Thursday, 28 August 2008


I am physically and emotionally exhausted !

These past few days have been exceptionally busy, not just the number of births attended but the nature of them. As I have explained before, Bwaila maternity hospital serves as the referral unit for the whole of Lilongwe and surrounding areas. This means that anything that can't be sorted out at health centre or district level comes to us.

Today has been one of those days when we have been continually receiving referred patients. Yes these are true patients. There situation/condition means that the birth is now not normal, has passed to the realms of pathalogical, of difficult, of dangerous or very dangerous.

I arrived as usual soon after 7am. at the same time as an ambulance bringing us 3 women from the same health centre. It sometimes makes me wonder what they have been doing with these ladies all night ? A retained twin, now dead with one arm visibly hanging from the vagina.Two prolonged 2nd stage..this means that they have been pushing in vain for hours without result.

I started to prioritize. We have only one operating theatre, so who needs to go first?

The baby is already dead, in case one, so she can wait. Severe fetal distress in the second means an emergency c/section to save the baby. But the third although there was no fetal heartbeat to be heard the mother had a ruptured uterus thus endangering her life. Maternal life before fetal wellbeing meant the second had to wait. Her operation was carried out later and the baby is alive....just!
And that was how the morning went. When I had time to look at the clock I found it to be already 1pm. No wonder I was hungry and thirsty!
It was a morning of assesment, evaluation and decision making. It was an immensely challenging morning. I was encouraged at times to find a true feeling of team work with my Malawian colleagues, clinical officers, medical staff and midwives. As we hurriedly passed each other in the ward, one of the C.O's gave me a "thumbs up" sign as if to say " another one safely delivered" It was great to see his obvious pleasure at a job well done. This is not something I see very often as mostly I think that the Malawian staff don't believe that what they do, how they act, will really make any difference. It made me realize how driven I am, personally, by this feeling of 'making a difference.' To just one mother or baby just one at a time. Its what keeps me going. Its what makes my days worthwhile. Its what makes me cope with the tiredness, the exhaustion ,the frustrations, that feeling that I am really making a difference. The day I dont feel this I might as well give up. If money isn't an incentive, which here in Malawi it obviously isn't, then there has to be some reason to keep going. If they rarely feel they make a difference then this may account for the uncaring, negligent behaviour I often encounter.
I was further challenged to assist a twin breech delivery. Both came feet first and weighed over 2.5kgs. this is large by Malawian standards. Both presented difficulty with the birth of the aftercoming head but with my now greater knowledge and experience I was able to help these little ones out safely.

I cannot tell you all the situations that I find myself confronting in labour ward, but sufficient to say that daily I find myself putting my skills to the test, learning, becoming more practised and confident and able to help these lovely Malawian women and babies.

My girls will be here this time next week. I can't wait!
Untill then I go to rest, to have fun time with Lucas and my friends, to live each day to its full.
There is so much to do and so little time....ENJOY!

