Sunday, 28 November 2010
It’s been a very hard two weeks. Since the new referral unit opened at Kamuzu Central Hospital and we at Bwaila became a District Maternity Unit the number of births we are attending has hardly changed. We are daily attending more than 40 births many of which need very special care and attention.The new central unit took some of the more difficult cases but they also took ALL our medical staff. We are now led by the District Health Management Team who for many reasons, not least the huge area/population that falls into their responsibility, are noticeable by their absence. Staffed mainly by midwives, with their continued reluctance to take on more responsibility, a few clinical officers with very varying abilities plus interns and students it has become evident that the care we are giving is less than adequate and the women and babies are suffering.
Having diagnosed severe fetal distress in a young first time mother who was still not in active labour I found the clinician in charge to request an immediate c/section. It was 12.30pm. Theatre was informed, the admission nurse was ordered to prepare the mother for theatre and I had to leave the unit for one hour. On my return I asked after her and it was presumed that she was in theatre. I thought no more of her and continued with other work. A 2pm I overheard a conversation which sounded as if it concerned this woman. I was called to scan a woman as the midwife couldn't hear the fetal heart. Entering Room 8 I found my emergency c/section woman still waiting to be prepared for theatre. She had been put in a room and been forgotten. I quickly scanned her and to my relief found that the baby's heart beat was still present but extremely fast. This baby was in severe distress. We prepared her for theatre and the baby was extracted at 2.50pm nearly and two a half hours after I had first recognized the problem. The baby was born dead.
This is unacceptable.
Our protocol on the unit is to perform c/section on all first time mothers whose babies are presenting breech (bottom first)
Wednesday morning on arrival at labour ward I was told there was a breech delivery on a primigravida, fully dilated and pushing, in Room 4. On entering the room I could see that both the baby's feet and legs were visible, blue and puffy. This baby needed delivering fast. Realizing that it was too late for a c/section I quickly put up an IV and emptied her bladder. I delivered the baby with the appropriate maneuvers and some help from a young Norwegian midwife colleague. After resuscitating the baby it was able to stay with its mother without need for nursery care. This mother had been on our labour ward for most of the night but the breech presentation had not been diagnosed.
This is unacceptable
Thursday morning I arrived as usual at 7.15am. I enquired if there were any problems and was told there was a breech to be delivered in Room 2. On entering I found both feet and legs already delivered, blue and puffy. Glancing at her case file I realized she was a primigravida... NOT AGAIN! I commenced the IV line and emptied her bladder and couldn’t believe that I was facing the same again, two consecutive days. Slightly encouraged by the experience of the previous day though a little alarmed by the size of the baby's feet (I imagined a big baby) I started to deliver the breech. The shoulders came well, with the correct maneuvers, but the head got stuck. I attempted all the correct maneuvers, instructed a colleague to assist and at last the baby's head was born. I rushed the baby to the resuscitaire but my attempts were in vain. The baby died.3.3kg...Too big for a 17 year old woman. Looking back over her file I found that she had been admitted before midnight, the midwife had not been sure of the presenting part so requested USS confirmation. The young intern performed the scan and was also not sure but documented that the scan should be repeated in the morning by seniors. Both recorded a head presentation. She spent the night on the Ante Natal Ward calling for help around 7am as she felt her 'waters' break and 'something' in her vagina. She was attended 30 minutes later when she was found with the baby's feet protruding. They rushed her to labour ward which is where I found her. Three mistakes from inexperienced staff with no senior back up resulted in a young mother with no live baby.
This is unacceptable.
