Thursday, 29 January 2009


How to be a good Mum and still continue to give to the women and babies in my care?
This has been in my thoughts almost permanently during the past few days.
On Saturday Lucas started to feel unwell. Most of the night was spent trying to keep down his fever and encourage him to drink. Living in Malawi means that every fever is possible Malaria. By Sunday he was weak and drowsy, had no appetite and just wanted to sleep. He refused all food and it was difficult to persuade him to take fluids. I was concerned but as the symptoms were very different to when he had Malaria last year I decided to wait and see. I am loath to treat without a pretty definite diagnosis. He continued to fell unwell but was not deteriorating. Monday morning he was not well enough to go to school nor did he want to eat but I felt that he was slightly improved. Instinctively I felt that it was not Malaria but could not find any reason for his persistent fever. I called by to inform his teacher. To be expected she was unable to support my decision to wait and see encouraging me to take him for Malaria testing. I began to doubt myself. The test was done much to Lucas’ disgust who also reassured me that it was not Malaria! I was negative. Leaving him with the nanny I went to work. A busy morning on labour ward then a meeting with Tarek and the project manager of the new maternity units to make some last minute changes to the theatres.
Arriving home at 5pm I found Lucas with fever and still feeling unwell. I had asked his nanny to inform me of any changes but she hadn’t. That night the fever continued and we passed another restless night. Tuesday he still wasn’t fit for school but he was somewhat better than the previous day. I still felt I should wait and not rush into unnecessary treatment which I truly believe would be detrimental in the long run. I left him once again with his nanny. Tuesdays are workshop days. These times together with the Bwaila midwives have become enthusiastically attended. They form an important part of my work here in Malawi. We had undergone a ‘quality control’ assessment during the past week and we now had to hear the outcome and discuss its relevance. It was not a surprise to any of us to find that the results were extremely unfavourable. Much can be attributed to the dreadful environment and facilities in which we are working but of course not all. There are so many areas for improvement. I was encouraged to see how quickly and openly the midwives began to participate in the discussion. It is so important that the solutions or recommendations come from the midwives themselves. I was able to stress the importance of working as a team and try and find small attainable goals on which to start improving. We have actually put some of these into practice already. We are also using these workshops to audit maternal death files of which we have four since the beginning of the year. We look at the details surrounding the death picking up any areas of poor or insufficient care or attention. Lack of staff or materials including laboratory or blood transfusion services. We then decide on actions to be taken and personell to be informed. This is proving to be a strong teaching aid. It confirms my belief that most of the midwives have the knowledge but very often are not converting this into everyday situations. How to achieve this has become my greatest challenge. So I returned home after another busy day. Lucas still had a slightly fever. He was now eating small amounts but as he explained to me “ Mum, I feel strange” Now I was beginning to feel insecure. Was I making a big mistake? Did he need to see a paediatrician? Was I withholding necessary medication? Was I being stubborn? Did I really know what I was doing? I made a decision there and then......If he continued to have fever the next morning we would go hastily to consult a specialist.
We both slept well that night. The best night’s sleep in days. On awaking this morning I could tell that he was better. No fever, hungry for breakfast and willing and keen to go to school. What a relief! I arrived on labour ward soon after 7.30am. The ward was full of women, many waiting for beds. It was going to be another crazy day! Our Norwegian obstetrician was calling for help. The placenta had separated from the uterine wall and the woman was bleeding profusely. The baby was already dead but she feared for the life of the mother. She quickly delivered the child with a vacuum extraction. We were prepared with IV lines, medication and most importantly with a ‘team’ of people. The massive haemorrhage was controlled, blood was available for transfusion, her life was saved. On another bed Stella had pushed out a 24week foetus (abortion) totally unattended. She was lying in a pool of blood, amniotic liquid, urine and faeces. I gave her the appropriate medication to prevent bleeding and began to clean her up. If she decides not to take away the foetus it goes in the bin along with the placentas.....that was the hardest part for me. That was just that was just the start of the day. Then came the usual pre eclampsias, post partum haemorrages, obstructed labours, foetal distress, birth on the bathroom floor ( not to be recommended ..the floor is filthy) I performed 2 vacuum extractions for foetal distress and fortunately just before leaving for home at nice straight forward uncomplicated birth. No babies died, though some had to be resuscitated, nor did we loose any mothers. My legs were aching, my throat was dry, I suddenly remembered I hadn’t eaten all day.
The best was arriving home. Lucas came running out to meet me. No shirt, no shoes with his arms open and a big smile. He was obviously better. He stopped when he saw me “I’m not going to hug you with all that blood and stuff on you” The troubles of the day disappeared, the tiredness left me as I took him up in a big hug despite the smelly uniform!

