Friday, 23 May 2008


Today I'm taking "time out" I can do this. I need to do this

Teaching is going well . My twins and my miracle babies are just fine. But yesterday was just

Labour ward was as busy as it gets. We were 5 midwives and many students. With 1 midwife in admissions and another nearly all day in theatre we remained just 3 on the ward. The students, with little experience, were attending births with little supervision. I moved from bed to bed trying to keep abreast of each situation, helping out when things were going wrong whilst also trying to care for the more complicated "referred " cases. I had to drag myself away for 2 hours to teach in my workshops, and found on arriving back the situation was no better, it was worse. We only have one operating theatre at Bwaila hospital so please tell me what to do when we have 4 very serious cases waiting for a c/section? Just please tell me which one has priority?
The woman with the cord prolapse who was referred from a health centre. The cord was still pulsating, the baby was still alive ..but for how long? Or maybe the young primigravida who was sent by the TBA (tradition birth attendant) from her village. She had been "pushing "for more than 24 hours, her baby was still alive but severely distressed and she could rupture her uterus at any minute? Or the woman on her 10th pregnancy with 4 live children and severe fetal ditress? or maybe the woman who arrived with ruptured uterus with a dead baby but in risk of loosing her own life?
Someone just tell me, just please tell me who has preference? Who should make this decision? What are the priorities ? Who should live and who should die? Whose life is more important ? What should be our criteria?
Nobody told me how to make such decisions, it wasn't part of my training, yet I found myself there alongside the doctor doing just that.
That woman has already 4 children and her life is not in danger...Yet...That one is her first child and she may rupture. Was that a good enough reason for taking her first?
By 5.30pm. they had all been attended. I had been at work since 7.15am. without taking a break. And even as I tried to leave a student called me to help her with some difficult shoulders and another to suture a perineum. So it was gloves on and "just these 2 more and I must go" We left the ward full of women in labour for the night shift. As I walked away I heard comment. "At least with all that we only lost 1 baby" It was true, but that was someones baby, some mothers child she had loved and carried for 9 months, she had laboured and pushed for two days. Some fathers son, some grandmothers grandchild. It was one loss too many. It was avoidable if the conditions had been right and adequate, if these women really did have the right to decent proper health care if these women and babies really did have just some basic human rights.

TBA's form an important part of Malwian health care. There is such a huge shortage of midwives a least someone is attending the women in the rural areas. These women have no official training but will have learnt their skills from other women in the village. Passed on by the older women as tradition allows. Some will be good wise women who work skilfully and have achieved great knowledge and art. Unfortunately, others will have little or no skills and can be downright dangerous. The ministry of health has a problem. On the one hand they need them as they cannot supply enough trained nurses or midwives so they wish them to have some formal training. On the other hand they would like all women to be attended in health centres or hospitals so don't want to encourage them by giving training. Malawi is not supplying sufficient health care to do without them and does have not the means to do that. It is a problem. I have already made contact with a NGO who are looking at a project to provide these women with basic skills. I find this an exciting and interesting challenge. I will keep you posted.

Grace's baby is back in hospital with another chest infection. She is just 3 months old, weighs 2.800kg. and has been in hospital twice. I still wonder if she does have that underlying congenital heart condition but it seems impossible to get anyone to do any further investigations. Could it be that its just not worth it? There is no pediatric cardiac surgery available in Malawi so why bother making a diagnosis?

Today I had breakfast with some good girl friends and tonight we will go out to supper with other friends. I feel loved and supported. Today I had a good moan to Tarek too. Of course he understands perfectly. Has seen and heard it all before. But he's a good listener and I thank him for that.
Luki is having fun. He's looking forward to being in Spain with his dad and brother and sister next month, though I shall miss him terribly. I manage to talk to my other children regularly and that makes me feel so good. I have started to make plans and bookings for Alasdairs visit in July it will be such fun to visit new parts of this beautiful country. Sometimes its hard to believe the things that are happening behind the walls of Bwaila hospital. We must not close our eyes and pretend they are not there, that they do not exist. That is why I write, so that you too can know the reality of the very poor, the powerless, the defenceless, the women and babies of Malawi. Only then can something be done, can we begin to encourage, to force, someone to take notice, can we begin to make a difference.

