YOU'VE GOT TO BE TOUGH WHEN YOU'RE TINY.

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!!