwives who work in the unit who are largely responsible for all the care given and medical decisions. There are, at present, four of these nurses one of whom is not available as she is studying. That means three nurses are covering round the clock 24 hours a day, 7 days a week! Is it suprising then that the care is far from good and sometimes actually missing?
We have limited resources and with no medical presence limited level of care.(eg. no IV drugs or fluids ) Almost no blood tests or other diagnostic means. As I mentioned before they are either strong or lucky.They either get better, more or less on their own, or they die.
The nurses do as much as they can..some are more capable than others. The mothers are very present but need a huge amount of guidance when caring for their tiny baby. Today we had 15 babies weighing less than 1.5kg. and a total of 34 babies. There were just two of us , there would have been one but I was there! The mums express their milk, more or less satisfactorily, pouring it painstakingly into the little open mouths. Sometimes it reminds me of those little birds fallen out of the nest that we used to try and keep alive as children.
Today was weighing day. This occurs 3 times a week. Unfortunately it is more often than not irrelevant as no one bothers to look at the weights to see if they are gaining or loosing. I have not yet found a way of insuring and recording when or if the babies get fed or how much.But I am working on it. It has to be extremely simple and something the mothers can do.The nurse would definitly start off with enthusiasm but quickly give up for lack of time or motivation. I have been watching over the mothers like a hawk and am slowly getting to know which baby belongs to which mother. I am recording how much and how often they feed and giving help and advice on breast feeding and "topping up" with formula, for the mothers who just dont have enough. This is sometimes caused by lack of stimulation. I was amazed to find that several mothers were not feeding their babies at night ! For a 1.2kg baby to go 8 hours without feed is not a good idea!
There is a brand new electric breast pump available which has hardly been used. Today I had the mothers asking to use it as word has got round that it is much easier, less time consuming, and less painful than manual. It really isnt so hard to convince the mothers you just have to want to!
Each day when I arrive I look to see which little one hasnt made it through the night. I am also amazed by their strength and grim determination to hold on and have witnessed some tiny wee scrap pull through start to gain weight and go home. As soon as they start to gain we have to send them home, some are less than 1.8kg.
I wonder what happens when they get home ?
The kangaroo nursery, where the babies are looked after always on top of mum, is highly successful for these small or prem babies, in that it is obviously clear that the method works.
Babies are warmer, happier and gain weight faster. Unfortunately there are only a few mothers who are prepared to devote themselves totally to this type of care. I find that sad and difficult to understand.

I will stay in nursery next week. I am not ready to go. I need to understand more and find some small workable ways to help improve their chances just a little.
Labour ward calls me back, but I have time and feel I should be with the babies a while longer.
Maybe i'll just take them all home with me!!

Monday, 18 February 2008


Just a quickie to let you know that Pirilani was discharged home today. She looked good. She has made a really amazing recovery. The Malawian women are so strong and so powerful. I long for the day that they realize this, that they realize their true worth. The day they find the confidence and strength not to allow themselves to be treated so badly. That believing in themselves and how much they are worth this begins to reflect in their behaviour.
I took the twins to nursery to weigh them before leaving. They both looked good. Pirilani now has a good supply of breast milk so on my recommendation will only supplement with formula when absolutely necessary. The twins had been with her since the 3rd day.This is against the rules but as she was doing so well I decided to plea her case and it was allowed. I was thrilled to find this morning that each one had not only regained its birth weight but weighed 50g more !! This was surely due to being with the mother all the time. It is well recognized that babies cared for in this way thrive and gain weight much better than when separated from their mothers. (kangaroo care)
I said goodbye to them all giving 500kw ( less than 3 euros ) for their bus fare home and promised to go to their village in 2 weeks time to follow up the babies progress. (they live too far away to return to the hospital )

This week I am working in the nursery with the ill, premature and low birth weight babies. I am happy to be there although it is heart breaking to see the little ones who once again will survive if they are strong or if they are lucky...or if their mother wants them......
We are so close to nature here, as in the animal kingdom, the rule is generally ... survival of the fittest. The weak ones have little chance but maybe, just a few of them, with my care, will have a slightly better chance ??