Friday, 16 May 2008


I arrived at labour ward yesterday ay 7.15am. By 7.45am. I had attended 2 births, performing vacuum extraction for fetal distress on one and resuscitating both babies. Thats how it is in the morning. The night staff are tired after their long 15 hour shift. Those that are unlucky enough to need attention between 5.30 and 7.30am. will be at risk. I never quite know what may have happened during the night which makes it difficult take over in the morning. How long has she been pushing? Are these signs of fetal distress recent or is this baby in its final stages of coping?
Was this woman with a previous c/section really in labour all night with a baby that is just too big to come down or should I wait a little longer and risk a uterine rupture? It is very often difficult to make the right decision so I try to watch her closely and hope that Tarek or one of the "real" doctors will be along soon to discuss the case. Protocol is to call for the clinical officer.It sometimes works, most are now quite willing to listen to me, but so many of them have so little experience I find it difficult to refer to them. The charge midwife called to say she would be late as her transport had not arrived. As the most senior midwife I took charge. Assessing the women, organizing the students, trying to ensure that they are suitably supervised ( difficult with just 2 other trained staff!) Then there is the ward round. At 8.30am. the obstetricians plus a whole host of CO's, students and others, patrol from bed to bed discussing each woman, taking the opportunity to teach the students or make decisions on difficult cases. I insist on maintaining as much intimacy and privacy as possible for the labouring women.This is a huge task. The curtains that should hang between the beds to give just a pretence of privacy are either broken or torn, many are just not there. Up to 20 persons trying to fit round the bed..most of them male.. make it almost impossible, but we try. Covering the women with their colourful cloths (chitenges) putting ourselves physically between her and the crowd, we achieve something. Yesterday was full of problems. Everyday we receive many women referred from other centres. By the time they reach us at Bwaila they have already passed through the health centre and maybe a local hospital. After waiting for transport between each centre these "emergencies"arrive on labour ward. We were just finishing the "round"
" Ruptured uterus" I heard them cry, as they wheeled in this poor, shocked, traumatised woman. Without waiting I went to the bedside. Luck was on her side as all the medical staff were still on the ward. The decision was made for immediate c/section and hysterectomy. I knew we should move fast. But "fast" is not, evidently, part of the Malawian vocabulary! IV line, urinary catheter..she was bleeding from the urethra..not a good sign, Consent signed, take blood for laboratory, she would most certainly need a transfusion. I got hold of the trolley and started pushing her down the corridor towards theatre, administring her IV antibiotic on the way. Later I heard that one of the CO's had gone to theatre to inform them and shouted loudly that they had better get on and stop laughing and talking there was a ruptured uterus on its way! It is so unusual and so pleasing to hear that someone understood the emergency.
The operation was quickly underway and whilst I stood waiting to receive the baby I realized that we had not listened for fetal heart sounds. I remember reading in her referral notes that they were not sure if it could be heard. What the heck! What difference would it make? We couldn't move any faster and we were saving the mothers life. I commented to the surgeon. "I dont know if the baby is still alive but I doubt it" It was not an easy c/section, intense hemorrage made things difficult. The baby was well down in the pelvis, stuck in the bony outlet for how long? Completely stuck for enough time to cause her uterus to rupture in its intent to push it out. I pushed upwards on the head whilst the surgeon tried to pull through the abdominal opening. It took a while, I thought it would never come, but then I felt it come loose and the baby was delivered.
" Its alive! " the surgeon exclaimed as the baby made a small noise. I knew it was now up to me. This baby deserved chance! I must do a good job on resuscitating. As I inflated its little lungs with oxygen and sucked the liquor and mucous from its nose and mouth I really prayed for this little one to make it, to find the strength to live. And it did! Small gasps at first then stronger and it started crying. Turning a lovely shade of pinky brown I knew it was on its way. Boy or girl ? they asked me. Its a girl. Of course it would be! Everyone knows that girls are stronger, real fighters! You may laugh, we all laughed in theatre but its true, the girl babies do fight harder ( comments welcome!) The outcome of that story will keep me going for a week. You see it made me realize that it can be done in Malawi, it can be done in Bwaila. It justs needs the whole team to work together, to move fast, to really believe that the way they work that what they do WILL and DOES make a difference. That it is in their power to save lives not once or twice but many times. Before I left theatre with that baby and put it into the outstretched hands of the guardian I thanked them all, the doctors and nurses and theatre staff and told them what a wonderful job they had done. Later I used this example in my workshop to illustrate once more that what we do and how we act can make a difference. They need to be told. I think that they often think that what ever they do nothing will change.I dont believe it ...not yet...please.. not ever.
Befoer I left today I went to post natal ward. There I found her. A strong looking woman lying on her side with her little girl suckling at her breast. I wonder if she realizes how lucky she is to be alive and to have a live baby?

