Friday, 25 April 2008


Lucas has had Malaria!!

I knew this could happen. Actually what worried me most was not recognizing the symptoms sufficiently quickly for early treatment. I had been told by all that rapid diagnosis and treatment was the key to success. As it happened I need not have worried. Lucas had a text book case, it was unmistakeable even for my untrained eye. Saturday morning we went off to football as usual. Lucas played well though I felt he was more distracted and came to the side line more often for a 'water break' After, we passed by a small shopping centre to pick up some groceries and met Tarek. It was his birthday so we stayed to have a milkshake with him. Without finishing his drink Lucas proceeded to fall asleep at the table. We made some comment about men and there sleeping habits but I knew something was wrong. Lucas NEVER slept during the day. By the time we reached home he had a slight fever 37.5C I wondered what he was sickening for? Over the next 2 hours his temperature rose to 40 C . He was sleepy and complained of headache. He was too tired to eat or drink and was too weak to even walk to the bathroom. I didn't hesitate. I carried him to the car and drove less than 10 minutes to a small clinic that had been recommended by a friend. We were seen immediately. Excluding any other signs or symptoms of infection a small finger prick sample of blood was taken which they examined straightaway under the microscope. It was confirmed in minutes. Affected red cells were seen but we had caught it in its early stages. Treatment in the form of tablets was prescribed and we went home. I was advised to use paracetamol to lower his fever and cold flannels or baths if necessary. Well everything prooved necessary! His temperature osscilated between 38.4 C and 40C for 36 hours. All weekend activities, including a birthday party and " sleep-over were cancelled. I stayed at his side constantly during that time either in bed or on the sofa. I was amazingly support by friends both by phone, messages and visits. Most had experience of the same with their young children, I found this most comforting. I think the worst moment was the first night at midnight when he was supposed to take his second dose of treatment. He immediatly vomited the lot! I phoned the clinic who helpfully told me to give an anti sickness tablet, wait 30 minutes and repeat the dose. This I did and much to my relief it stayed down. Then it was a waiting game. Sunday didn't see much change and I had my doubting moments but he was also not getting worse, which served to console me. Monday saw some improvement and he started to eat and drink a little. Its amazing how we feel so much better when children eat! Right from baby and infant time if they would only eat, breast feed, take the bottle, then they must be alright! By the evening I could see the difference and on Tuesday he wanted to go back to school! He stayed at home with his nanny and I felt confident enough to leave him. Wednesday he went back to school and is now active and happy once more and very proud to be the only one in his family who has had Malaria!
In conclusion I would say it has been a great learning experience for us both. That Africa is definitely the best place to be sick with Malaria! They really know what they are doing. The attention and treatment was fast and effective. The medical staff were knowledgeable, understanding and short ,with all their short comings in other ares I could not fault them.
So now I'm not so scared of Malaria! It might still sound desperate and frightening to you all but this is Africa and we are learning to live with and in it.
Malaria is a killer disease here in Malawi. The people live too far away from health facilities. They have no money for transport. Although medicines should be available free many times charges are made and the 500 MKW is more than most can afford. ( I paid 3.500 MKW in total for Lukis treatment as we attended a private clinic, this is totally out of the reach of most Malawians who maybe only earn that much in a whole month)
There is so much malnutrition, HIV, Hepatitis, chronic anaemia and other ailments that Malaria kills. We are the lucky ones. Lucas is a fit healthy active child. He was diagnosed and treated fast and his body responded. Yes, the medication is available....but only for some. Yes, the medication works.... but only for some.

And what about the miracles then?