Friday, 15 February 2008


Could a seemingly right decision that turns out wrong, be thus called a wrong decision ?

Or a wrong decision, for turning out right, is therefore right ?

This is where I am this week. Let me explain....

The woman was in labour with a twin pregnancy. Not large babies, no over extended uterus. It was her forth pregnancy .First child born by c/section, no details but didnt survive the neonatal period..probably severe birthing problems .Second and third born normally and still living. Her labour was abnormally violent ..probably as a result of herbal potions that can be bought or obtained just outside the gate of the hospital. These very often cause too many contractions and much too strong right from the begining of labour thus leading to fetal distress and unnecessary pain and suffering for the woman.But African ways and tribal powers are stong and the women are easily influenced. I/we made the decision to try for a vaginal birth rather then going for an immediate c/section. Surgery of any kind carries a very high risk here in Malawi and should be avoided as much as possible.It is often difficult to make the decision between the fetal well being and the mothers health. A live baby has limited posibilities with a dead mother. The babies were born quickly, both small but lively, active and healthy. 1.500kg and 1.800kg. All was going well untill she started bleeding.
At Bwaila there is no sense of urgency. Nothing moves quickly so whilst all was set in motion to attend this urgent situation, time passed. When a woman is bleeding after birth there is little time. It was one delay after another. With only one operating theatre the c/section in progress had to be completed, theatre cleaned and prepared. No blood in the blood bank meant sending to the nearest hospital 4kms. away through traffic and unfortunately staff lunch hour. Lack of materials plus nothing is ever where you think it should be, resulted in a difficult situation, becoming a live and death situation. Pirilani is still alive. Her bleeding uterus was removed and apart from a fever post operatively, important anaemia, despite the blood transfusion, she is on her way to recovery. The twins are OK for now. Having spent the first night in the nursery with little care and just a little glucose to drink I went to collect them the 2nd day and was thrilled to see how they excitedly latched on to her breasts. Since then I have tried to advise her on how to suplement her diminished milk supply bringing them myself formula milk powderfrom home. I only hope they will follow my instructions and boil the water first, give the right strength and continue with the so very important breast feeding. I worry that I may be causing more problems than I am solving. But without supplements they will surely die.
So maybe now you understand ? Are these decisions good ones ? Or will it only depend on the outcome ?

Work had been steady all day Wednesday untill 4pm. I suddenly found myself assisting births on the floor practically under the beds.I am still not sure where they all came from but when someone shouts "baby coming" whoever is available grabs a few materials and runs. By that time of day materials have not been replenishing for night staff, meaning that there is normally hardly anything available. So with 2 pieces of thread and a razor blade not forgetting a handful of gloves I do what I know best what comes automatically..I catch babies. With a smile, with a squeeze of the hand with gushing words of praise, for this woman has laboured alone, in pain and often frightened she has done what all women instinctively know how to do but should never do alone. She has successfully brought another small child into this world. Much to the amazement of my Malawian colleagues who all came to stare I then proceeded to suture a small perineal tear kneeling down on the floor. My time at Acuario and my home birth experience had trained me perfectly for this, it certainly wasnt the first time for me!! I went home late and exhausted. Its great to find Luki there when I get back it just somehow puts things right and normal again.

Entering labour ward at 7.15am on Thursday morning I found every bed full.
In that first hour I assisted 5 births. One with birth asphyxia, two post partum hemmorrages,one shoulder distocia..shoulders got stuck.. twin breeches and prepared a woman for a much needed c/section. Where was everyone else.The night nurses were going off duty and the day nurses had not yet arrived or were chatting and exchanging news. The cries and pleas of the delivering women were completely ignored or not heard nd I was left to catch babies again. Just time to change gloves but little else, thank heavens for Janet, a dutch midwife, who called in on her way to nursery and delivered placentas for me and helped out with the emergencies. Most of the problems encountered at this time of the morning...and there are many directly due to lack of care and attention during the night, in short, to negligence. That day I finished at 13.30 and took the afternoon off. I really couldn't do any more, I ached and I was tired and not a little disheartened.