I've bought my car! Its blue, its little and its nippy! Its a four wheel drive and much higher off the ground, just right for my vivits to the villages. Next week I shall try it out as I go to visit my twins and my miracle baby. Now I have another miracle baby.... I hope I will have many more.

Some of you have asked how you can help my mums and babies how you can get involved. I refer you to my friend Carol who is supervising my sponsorship and continues to raise money for Bwaila hospital. SOS Malawi I'm sure she will be pleased to hear from you.

Friday, 9 May 2008


Firstly I would like to say to all those who send comments to my blog "Thankyou" Yes I do receive them. Yes I do read them. It feels good to know that you are out there sharing with me these amazing experiences and supporting me with your love and thoughts and words.
"Keep them coming"

Its two weeks since I last wrote and many things have happened since then. Last week Linda ( from Scotland) came to visit. Linda is responsible for a small charity called MUMS ( Malawis underpriviledged mums) She/they have done amazing things in raising huge sums of money to directly support Bwaila hospital and in particular the new hospital buildings. They are also involved in other projects here in Lilongwe. MUMS is one of my sponsors who along with one other private businessman have and are making it possible for me to be here. It was good to spend time with her. Apart from having a fun time together we were also able to make some useful and rewarding contacts with others involved in our area of work. I was particulaly impressed by the director of the Nurses and Midwives Association ( who act as a trade union supporting and caring for the carers) A strong passionate woman not afraid to speak out in favour of the health workers, doing a wonderful job at local and government level to try and improve things for nurses and midwives. Looking for ways and incentives to keep these valued professionals here in Malawi. I hope to keep contact with her. It is unusual to find a Malawian of her kind , especially a woman.
I cannot let Lindas visit pass with out telling you of the ' dance ' we attended . We were invited to attend a dance with local music and including a famous Malawian singer. It was to be in aid of the 'national nurses day' to be celebrated this week. We both imagined a large hall filled with midwives and a traditional band, so we deciced it should be fun. To our amazement, when we arrived, the venue was full of young men! I mean 100 men and no more than 10 women! Why should we back out now? We took a deep breath and entered. Well it was like bees to a honey pot! Most of the guys were young enough to be our sons but what the heck ! In the absence of greater and more beautiful talent we spent the entire evening dancing with and being surrounded by young, good looking, girating, black men! It did wonders for our ego but when several hours later the drum beat started hotting up and the beer taking effect ( its amazing how even an older white woman can suddenly become very attractive to these young guys in search of free beer!) we decided it was time to leave. I became slightly worried when one guy told me that the one I had been dancing with was only a 3rd year student whilst he already had a proper job earning 100.000MK ( 500 euros) a month . Definitely time to go !

