TOO MUCH TO TELL

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!