I arrived on Labour ward, as usual, at 7.30ish on Tuesday morning. What would I find today? A second twin waiting to be born! Quickly I looked in the notes to see the time of birth of the first....5.30am! more than 2 hours ago! I tried to find the fetal heart but without success..or maybe yes, maybe I could hear a faint heartbeat or not? I decided to actively get that baby born. It was her 4th child she should be able to push it out quickly, it would be quicker than a c/section if it was alive and I could not send her for a c/section if it was dead. So where was that baby and why hadn't it been born yet? I examined her, she was fully dilated, was it a head I felt? I broke her waters and found a hand and an arm! Oh no this was not a good sign. But wait, I was right, I could also feel a little head. I called for assistance and encouraged her to push. Chimani...Chimani...push..push, kwambiri....kwambiri...more..more. That mother was amazing. I dont know if she realized she was pushing to save the life of her baby or if she could hear the urgency in my voice, could sense the need to respond, but she just pushed with all her strength and out came that 2nd little girl with one hand up alongside her head. I thought she was dead. Quickly cutting the cord I felt for a heart beat. I couldn't believe it! It was slow, but it was there. At my side was Anne the Norwegian midwife, she took the baby from me straight to the resussitaire and started work...suctioning out the mucus that obstructed her airway and forcing oxygen into her little lungs. I heard a small infant cry! "She 's coming round" shouted Anne. And she was! An hour later her mother got up, showered and proudly took her 2 little babies to postnatal ward after breast feeding them both. It took a while for the adrenelin to subside but I'd never felt so alive!
Today I had a meeting with Lucas' teachers at 11.45 so I decided to go to labour ward for a few hours untill 11.30. Lucky I did, as we were just 3 midwives, 5 students and a full ward. Anne and I started to sort out who needed what and when and before 11am most of the babies had been born. I was walking past a bed where a doctor was examining a newly admitted referred patient. I could see the umbilical cord pretruding from her vagina. Oh no! cord prolapse! Is the baby dead? Is the cord pulsating? " Yes" When, at what time, how long had the referral and journey taken? There was no time for those questions they were not important now.. First baby or multigravida? "3rd" is she fully dilated? " yes" what is the presenting part? " a foot " Then we can get the feet down and pull, we can deliver this baby, it will be its best bet, its only hope.
The Norwegian obstetrician was at my side, Anne came quickly to help, we worked as a team and the little one was born. Just a faint heart beat was felt. We worked together to help that baby to survive. It took a while but slowly he started gasping, taking little breaths, getting pink ( yes African babies get PINK too!) I took him to nursery. Will he make it? I don't know yet but at least we have given him a chance.

I could tell of the ones that didn't make it but I think that this week I'd rather end on a positive note. The two Norwegians that I have talked of will be leaving next week. Two more have come in their place. Their government has promised to supply these medical staff for a period of 5 years. They each do a 6 month stint. I shall be sad to see them go. They have become well trained and experienced collegues during their time here, they will be greatly missed on labour ward. It takes time to learn and accustom oneself to Bwaila and now they are leaving. I wish them well. Who knows, maybe one day they will come back? Africa needs such as them, Bwaila needs such as them, the mums and babies need such as them, I need such as them.

Friday, 18 April 2008


As time flies by and each week passes I find it increasingly difficult to find the right moment to sit down and write to you all. Everyday there are stories to tell as I become more and more involved in the different aspects of African life and health care.

It has been a week full of teaching. I find myself particularly involved with the clinical teaching on labour ward passing from bed to bed observing and questioning, trying to make the students think about their practise in a new way. To see the woman as an individual with a story to tell quite unique and special and therefore to be treated as such. Sometimes its difficult to stand back and let them attend, even whilst I am supervising. Inexpert and clumsy, results in torn perineums or less sensitive handling of mother and baby as they perform their tasks but I guess thats just part of teaching. and learning. Its a priveledge to be with them to be part of their training, to maybe have some influence. I hope that my words will be remembered and my example sufficient to aid them to be better more caring and knowledgeable midwives in the future.
But not all the students are receptive and many have a dangerous overconfidence after just a short time on labour ward. Then there are the students that are more concerned about filling in their papers for x number of vacuum extractions, twins or breech deliveries and can be found attending these births totally or inadequately supervised. I returned from workshop on Tuesday to the cries of a woman in bed 2. Behind the curtains I found a very newly trained CO supervising a student midwife with a vacuum extraction. I had been aware earlier that she was "on the look out" for vacuum extractions. Things didnt seem to be going well. The whole scene was chaos and the woman out of control. On enquiring as to the whereabouts of the fetal stethescope to check the baby's condition I found that they didnt have one. They hadn't seen it as and important part of thier equipment! I could not let this continue and pushed past to examine the lady. I found that the conditions were not favourable for this sort of intervention and told them to stop untill I called a senior clinician. I ran to operating theatre where I found him having lunch. Fortunately he was finishing and came straight away. ( Luch hour in Malawi is sacred and even an emergency will not be attended to untill after lunch!) He attempted to extract the baby but soon decided it was not possible. I hurried her to theatre where the baby was born by a difficult c/section. I stayed to recussitate a very floppy baby then transferred him to nursery. Today the baby has been discharged from nursery and is with his mother. He is one of the lucky ones. I dont understand this behaviour. I cannot condone this behaviour. But it exists and it continues. The workshops are going well. I am called the ' facilitator' Its the new word instead of teacher. I rather like it! I have now finished the first session which consisted of 4 groups. 35 midwives attended in total. Feedback has been good so far and I am encouraged. Next week I will introduce a new topic as we start to analize our individual practices and attitudes.