I must tell you about my little miracle baby. The one whose mother arrived with the umbilical cord prolapse and I thought would never survive. I try to follow up the mums and babies that I attend who have special needs. It is impossible to remember all of them. So on Monday morning I went straight to nursery to see how this little one was getting on. It is with some trepidation that I enter. I always fear the worst as so many of those little ones just dont make it. I couldnt find him! On asking of his whereabouts I was told that the mother and grandmother had signed his discharge against medical advice and that he had gone home on Sunday. I was determined to find out how he was, so took note of the name of his mother and the village where they lived. My opportunity came the following day. After finishing my workshop I found labour ward was quiet and one of the midwives who had attended the training was eager to accompany me. So we set out for the village. I had asked directions but after following this route down a dusty mud road for more than 6 km. and still not finding the village, we decided to go back. I was not to be beaten. Its always good to have a native Chichewa speaker to ask directions and soon we were on the right track. This took us right through the middle of a typical mud hut village where as usual I caused a stir as the children ran out to the car shouting "msungu..msungu" ( white woman)
At last we found the village and asked for the family ' Luko' We were taken to the hut and welcomed with huge smiles by the whole family who were amazed to see me. My midwife companion was able to translate as she told us the story of her journey to the hospital via the health centre . The grandmother said when she saw the cord protruding she knew that it was dangerous for the baby. The mother had talked of the white midwife who had helped and been kind to her. They knew that we had saved the life of her baby. I asked to see the baby. We were invited to enter her hut and a cane mat was spread on the floor. We took off our shoes and sat down. I had taken some gifts of fruit and vegetables but hadnt dared to take baby clothes. I half expected the little one to have died. There he was lying on the ground, round and fit and healthy. Tears came to my eyes, I really did feel that he was a miracle baby! I was asked to give the baby a name, this is quite a honour, a bit like being a god parent. One is expected to maintain an interest in that child as he grows bringing gifts and food. ( so maybe there was a ulteria motive?) Never mind, I felt proud and priveledged ! At first I thought of Lucas but Lucas Luko was not a good idea! I said I would think of a name for next time. Maybe he will be called Joseph ( son of Rachel in the bible) certainly he was a lucky guy!

On Wednesday I was invited to attend a meeting at the District Health Office. These are monthly sessions to discuss maternal mortality rates. (The rate in developed countries will be around 5-10deaths in 100.000 whereas in Malawi it can be as high as 1.800 in 100.000) Cases are presented, discussed and questioned. Positive critiscism is encouraged to try to evaluate where, why and at what level there may have been a lack of care, materiales, information etc. This evalution will be returned to the health facilities involved in an effort to reduce maternal deaths and improve care. There must have been 50 or 60 health care workers present. I think that not more than 6 made any contribution to the discussion and one of those was me! The case studies lacked vital information. The recording of care is a real problem, one never knows if it wasnt done or wasnt recorded. One of the cases was a young 14 year old girl, married and in her first pregnancy. She died of Streptococcal meningitis, an illness perfectly treatable in the developed countries. We found a delay in taking her to the health centre on the part of her family..reasons unknown. A lack of care at the health centre who did not examine her fully and did not begin treatment of any kind. They immediatly referried her to the hospital. It was not recorded as to how long it took for transport to arrive. An overnight delay in her being seen by a clinician once admited in the hospital was evident so that when correct treatment was started it was too late.
This story is not uncommon, stories like this are heard everyday somehow along the way they have become acceptable. We are not suprised but for some of us we are sad, we are frustrated, we are angry. What were her rights to health care ? To good health care ? What were her human rights? What are Human rights? Where are they in Malawi ? What do they really mean in Malawi for these poor women?
Witchcraft is very much part of Malawi. It is very much part of day to day life. Superstitions and 'traditional medicine' is often where the people go to, turning only to the health care and hospitals when that has failed. There is, nominally, a move to educate the people away from this but it is slow and not terribly effective. On discussing the second case I was surprised when no formal diagnosis or cause of death was recorded or seemed to be necessay. I suggested that if the medical profession bothered to give families a real cause of death this would make it hard to blame it on some witchcraft or bad omen or as a result of evil behaviour. This was taken down and recorded. It seems that nobody had ever thought of this before!

This weekend we are going to Dwangwa sugar plantations. It is good to get away from Lilongwe every now and again. I need this time to forget for a while, to refresh and recharge. I am grateful to the good friends I have made who make this possible.

Last big news...I have found a small, jeep type, car to buy. I hope to take possesion of it on Tuesday. It will be better for my village visits and hopefully more economical than renting.