Wednesday, 20 August 2008


Friday of last week I was going to write to you but I was too angry. I went to a braii (barbeque) instead! Tarek had arrived back from his time away in Europe and along with him a new obstetrician and nurse from Holland. It was good to meet new colleagues although, unfortunately, they will only be here for 5 weeks. I was also able to vent my anger and frustrations to a listening understanding ear. As I have mentioned before Tarek normally comes up with some helpful insight into the situation and he didnt let me down this time. Opinions that evening were that I should still write. I should write with my anger along with all the other confusing emotions that confront me daily. But now it is Wednesday and the anger has calmed. Today I still feel some of those angry feeings but I am also encouraged by the students with whom I have been working hard during the past 3 weeks and their changing attitudes.
Sometimes we are so busy on labour ward that we really cannot attend all the women and babies however hard we try. Women are neglected to birth alone and difficult births end in tragedy.
But on Thursday morning there were only 3 women to attend. I arrived later than usual (8am)
The midwives change shift at 7.30am. I was met by 8 senior student midwives and 3 midwives chatting, cleaning, generally milling around. Having greeted everyone I donned my plastic apron and approached the first bed. There was no record of maternal or fetal observations in the past 2 hours. I listened to the fetal heart beat...I heard severe fetal distress. On examining her I realized I could assist the birth with a vacuum extraction. I called one of the students to help and the baby was born quickly. I resuscitated the child whilst the student attended the mother and all was well. It was now 8.30am. I passed on to the second my horror I saw that this baby was last observed at 6.45am. now nearly 2 hours ago. The baby was ok, so after encouraging the mother to get off the bed and try some more comfortable positions I then went to the 3rd bed. This mother and baby had not been attended since 7.20am. It was now 8.40am.
Only 3 women .... 3 neglected women and babies.
I was furious! I marched over to the milling crowd of midwives and students...
" We have only 3 women to attend" I shouted. " I have already assisted a baby with fetal distress and the other 2 have not been attended for 1 or 2 hours this is not acceptable, I cannot cope with this!"
I attended one woman, whilst 2 students went to the other bed. They called me immediately. The heart beat was low the woman could not push out her baby she needed an emergency c/section. At 9.40 the baby was extracted in operating theatre. It was necessary for us to perform extensive resuscitation but the baby lived...just... and is now doing well.
Later I apologized for shouting. " No, no " they replied, "you were right" Overall they are a really good set of students and I am encouraged daily by their progress and how they are quickly learning to become competant in their tasks. It was also good to hear them readily accept that in this instance they had failed. I hope they will remember my anger and it will teach them just a little about their responsibilty to the women and babies in their care.

I am continuing with the weekly ' workshops' for our midwives at Bwaila. I was thrilled to find that whilst I had been sick and then away with Alasdair the courses had continued under the leadership of the matrons. They had been well attended and the midwives were very positive about them. In meeting with thematrons to plan ahead for the period from now untill the end of the year we were able to agree on subjects to be covered and divide the teaching between us.
I am so pleased ! This may just be sustainable... and thats what its all about. How much better that they are also being lead and encouraged by their own matrons.

Lucas is back at school. He seems happy with his new teacher, "...who doesnt shout, not like you mummy!" But seems to have some pretty tight rules!
Social life has started up again as everyone returns from their summer(Europe) winter(Malawi)
holidays. We have a new Zimbabwean family living on the compound which means Lucas has constant playmates. Not always a good thing!
We are counting the days untill Katy and Fiona arrive at the beginning of do I miss my kids!
I want to leave you with one of Luki's many astounding comments /observations.
" I dont know why children are not allowed to watch Lord of the Rings because it is too violent? It is the adults that shouldn't watch fighting and killing because they can do it, but the children can't, they just stay with their mummies."
Worth thinking about don't you think?

Wednesday, 6 August 2008


My health has forced me to take time off from my work at the hospital. This beautifully coincided with the return of Lucas to Malwai after his trip to Europe. He was able to have time with my family in UK and catch up with his dad in Spain. He was accompanied...I'm not sure who accompanied who?... by my eldest son, Alasdair, who stayed with us for nearly three weeks. The timing was perfect. I was in great need of family love and care which is exactly what he's good at and which he did to perfection...thanks Alasdair. We had already organized to explore some of the Southern part of Malawi together and were away for 9 days. Alasdair got thrown into Malawi life straight away as he took over all the driving. Our trip included time at the lake..warm sunny and swimming. 2 days in the mountains... chilly, log fires and pine forests, followed by a 2 day safari. This was an amazing experience for us all. Unrepeatable episodes with elephants were the highlights of our trip as we managed to get the car into the middle of the herd.. this is not recommended and was a cause of a huge adrenalin rush and much fear for a while! We also had a huge bull elephant grazing outside our cottage just 1 metre from the window! I should also mention the tyre that punctured on the road to the lake. We thought we were in a pretty remote spot untill we found ourselves rapidly surrounded by a dozen locals all offering there services. I must admit the pit stop was unbelievably quick. Alasdair was quite willing and able to change the tyre but didnt get a look in, he just handed out wet wipes for hand washing afterwards much to the amazement and amusement of all!
We have many lovely stories and incidents from our trip too many to write down now but sufficient to say it really was just what I needed. I feel strong, I feel positive and refreshed I am ready to continue with all that I believe I still have to do here. I am looking forward to being back with the women and the babies at Bwaila.