The teaching plans are moving forward.I shall have 4 groups of 7 midwives in each group.I will repeat the same workshop over 2 weeks. Tuesdays and Thursdays for 2 hour sessions.
It wont be easy and I shall have to adapt so much of my material for we are not starting from the same baseline with the same feelings or objectives. They will be informal sessions with lots of group participation and lots of feed back. I have a lot to learn and much to share .I am confident I will find a way forward to reach these midwives and something really positive will come from our time together. This will be an ongoing thing which will hopefully last during my entire stay. Other teachers could also be involved. I am hoping it will become such a regular occurence that the midwives will see it as an important part of their working life. A time when midwives can share experiences, discuss cases and practices and complain all they like. Oh how I wish midwives would complain! How I wish women would complain!

Friday, 8 February 2008


Exciting news this week. Its seems that I will officially be able to start teaching. A project has already been funded to set up an ongoing teaching program for the midwives (and I hope others) at the hospital. I have been asked to take part.
Details are still uncertain but those who attend will probably be given a meal or some sort of incentive. This is always attractive to the highly underpaid health professionals.

This week has had its slightly quieter times on the labour ward. I took advantage of one of these moments taking aside any students who wished and I talked about pain. What was their perception of pain and particularly pain in child birth ? How did they percieve the women's pain in labour and did they think they could or should do anything about it ? I soon found I had 10 people gathered round me, mainly male clinical officer students, willing and eager to listen. It was a good moment, I shall try to do this as often as possible along with the clinical teaching each day as they work alongside me. Their training is really quite inadequate and they find themselves in positions of responsibilty with very little preparation, experience or knowledge.This leads to the strict following of rules, as I mentioned in my last blog, with decisions being made too late with disastrous consequences. Recently a fetal monitor was given to the hospital. The foriegn midwives are using this for cases of suspected fetal distress. It was sad, but understandable, to find that many clinical officers did not know how to use this or how to interpret the findings on the graph.

Other big news is that I finally took my birthing stool into the labour ward last week. I had already approached the idea of vertical birth with posters and photos from Spain and had assisted a few births with the women in crouching position, though rather precariously on the bed. One of these had been particularly sucessful as it had been to aid the birth of a 2nd twin. The Malawian midwife was getting concerned. The first baby had been born easily but the second didn't seem to want to come down. I confidently suggested she be told to get up on her feet and crouch.With 3 pushes the baby was born. It did wonders for my credibility !
A few women have now used it for pushing in 2nd stage and 3 women have given birth sitting on the stool. The midwife on the rather dirty floor to the amazement of our malawian colleagues and me sitting behind to support the woman. At the moment it is just interesting and maybe a bit crazy but its early days. I hope time and experience will show the huge advantages of vertical birth. It is not only the midwives we have to convince, the women too are highly reluctant to get off the bed. We have to be careful not to create insecurity and distrust.

I have so much to learn about the people, the women of Malawi.
I was told by a fellow midwife " you have to treat them with aggression, that is what they are used to. If you are too soft and kind they will not co operate." I find this difficult to believe and more difficult to do. I can be firm but kind, but to be aggressive to a woman giving birth ? I think not. Sometimes communication is difficult.
Many babies are unwanted. A result of rape, incest or agression. It is easy to distinguish these women who often have their babies pulled out of them with the same agression as which they entered. These cases are particularly difficult. She may be just 13 years old , very often young girls under 18. There will be no counselling or emocional support for her just rejection and scorn. Many babies will be " just another mouth to feed " All this is reflected in the way she births and the way she receives her newborn. Of course this happens all over the world but here in Malawi it happens a lot ...too much.

I have been fortunate to be able to visit 2 mission hospitals in the Lilongwe area. Both primarily supported by the catholic church. What a difference! Much cleaner, more materiales, more space, sheets and blankets, but more importantly a feeling of caring, of love and concern.This is generally missing at Bwaila. Lucas has been with me on these visits and loves to visit the pediatric wards to see if he can make the children laugh.This is often difficult but when we achieve a smile and a giggle then he is happy. Two cases in particular have stayed in his mind. The small child with severe malnutrition, literally "dying of hunger" and the children with burns. "
" But mummy, when their skin is taken off they are pink just like me !"