Wednesday, 26 March 2008


This morning I decided I should finish my obligatory "orientation program" for my official registration with the Malawi nurses council. This means spending 3 days in the Ante natal clinic. Up to 100 mothers are seen between 8am. and 12am. As you can imagine they are passed through at great speed. It seems that the basic checks are done but there isn't much time for midwife/mum chit-chat! In the same building is the underfive vaccination clinic, family planning and a special HIV follow up clinic.This means lots of mums and babies milling around. I am amazed to see how well everyone knows where to go and in which line to queue. On asking for an explanation for this very organized chaos I was told that there is excellent communication and support between the mothers. It was evident, the next mother in the line would look after the young baby or child while she was being seen. I think we could all take example from these women in this way and also find some of their endless patience as they wait their turn happily chatting away to each other without that feeling of anxiety, impatience and stress that is so palpable in European waiting rooms.

Before I tell you all about our weekend on the Lake, I should first let you know how Pilirani and her twins are getting on.

OnWednesday morning we (Doreen and I) set out early to do our visits. Lucas was at school and would be picked up at lunch time by a friend.

First I called in to the nursery to fetch the portable scales for weighing the babies. We then passed by the market and bought fruit, vegetables and bread. I had already prepared a tray of hard boiled eggs as I worry about the lack of protein in the average diet which mainly consists of a maize flour porridge. This serves to fill their stomachs but instead of being used as part of a balanced diet it is often the only thing they eat.

I had been in contact almost daily with Grace and her tiny, prem baby. She had left nursery weighing only 1.500kg. and with a possible heart problem. We would first go to see her.

I wrote the above last Wednesday and have tried unsucessfully to complete and post 5 times since then! It has been so frustrating! I am daily learning the lesson of how little control I really have over so many things. I am told that all the internet conections in Malawi were either down or slow and could only access some sites.. obviously my blog wasn't one of them! So, for those of you who began to worry that you hadn't heard, I thank you for your concern and for those who are eagerly awaiting my next goes!!

Grace met us on the "main" road, a muddy potholed track leading to who knows where! She was thrilled to see me and gave me a big hug. She climbed in the car and off we went onto the minor tracks. I still havn't managed to acquire a more suitable vehicle so was particularly challenged by a narrow wooden plank bridge and a steep muddy grooved incline. I even stopped to take pictures as I thought no one would believe it possible to pass! I have now realized why both Doreen and Grace are so confident that we will get through...Neither of them has ever driven a car!! Still their encouragement definitely helped! Grace is living temporarily with an aunt and uncle whilst the baby is so tiny. It was obvious that they have a little more money as the house is built of bricks and there is a small amount of furniture. I was shown into the main room and we sat on the sofa and talked for a while. Grace speaks some english but it was good to have Doreen there to make sure that we fully understood each other . The baby had not gained weight in the 2 weeks since discharge from the nursery. This is typical of babys with heart problems. I also felt that she was not giving enough feeds so advised her on 2-3 hourly feeds day and night. The little one, weighing just 1.5kg looked strong and active so I hope that when I next visit I will see some weight gain. I left her with the milk, sugar and fruit I had brought promising to return in 2 weeks time. Before leaving I was desperate for a bathroom so I was shown to the toilet facilities. I have still to improve my aim when peeing down a small hole in the ground but am working on it! I was touched when they brought me a bowl of HOT water to wash my hands. Its these little things that bring me such pleasure.

Precariously we took the road back, I was glad to reach the main road and drove the 30 minutes to reach Piliranis village. The welcome was tremendous we were greeted this time by the great grand parents. On enquiring their age nobody could remember ! The twins looked great and had regained the weight they had lost. I do hope this continues. I am concerned about Piliranis diet untill the new harvest begins. It is a great strain on an already hungry body to be feeding 2 hungry babies. I shall take what I can but I can't feed the whole village, I never feel I have taken enough.

Easter weekend was spent on the southern shore of Lake Malawi. It was an oasis of calm and peace. The incredible richness and beauty of this country made it hard to believe the reality of its poverty.
We were generously entertained by some friends we had met at the airport on arrival.
Time was spent relaxing, eating, swimming, canoeing, snorkeling and daily trips in the speed boat to visit small islands and coves. Luki was able to show off his already acquired fishing skills (endless hours fishing with his father in Spain) catching 3 or4 fish each day. These were later prepared and served for our supper. One of the highlites had to be "feeding the fish eagles" Fish were caught in the evening, then on an early morning trip to a nearby island they were thrown to the eagles who swooped down to retrieve them as they touched the water.It was truely amazing! After 5 days of sheer bliss we returned to Lilongwe.As you can imagine Luki wanted to stay for ever. I wouldn't have minded either!