Last Thursday we said a sad farewell to Alasdair and on Friday morning, bright a early, I was back on labour ward.

I was very warmly welcomed back. My fellow midwives kept telling me how much they had missed me. ( I expect they have to work harder when I'm not there!) I too had missed them, the work, the mums and the babies.

I have worked every day since then. I shall tell you that when I left this afternoon we had recorded 340 births during the month of August. Today is the 6th ( tomorrow is my birthday!) that means more than 50 births a day!
This is unbelievable, this unimaginable, this is totally crazy! If you could just see the size and condition of labour ward. The women who dont have a bed and birth on the floor. The lack of clean ..not to mention sterilized instruments, of gauze swabs or cottonwool, of gloves, but more importantly of midwives. Today I apologized to the woman in the bed opposite..."pepani, pepani... sorry, sorry". No one should birth alone. I was attending a post partum hemorrage an emergency situation. She screamed and she pushed "nursey, nursey" but I could not go to her so her little one slithered out alone. They were alone. I called to her to encourage her I could do nothing more. My priority was to attend the other woman. So there were no caring hands to catch him, no one to scoop him up and clean him off, no one to stimulate his first breath he /they were alone. It was lunch time. The student midwives and clinicians had gone for lunch, one midwife was in the admission room and the other was in theatre with a c/section. I looked up, I looked around, I was alone. I attended 5 births in the next 2 hours. At last I saw a clinician attending at the other end of the ward. I called for help. When he arrived it was to ask me to help him perform a vacuum extraction for fetal distress. I quickly left the woman that I was suturing..that could wait till later..the intervention was quick and simple the baby was fine, I left him and returned to another woman pushing. She had been on labour ward for more than 1 hour but nobody had examined her or listened to the baby's heartbeat. I could see the baby's head. I tried to explain to the lady I was suturing that I would be back, that I had not forgotten her as I rushed to find some instruments, some basic materiales to attend this birth. Three pushes and the child was born but its condition was not good. I hurriedly took him to the resuscitation area. As I worked on the baby, who responded well, I was thinking of the woman lying there on her own. Was she bleeding? Was the placenta out? did she need me? Where should I be? with the mother or the baby? There was no one to help me, I was on my own too.
All these mothers and babies are now fine and well. When I had finished and left them all clean and dry with their babies suckling at the breast I had to fill in the labour files and charts and found I could not remember most of the details of each one, no times of birth, boys or girls? it wasn't important so I didnt know! 2 hours had passed as if it had been 5 minutes!
Dont think this is a strange situation, that this happens every now and then. No.. this is happening nearly every day and most nights. Where are the other staff? how is it possible for them all to disappear at once? These are the very questions I continually ask. And I do ask, but I get no answers. Now can you understand why the busiest maternity unit in Malawi and one of the busiest in the whole of the South African continent has such a high maternal and neonatal mortality rate? Why oh why is it like this? why do these women not deserve better? They do deserve better. I am trying oh how I am trying, but it sometimes feels impossible. However hard I work, however quick I run I just can't reach them all. I suppose this is normality for the Malawian staff, but I have seen better, I know better, I know what should be, but how?

I was so angry yesterday. I was told that on " bed one" the baby had died in the first hour of life. On examining her file I found that she had been pushing for 5 hours. The clinician had been called but arrived 3 hours later, meanwhile no one had checked nor the maternal nor the fetal condition, nor had they used any interventions to aid the birth. This happens with referral cases that have to journey fron outlying districts, or have been attended by poorly qualified attendants. But this woman was on our labour ward in our hospital! I informed as many people as possible. I was not prepared to keep letting these incidents happen without any accountability without any responsibility. On talking to one midwife she informed me that some midwives believe that if the woman pushes and the baby doesn't come it is her fault for not doing it properly for not putting in enough effort. The mother is responsible! This is the attitude I knew existed in the villages but we are a hospital with trained midwives! Could it possibly be that some of our midwives share these beliefs? I despair.....but I am strong and I can carry on.

There is so much I could write today. I am feeling good and positive and confident despite all that I face daily. If I can save just one baby or one mother If just one baby or one mother is better cared for because of me it is enough. At least for today...I wonder how I will feel tomorrow?