Friday morning I arrived at the same time. I looked into Room 2 and saw one of our new midwives attending a birth. I opened the door to greet her and ensure she was OK when I became aware that a breech was hanging out delivered to the level of the umbilicus. The shoulders and head had still not been born. I noted that the baby's colour was blue nearly white and the umbilical cord was not pulsating, this is not a good sign. I had no idea of what had happened prior to my entry nor how long the baby had been waiting to be born but I could see that it needed delivering quickly. I encouraged the midwife to actively assist with the birth of the shoulders when it became obvious that she was unsure as to how to manage the situation. I tried to explain but quickly had to 'take over.' The shoulders came easily. 'Is it her first?' I asked. 'No it's her second child' I was told. That made me feel better. I soon realized that no contractions were coming to facilitate the birth of the head. 'Put some Oxytocin in her IV line' I ordered. I looked up...There was no IV line! I had been quick but by now I was extremely concerned for the well being of the baby. Still there were hardly any contractions meaning that the mother’s pushes had little effect. I had already called for help from another midwife who I instructed to assist with the flexion of the after coming head. Should I take time to put up an IV line or continue to try and extract the head? Time was running out and I knew it....whatever I did would be wrong, whatever I did would probably not be in time....I couldn't believe it, I didn't have time to save this baby. Time had run out. Too much time had passed. The baby was already dead, maybe it had died before I entered the room? I don't know, but I felt useless, I felt impotent, I was angry, I was frustrated, I was devastated. I told the mother I could do no more. I calmly put up the IV line with Oxytocin, I emptied her bladder of over 1000mls. of urine and with no more than 3 good contractions and pushes I easily extracted her 2.9kg baby. The baby had died due to a full bladder that had prevented the head from descending, poor uterine contractions with no IV line to allow me to give the correct medication and a huge lack of skilled staff.
This is unacceptable.
Of course it is not only due to lack of staff, to lack of experienced staff, to lack of the drive to improve skills, to implement knowledge and skills that cause these tragedies. No, it is so much deeper and more complicated than that. The wages are unacceptably low, the work load is heavy, constantly heavy, the moral is low and the staff are little appreciated by the higher management. They are easily and quickly critiscised when things go wrong but rarely praised for their efforts.
This is unacceptable.
A few weeks ago our only ambulance was taken to be used on ‘stand by’ for the African Union Conference in Lilongwe. It was parked for a whole week outside the hotel just in case one of those eminent people should need emergency transport. An open ‘pick up’ truck was provided some days or else an old hard top truck. It was in these vehicles I made two emergency transfers to the central hospital. The mother had been transferred to us through a local health centre after a home birth. She had had a massive hemorrhage and was critically ill. We stabilized her condition at Bwaila and managed to find one bag of blood to transfuse but she needed more blood and to be cared for in the ICU. Just getting a patient in this condition into the back of a truck is a challenge but then we also had to transport her numerous relatives with bags and bowls and even a bundle of fire wood. I took up my seat in the front facing backwards to check her condition and carrying an ambu bag just in case she stopped breathing. I prayed that her condition would not deteriorate as I could not imagine performing effective resuscitation in this truck. I ordered the driver to get there quick, that this was an emergency. We started off out of the hospital and onto the busy shopping area surrounding Bwaila. “Put on the siren” I ordered. There was no siren. “OK , then sound the horn” The horn was not working. “Lights” No, not working either.
This is unacceptable
What an amazing driver! Totally oblivious to any danger, or so it seemed, he pulled out into the centre of all the traffic and just kept going. Not to be deterred by either on- coming trucks or pedestrians he just kept going. Luckily I was facing backwards for most of the journey, except when we came to junctions or traffic lights when I stuck my head out of the window, waved my ambu bag and shouted very impolitely for people to get out of the way. It worked .We arrived in record time and delivered our patient into the care of the ICU staff still alive. Our return journey was somewhat more sober. “ Madam,” exclaimed the driver. “ We were all very impressed with how you cared enough to make sure we got there quickly, this is not normal behavior, the relatives have asked me to thank you”
( No I guess this is not usual Malawi behavior but I had done it before. I was reminded of an incident when I was seen almost flying down the mountain road in Spain, waving my white flag out of the window, as I personally and successfully transported one of my ‘home birth’ mothers to the nearest hospital.)