Back at the hospital and after 3 days in Antenatal clinic I returned to labour ward. They were obviously pleased to see me. It is good now to feel part of the team. I am accepted and welcomed in all departments. Yesterday I was attending a young unmarried girl, first baby.( Its difficult in Malawi to have a baby outside marriage, culturally not acceptable) It was a long tiring labour and equally long 'pushing' stage. We went over the official time limit both for first and second stage. The senior midwives began to ask questions. Although I explain clearly that both mother and baby are fine, that women are all different, that we must be capable of adapting to the individual needs of each woman and each birth, they find this concept almost impossible. I was not following the rules and that made them feel insecure. At last a healthy baby boy was born with minimum intervention and a lot of hard work on my part. Not to mention that young mother. The senior midwife commented that I must be very tired. They do watch! they are noticing! at the moment that is enough for me. I managed to catch 2 other babies during the same shift and although labour ward was not busy, women laboured alone and even one popped out unattended.
Where were the other midwives? Why weren't they alongside caring and encouraging? I still can't answer this.

Next week I start teaching... officially! I prefer to think of it as group leadership of midwives who will regularly get together to talk, share, discuss and learn. It will be a time to explore our own feelings and motivation. We will be realistic within the environment in which we work but we will be willing to change, to improve. From these groups we will go out with a new/renewed vision to experiment new techniques with the sole aim to improve our care to women and babies.
Well at least I hope so!!!

Monday, 17 March 2008


I didn't write last week, I couldn't write last week.

What could I tell you?

Of the mother that should have been taken to operating theatre at four in the morning, who failed to be assessed and examined by the clinical officer on duty. The c/section was done at 8am. the baby was dead, the mother hemorraged so severely she needed a hysterectomy and later died in the ambulance on the way to intensive care in the central hospital. No blood was available at either hospital .

OK.. so she was HIV positive which was probably the cause of her poor general state, would further complicate her chances of responding to the hemmorage and lead to her death ...BUT ... here in Malawi there are more NGO', charity organizations and do-gooders spending huge sums of money on AIDS projects then any other cause, so I am afraid I can only ask why? why?

Or should I tell you of the morning that on arriving at labour ward I was asked to attend bed two where the 2nd twin was waiting to be born. I listened for the fetal heart and found nothing. I examined her and felt the umbilical cord presenting and not pulsating.The baby was in an impossible position for a vaginal delivery. So when had the 1st twin been born? At 4.20 am. more than 3 hours ago! The clinical officer had visited at 5.10 am. the fetal heart was heard, he told the midwife to wait! She waited. Too long for that baby. ( one midwife's comment was " well she does have one" )
But she had two babies! two healthy babies! untill she came into the hospital!

Or maybe I should tell you of the 2 prem babies. Just 28 weeks gestation, weighing around 1kg. Both breech presentations both difficult to deliver the head. The first was determined to live but lasted just 5 days the second was just too prem. too small.

Or I could tell you of the mother that transferred in after delivering the first twin in a local health centre. It took 3 hours for the ambulance to arrive. The second twin was dead and the mother needed a c/ section for bad presentation.This was confirmed by an ultrasound scan done by one of our clinical officers. Whilst waiting to be taken to theatre she pushed out a live healthy 2nd twin head first!!!

I can talk about it now but I couldn't write it all down last week.

I went to see Tarek, I just needed to talk, to get it all out of me. As usual, he listened and he talked and I felt better. He also gave me something to read, things he had written about human rights.. what are they..what do they really mean to us, to you, to the developed world, the politicians and how relevant are they to the mothers and babies in our care. It started with a quote which I would like to share (actually I'd like to share it all, but its not mine to share.
"It is possible to adapt to a given situation precisely because you have got to live it and you have got to live it everyday. But adapting does not mean that you forget.You go to the mill everyday-it is always unaceptable to you, it has always been unaceptable to you and it remains so for life-but you adapt in the sense that you cannot continue to live in a state 0f conflict with yourself"

My second visit to Pilirani was less eventful as we managed to take all the right turns.

She looks well and the c/section scar is totally healed. When I asked if she felt strong her mother replied that she can now carry a full bucket of water on her head. I guess that means she is very strong! I certainly couldn't!