Sunday, 18 January 2009


"Megan's mummy died at Christmas so she could have her presents in heaven"
This was Lucas' news after his first day back at school. How easy how simple it was for a child to accept the unacceptable, to rationalize the unrationable, to fathom the unfathomable.
Is this why we hide the truth from our children? To protect them from reality, from the pain of knowing too much?
"But she died at the wrong time" he continued.
Now I was confused... I thought he had it sorted out? What did he mean now?
"Well you're supposed to die when you are old and she was just forty or fifty!"
That night he found it hard to get to sleep, we talked and we cuddled. He demanded I stay with him. I held him tight and he slept.
Being in Europe during our Christmas vacation was a bit like that... it made me realize how easy it is to hide from the truth, from the reality of Africa. Most people didn't want to know, didn't ask. They didn't want to hear of the poverty, the appalling conditions in the hospital, the critical shortage of nurses and doctors, the preventable deaths.... No, that would upset their comfortable world, so better not to ask. But not all ...some like Lucas knew there was more, that they wouldn't and shouldn't be protected from the pain. Here I found great generosity of spirit and of love. I found both financial and emotional support and for that I am grateful. You know who you are.. I don't need to put names but I do thankyou from the depth of my heart.
Christmas in Spain was all I expected and more. Being together with all my four children is such a priviledge and a joy. I am such a proud mum! How I miss them...but how lucky I am! Lucas spent many happy hours with his Dad which was just what he needed. He was pleased to find that he hadn't forgoten how to speak Spanish and even communicated with his Spanish family in Valenciano with ease.
We then spent time in UK visiting my family and a few old friends. I was so pleased to find my Mum in good health and spirits despite her recent operation. Its so much easier to be working here, however difficult it might be at times, knowing that these people love and care for me/us.

And so we arrived back in Malawi after a long and tiring flight through Nairobi and Lusaka. It felt good to be met at the airport by our good friend Mina, she and her family have adopted us since the day we arrived.
Going back to labour ward felt good. I was received with such warmth. Cries of how much I had been missed and lots of hugs. It's strange how one feels after being away, that things should have changed, but then you find they havn't and that makes you feel comfortable. Of course there is so much room for change at Bwaila I should have been happy to find some signs of improvement but no things were just the same.
Thursday was a public holiday. I knew we would be short staffed so decided to start work early.
It was probably one of the busiest days ever with just a skeleton nursing staff and one clinician. From 7am untill I left, exhausted at 2.30pm women were delivering their babies anywhere and everywhere, On the floor, between the beds, on unwashed matresses finding space whereever they could. I spent my time caring for mostly high risk mothers although couldn't help but catch two or three as they popped out unaided and unaccompanied on the next door bed. During these times its all about prioritising, I can't attend you all so who needs me most? Sometimes its the one who shouts loudest but thats not always the right one. How difficult it is to ignore their cries of "nursey, nursey, pain, pain!" but they are often ignored. She was just 17 years old and already HIV positive having her first baby, what were her chances of surviving to see her child grow. ?
Another 20 years old also HIV positive with chronic anaemia aborting her first pregnancy at 24 weeks. Luckily we managed to find blood to transfuse ,the following day she was still alive. Then there was the woman carrying her 10th child but with no living child. Now 2 weeks past her due dates and with a dead child. And so it went on and on that day. When I left the beds were stll full but I could do no more.I was phisically and mentally exhausted. The hardest thing is to walk away. I dont think I will ever learn how to do that well.
Then I came down with a rotten chesty cough and cold. I remember thinking as I listened to that man on the plane coughing loudly I wonder how many of us will catch that? Well I did!
Friday no labour ward. I left my cosy bed to attend our weekly 'Quality Improvement' meeting.Tarek and I arrived both arrived on time at 2pm. By 2.40pm we were still waiting. When the first attendants started to arrive 45minutes late we were so discouraged by the lack of interest we postponed the meeting until next week. Saturday morning I was to meet with other nurses to audit the maternal death files. This is supposed to take place regularly with the aim of critically reviewing the circumstances around the death focusing on where the problems are and taking the appropiate actions. Once more no one arrived. I set about organizing the files and taking a brief look at some of them. I was eventually joined by one of the senior nurses. We only audited one file. For me that was enough. This maternal death was purely and simply due to absence of blood for transfusion from the central blood bank and delay in organizing family donation which may have saved her life. This must be difficult for you to believe but it is the continuing reality of Malawi.
Tomorrow is another day. I will do what I can...that is all.......