Each and every one of these women stays with me today. My heart is sad and my spirits are low as I leave Malawi. It is such a difficult place to leave. So much to do, so much suffering, so much poverty, such a hard life for so many. I love these people, I want to always do my best for them and it is so hard to accept that even my best is often not enough.
Now I am back in England in the arms of my family and soon I will be reunited with my children.
One is loved because one is loved. One loves because one loves
No reason is needed for loving.
Monday, 15 November 2010
As you may well imagine it’s an attractive proposal for any would be donor. It looks good on paper and sounds convincing…but…
Over the past year I have been actively involved with an expert team as they worked on creating the appropriate software. Funding became available for the setting up of a simple registration system to suit the needs of the unit and provide the necessary hardware. For this we are grateful. Latterly more funds became available to expand the project, meaning that I have needed to dedicate more of my time to attend meetings and aid with preparatory work. I trust this time away from the clinical situation, away from labour ward has been well spent…but…
Inevitably there will be some resistance from the staff at first until they become familiar with this new method of record keeping but we hope that it will lead to far greater accuracy and therefore better care. Leaving paper behind and changing over to electronic recording should ease the constant challenge we face daily when paper is not available for photocopying. We are assured that it will prove to be easier and quicker but at present I doubt it!
I arrived on labour ward last Friday at the usual time (7.15am.) I found the ward full of laboring mothers with many women sitting on the floor outside the Admission Room waiting to be assessed. On enquiring as to how the night had been I was informed that for the second time in one week there had been just 3 midwives on duty…. Three midwives to attend 27 births.
My first job is to take a look round the ward and receive the ‘hand over’ from the night staff. I must make a quick assessment of the situation and start to prioritize. I am usually the first to arrive much to the relief of the tired and overworked night staff. The arrival of my daytime colleagues is generally delayed and sporadic, meaning I often find myself alone or with one other midwife for the following hour. It has always been a difficult time as I try to sort out the problems left over from the night performing vacuum extractions on prolonged labours and subsequently resuscitating babies that should have been born hours before.
The morning report in the conference room attended by the clinical staff, in-charge midwives and matrons begins at 8am. It is an important time when we get together as a team to discuss the events of the previous 24 hours and the plans for the day. Very often I am not able to attend as there is no one else to cover the labour ward.
At 9.30am I was called to a meeting with the matrons of the Family Health Unit ( antenatal clinic, immunizations, postnatal clinic, etc. …all out-patients) We were to meet with those involved in the development of the new ICT program. I left instructions with the student midwife as to the plan of care for the mother with prolonged labour in Room1 and asked a more qualified midwife to cover her. ‘ If she has not delivered in the next hour please assist with a vacuum extraction or send her to theatre’ I always feel uneasy leaving the more difficult cases but I was needed in the meeting. One and a half hours later I returned to labour ward. The baby had just been born and needed resuscitation and the mother was bleeding. I quickly performed the necessary resuscitation and as soon as I felt able to leave the baby went to assist the midwife who was attending the mother. After controlling the hemorrhage I left the student to suture and document.
So I was in a meeting with the aim of improving care, whilst a baby nearly died and a mother nearly bled to death!
How difficult it is at these times to appreciate the possible benefits of a computerized system when we are having such huge challenges just performing the basic care.