Unfortunately the twins Edward and Alex weren't doing as well as I expected.They both looked lively and active but underfed and not gaining weight. In fact Edward who had been doing so well had lost weight. We talked about breast feeding, she said "they are very hungry babies" I could see that! She seemed to have plenty of milk but I did suggest that maybe she should supplement. I asked about her diet. She was eating just beans and potatoes.

Last year Malawi produced a bumper crop of maize..the staple diet. More than enough to see them through till the next harvest. Unfortunately someone sold off a large amount to neighbouring Zimbabwe and S.Africa leaving insufficient for the people of Malawi! No one seems to know how or why it happened but poor Malawians are now dying of hunger and severly under nourished due to some high-up political "mistake"

I took bread and bananas, it was not enough. This week I shall take eggs (hard boiled) and rice.

As I got up to leave, Pilirani went to her mud hut and came out with a plate of dried beans for me. She had so little but still gave me of the little she had. It was so difficult to take but I knew I should. I got in the car and cried. This is just one family that I have the priviledge to be part of, but how many more are there like that? It was all too much for me last week.

I must just tell you a last detail..... As we walked through the fields of maize that leads to her house we met a very small child walking towards us. I recognized her as one of Piliranis elder children.She is just 4 years old. On her back she carried what I thought was a doll (silly of me.. little girls in Malawi don't have dolls) I could not believe it when I realized she was carrying Alex the smallest of the twins, now weighing 1.550kg.!

Friday was my day off. I dyed my hair and painted my toenails with my friend Filly. The choice was dark or light brown. I now have a very youthful dark head of hair and bright pink nails. It felt good to do that!

On Saturday evening I had my first real "night out" since arriving. It was a charity dinner dance in one of Lilongwe's nicest hotels. It was a great night. The food only reasonable but the music and company fabulous. It was totally therapeutic. I danced nearly all night to the golden oldies.. of my era, lots of Rolling Stones, Meat loaf, Rod Stewart and Michael Jackson. I was exhausted but happy and felt this was a good way to recharge and prepare myself for what I might find this week.

Easter is close and school holidays.We will be going to spend a few days by the Lake with some kind friends. We are very much looking forward to the break. I am looking forward to the rest and Luki to the snakes!

On Tuesday I shall go to visit Pilirani again and also Grace, who has been phoning me everyday just to make sure that I havn't forgotten her. Well actually she gives me a missed call and I phone her back, but its always to say the same " dont worry I will come to visit and I havn't forgotten you"