Pilirani and the twins Edward and Alex are still doing well. They now weigh in at 3.700 and 3.050 kgs. respectively. The harvest has begun. The maize is picked and being ground into flour. This week she did not complain of hunger. The boys are hungry babies and growing fast. They are still taking 2 formula feeds a day and I continue to supply them with milk powder. I have however advised her to try stop these supplements now that both mother and babies are stronger.
Grace spent 5 days in hospital with little Angela whilst they treated a chest infection with antibiotics. I was disappointed to find that when I visited on Monday she had already been discharged without doing the cardiac scan. This happens often. If she has a cardiac complaint it will not be investigated untill next time she is admitted with the next infection or failure to thrive.
It is frustrating but it is Malawi. I hope that she will start to grow and gain weight and that it wont be necessary.

It is not uncommon for me to attend 5 to 7 births in one 9 hour shift. Some are quick and straight forward but many long and complicated requiring the maximum of my skills.
Just 2 examples this week...1. A referred case with prolonged dilatation phase. Aparently she would be unable to deliver due to an abnormal cervix. I was told to try a vaginal birth but it was unlikely. After much care she pushed out a healthy boy and avoided a c/section.
.... 2. It was her 5th pregnancy and she still didnt have a living child. She had been admitted during the night and was well in labour. I started caring for her at 7.30am. At 8.30am. the doctors do there "round" The orders were clear.. " This lady will be c/sectioned immediately " It was not for me to question this decision which was made in the interest of mother and child but I do question as to whether a c/section is really the safest option, not only here in Bwaila but in any part of the world? I started to prepare her for theatre. IV infusion, urinary catheter, consent form etc. She started pushing, what could I do? Ten minutes later she birthed a healthy bouncing baby boy! She was so happy and so was I! I'm not sure if the boss knows yet but I'm sure not going to tell her!!

Wednesday, 9 April 2008


Some days I sit down here in front of the screen and dont know where to start. Today is one of those days.

I am back on labour ward. This week we had an influx of students. Clinical Officer students and nurse/midwife students. Its their first time on labour ward, they need so much clinical teaching and training which is not readily available. They stand around confused or try to do the little that they know how, often making mistakes, not realizing the importance of listening correctly to a fetal heart or checking the uterine contraction after birth. The CO's have so little knowledge I am amazed, the midwives somewhat more. They need constant supervision but find trained staff with little enthusiasm for the task. I regularly find myself with 5 or 6 students round the bed, not ideal for the labouring mother, but I am aware that their need for training is so great there is no option. I enjoy this part of my work and find the students generally open and enthusiastic to learn. We are using the birthing chair more often and now I am not seen as crazy when attending a mother who chooses crouching position or ' all fours' to give birth. Yesterday one of the very newly trained midwives came to me to ask for the stool. She thought that 2nd stage (pushing) would be more effective in that position. She and another young midwife assisted the mother to birth on the stool and I was around to help. It was most encouraging.

My first official group session with the midwives took off yesterday. There were 8 midwives from both Bwaila hospital and Kamuzu Central. It turned out to be a relaxed fun time, which was my intention, but I was able to challenge them with some pertinent questions. If you,or your daughter were pregnant now and looking for the best possible care for you and your baby would you come to Bwaila hospital ante natal clinic ? Bwaila labour ward or postnatal ward? Would you have your baby looked after in Bwaila nursery? We looked at our own expectations of care and the care that we are giving. We looked at the uniqueness and individuality of birth and talked of choice. I showed some images of birth in Europe, natural birth in various positions with caring midwives and partners. They were able to see the joy and happiness that can and should be part of giving birth and which is far from present in our hospital. It was good to see their faces as I presented a totally different concept from that which they are used to. They all noted and commented favourably on the presence of the fathers in the birth. I realized that deep down, despite their culture and customs these Malawian women felt just like us, the need to be loved, cared for, and supported, especially at this time. To share the birth, this life changing event, with the person they love most, the father of their child.

Somebody said to me today that the Malawians are cold, emotionally dead, that they dont care. That they dont know how to love their children that none of that really matters. I dont believe it. Maybe their circumstances and experiences have made them keep their distance, not love too
much for fear of being hurt, for fear of too much pain, for fear of loosing. Maybe they have just shut down, maybe its the only way to survive.