Friday, 7 March 2008


Monday was bank holiday, Lucas had a day off school so we decided it would be a good day to go looking for Pirilana and her twins. At 7am I was in the hospital nursery starting the days work. I knew they would be short staffed that day so I was able to help out with the daily cleaning of cots and weighing of babies. The mothers wait anxiously to see if their baby has gained weight, if today will be the day she can return home? Some of these mothers live a distance from the hospital which means that they may have arrived well before giving birth and been camping out away from home for some time. Their stay is then extended whilst the baby is in nursery making them impatient to get home. Most of them will be accompanied by a "guardian" and often other siblings. The guardian will look after them during this time preparing their food in the basic hospital kitchen and washing their clothes. They will have very little money to buy food so if they then have to stay a week or more after birth it becomes very difficult for them. Basic meals are provided by the hospital courtsey of an NGO. but are not always sufficient. Breast feeding one or two infants whilst recovering from giving birth often with underlying chronic conditions like anaemia, TB. HIV. Hepatitis , malnutrition etc. demands a good diet and care, this is not present. I was able to give my sandwich and fruit juice to one of my mums the other day who had not eaten for 24 hours. It felt good to sit at her side and share in this way reminding me once again how much I have and how little they expect.
But back to my story of Pilrani and her twins!
I collected a portable weighing basket, met up with Evelyn (a Dutch medical student who is here for 2 months) who had asked to acompany me and went home to pick up Lucas. I had decided to take our " nanny " Doreen, with us to translate. Pilirani does not speak English and I doubted if I would find English speakers in her village. I met Doreen last time I was in Malawi so was pleased to employ her to look after Lucas whilist I am working. Though outdated, the word "nanny" is widely used to describe these ladies, as are many of the words used here dating back to the British colonial days. So we set off with our instuctions of how to arrive. Doreen insisted she knew where we were going and I believed her...first mistake! She was eager to please but her experience of travelling everwhere in an overpacked minibus had not made it easy for her to understand exact directions. So we missed the turnoff! By the time we had nearly arrived at the airport I guessed we had gone wrong so we stopped and asked! I was glad to have Doreen with us. We set off again with new directions and decided to take the "short cut" Turning onto a mud road I began to doubt we would arrive. Doreen assured me it was a good road! We are still in rainy season so although a dry sunny day the ridges, bumps and holes caused by the rain were evident! I am still driving a hire car..just a normal saloon..definitely not the best car for this sort of adventure. My farming background and four wheel drive experience came in handy and slowly, very slowly we manouvered our way through and around the difficult bits and arrived at the house with a white flag. I must admit I was expecting a large white banner, we found a small piece of rag, the size of a handkerchief, tied to a stick! Once again.. lucky Doreen was there !
There were a few mud huts alongside the track so we enquired as to the whereabouts of Pilirani.
From out of nowhere men and children appeared and offered to take us to her hut. Leaving the car to be watched over by one young man, we set off behind a " gaggle" of children all laughing and talking and running at our side. Through the plantations of maize ( this is used for everything and upon which their whole diet is based) winding round the outskirts of the village past the small mud huts with thatched roofs...yes just like the postcards or images on the tele..we turned the corner and there she was sitting on the step of her hut, home, breast feeding one of the twins. What a suprise! she didn't think I would come! She cried out and covered her face but we could sense how pleased she was to see us. It was a very special moment. The other ladies ( we later found out were her sister, sister-in-law and other family members) jumped up and fetched a cane mat.This they spread out on the ground for us to sit on. We took off our shoes and sat down. Again it was good to have Doreen who translated for me. She showed me the twin boys..Edward and Alex.. I could see that Edward, the largest, first born was doing well but Alex looked thin and ill. I guess I was glad to see them alive but became worried by Alex' condition. We weighed the babies and sure enough Edward had gained 400g in the 2 weeks since discharge but Alex remained the same. Doreen helped me to ask the questions and understand as Pilirani explain how they were feeding and her own worries about Alex. I took his temperature and was relieved to find that it was normal. His breathing was good. I listened to his lungs and they seemed clear. He showed no signs of infection but was clearly severely underfed. Edward was obviously taking the best, leaving little for his brother. I advised her to express breast milk and give it in a cup, thus supplementing the poor feeds as he was becoming slowly weaker and less able to take directly from the breast. I also left her some packets of milk formula with strict instructions, once again, on how to make and use them should she find that she does not have sufficient milk. I hope I did the right thing?
I had bought gifts of knitted blankets and hats for the boys and left them with one of my home baked chocolate and banana cakes. There would not be sufficient to feed the growing crowd that had by now gathered around to inspect the " msungu" ..white lady, but maybe enough for Pilirani and her family. We met her 2 older children and her husband, were introduced to the great grandmother and head lady of the village who came to meet us and shook hands with everyone. Lucas was rather overwhelmed by so many staring faces. His blonde hair is particularly interesting to the local children who laugh and giggle in a way that can be disconcerting to a 7 year old boy. After promising to return next week we followed the children back to the car where the young man was still on guard. The 100kw note (50 cent.) for his services was received as if it were gold and the car was intact. We waved goodbye. Finding the correct way home was far simpler but not nearly as exciting. I am negotiating the purchase of a small jeep which until bought I think I will return the easy way!
I think of Pilirani and her boys everyday. I hope I will find them alive and healthy when we return though I cannot be sure . They still have along way to go before I can feel they are out of danger. Edward weighs 2.250kg and Alex 1.450kg. In most countries they would still be incubators!
It was hard to leave nursery but I felt I should go back to labour ward. I have made friends there so will return often and have told them to call me if they are particularly short staffed or overworked. I hope they will. I will keep up contact with the mums who are caring for their babies in the "kangaroo" nursery I have some very special mums there. Look out for news of Grace and her little one. She has a heart murmur which seems to be the cause of her slow weight gain and "failure to thrive" Grace is a dedicated mum and we have a special relationship. I shall not loose contact with her.

My return to Labour ward was dramatic with breech twins. Helping to save this mother from an almost inevitable c/section was good. There were a few " adrenalin" moments but all turned out well. 2 boys ...1.900kg first then 2.200kg came quickly behind. Wow! am I learning a lot ! Mother nature is wonderful and so knowing and babies and mothers are stong even under the worst conditions. Thankyou!