I arrived on labour ward at 7.15am. The clinical officer had been called to attend a possible ruptured uterus. The baby was dead. Had died in the time the mother was on labour ward. There was not time to ask questions to find out why. I was asked to assist a vacuum extraction. The baby came easily. I think he forgot that it was dead and started to place it on the mothers abdomen. I took the baby, dried it and carefully wrapped it in the special 'chitenge' cloth she had brought. I looked into the mothers staring emotionless eyes and said I was so sorry and asked if she wanted to hold her baby. Her face told me nothing not grief, not suprise, nothing, it was blank. I was troubled. I asked the CO if anyone had told the women that her baby had died. He asked her.. in Chichewa. NO ! No one had thought to tell this mother. She was expecting a live child! I could not believe it, this is not acceptable, this is not professional, this is inhumane.
It made me question once again, had they been right ? did they really not care!

Update on Pilirani and the twins... Last week both babies looked good. Both looked lively and active. They were needing to supplement breast feeding twice a day with milk formula but they were growing and gaining weight. I could see that Pilirani had lost weight. I was not suprised as I know they will be hungry untill they start harvesting next month. This time I found maize flour to take plus sugar and other fresh fruit and veg. Not enough, but it will never be enough. I gave her a tin of milk powder for the babies. It is relatively expensive and out of reach economically for most families. It can be supplied freely at some centres but most do not have the means or money for transport to collect it. Also breast feeding is 100% encouraged for all its other benefits. Before I left the older children were sent out to the field to cut some maize cobs for us to take home. I look forward to my visits to this village these people are just amazing!

Our visit to Grace was somewhat frustrating. We arrived at the famous wobbly plank bridge to find that a minibus had broken down right in front of it, blocking our passage. It took us more than an hour to find our way over and around the small stream that separated us from her house. We could see her house in the distance but it was not safe to leave the car and walk. When we eventually arrived I was pleased to find that baby Angela had gained 400g in 2 weeks. She looked peaceful and content. Grace looked well. I could see her Aunt had been feeding her well and that she had gained weight. Grace wanted to know when she could come to my house? Maybe next time I assured her. Or am I creating a dependancy that could become difficult? How difficult? Why difficult? What am I afraid of?
Grace phoned me yesterday to tell me that her baby was sick that she was not feeding and crying a lot. I told her to take her to the hospital but I doubted that she would. This morning when I spoke to her she had no transport nor money. I picked them up at 11am. and we went to Central hospital ' under five clinic' Baby Angela has been admitted to the nursery with an infection. I mentioned that she may have an underlying heart problem so they have ordered a scan. Her condition did not look too bad though once again she had not gained weight in a week. I am pleased that this will be an opportunity to investigate a possible heart problem and that we took her in plenty of time to be treated sucessfully. One of the problems in health care, in general, is that by the time the children(or adults) are taken to be seen at the hospital they have already passed through the local health clinic, the traditional medicine (witch doctor) and often arrive much too late for our medicine to be effective. Tomorrow I will return to see how Angela is doing and take some food for Grace.

My last assignment to finish my "orientation" was a few days on the postnatal ward. There are 2 midwives on each shift. They are caring for High risk postnatal, postnatal and ante natal mothers. Around 70 to 80 women. This is what I wrote as I came off duty last Friday...
Today I felt that however much I do there will always be more to do. However much I give it will never be enough. However much I care still more will be needed. The queues are endless the corridors are full and overflowing. As we emptied out the beds so they filled. High risk went to low risk. Low risk went home and high risk was filled again from theatre. No bed available ? just put her on a matress, from that pile, on the floor. I laughed to find myself kneeling down on the floor putting up an IV infusion, taking blood samples and cleaning dressings. There was very little chance to get to know the women just get the basics done. The drugs, the dressings, IV lines urinary catheters, but its fun to do it with a smile and a word of encouragement even if more than half didn't understand a word I was saying! Being on postnatal ward also means attending the outpatients who come back for removal of sutures or any other postnatal complaint. If labour ward was busy, if Antenatal clinic was busy, if in nursery I never stopped, well postnatal was no different! Is it any wonder things get missed or mistakes are made ? Is it any wonder?

Two of the midwives were talking together I didnt understand but I knew it was serious. I asked what was it that was bothering them? They told me it was the extra shifts. They were expected, though not obliged, to work 2 or more extra shifts a week. For each shift they are paid 600MK. (3 euros) or 800MK for nights (4 euros) By the time they pay their transport and a meal there is almost nothing left. I asked them " so why do you do it?"
" because if we dont there is no one to care for the women they will be left unattended"
I felt humbled..
" so now if you see us sitting down, you know why"
I felt ashamed..

Life in Malawi is full of conflicts, life at Bwaila hospital is continually confusing..

But I love it!