The day continued to be hugely busy with many complicated and demanding situations. I was due to attend a further ICT meeting at 1.30pm. but this was just impossible. I could not leave labour ward at this time, especially after my experience of the morning. Lunch breaks range from 12.30 until 2pm when we work with just a minimum staff. I have always chosen not to take a lunch break preferring to work during this critical time but aim to leave a little earlier. As you can imagine leaving a little earlier does not often happen! Two women with severe pre-eclampsia ( high blood pressure etc.) were admitted during this time. Finding myself without a clinician but now totally familiar with the protocol and treatment of this very serious condition I go ahead and administer the appropriate drugs and care. The challenge then became apparent…… I needed to inject (IM)large doses of Magnesium Sulphate to prevent convulsions a truly dangerous complication of pre eclampsia carrying a high risk both to the life of the mother and the baby. This medication needs to be mixed with local anesthetic otherwise it is an extremely painful procedure. I knew we had been running down our stocks for the past 4 days but were now completely without it. I was aware that the midwives had been suturing the women’s perineums without it, which is totally unacceptable, but assumed that either it was ‘on its way’ or I could ‘borrow’ from another ward. But NO there was no stock in the hospital nor in the pharmacy. I made calls to the Medical officer in-charge who was in a meeting and would call later. The question was now whether I should give the Mag. Sulph. without anesthetic and risk the possible consequences or cause the mother intense pain? I gave the IV dose and waited. Before I left to go home 10 bottles were supplied and I was able to give the medication. I wonder how long that lasted and whether there will be any tomorrow?
Physically and emotionally exhausted by 3pm on Friday afternoon I was further challenged by the admission of a woman in advanced labour carrying a twin pregnancy complicated by a previous c/section scar. Our protocol advises that in our circumstances these women should not labour as the risk of rupturing her uterus and causing death of the child and possibly of the mother is very high. I had just sent another mother for c/section so knew that the theatre would be occupied for some time. I decided that in view of the fact that she was almost ready to push her babies out I would attempt a vaginal delivery. The first twin I delivered quickly and easily assisting with a vacuum extraction to prevent unnecessary strain on the uterus. The second twin decided to put its hand alongside its head making the whole process much more difficult. The little one was born, also with the help of a vacuum extraction 30min. later needing intensive resuscitation which was successful .Even though I gave the necessary medication to prevent hemorrhage the mother still bled excessively , but these are strong women and the outcome for both mother and twins was good.
I went home exhausted…..I burst into tears ….I had a warm bath and a cup of tea… then danced and partied until 3 o’clock in the morning!
It was just another day at Bwaila……….
Today is Monday so I went to check up on my twins from Friday. The little boy(number 2) is still in nursery but doing really well. I am always amazed and humbled to recognize the great power and strength of our instimct to survive. I also visited mum and first twin(big sister) on postnatal ward. I was greeted by huge smiles and hugs. The mother was so happy to have avoided a second c/section making her so much more able to care for her twins.
The toilets are still blocked since Friday and we are running out of local anesthetic again but life goes on at Bwaila and I am happy to be here.
Friday, 8 October 2010
The on call anesthetist just didn’t show up for duty
….but life went on at Bwaila.
These sort of situations are unimaginable in the developed countries but not with us here at Bwaila, one of the busiest maternity units in the whole of Southern Africa.
So what happened?
38 babies were born during that time.
6 mothers were transferred to the new referral unit it the central hospital for emergency c/sections and 2 babies died. Fortunately we didn’t lose any of our mothers.
I arrived on labour ward on Monday morning unaware, at that time, of the difficulties that had been faced by our staff the previous day and night. The only evidence was the half burnt candles still present around the ward. Many babies will have been born by the light of those few candles and many will have been born in darkness. I was approached by the clinician who had been on call that night. ‘How’s the night been?’ I enquired. ‘Bad, really bad!‘ he replied and proceeded to explain the situation. He asked me to come and see the woman in room 1. It was her 3rd pregnancy. She was fully dilated and had been pushing since 1am. That was over six and half hours ago! The clinician had tried to extract the baby with the aid of a vacuum extraction somewhere around 2am. but without success. He tried in vain to send her to the referral unit but was told that they were too busy. Unable to make any other arrangements and without the anesthetic necessary to perform the emergency c/section, she was still in her room contracting and pushing when I examined her at 7.30am. The fetal heart beat was still present but inevitably showed signs of severe distress. It was immediately apparent that there was no way this baby could be born vaginally. Time was running out for the baby and possibly for the mother, who after so many hours of obstructed labour was in danger of rupturing her uterus which would result in the need to remove the uterus and could lead to severe haemorrage and possible death. I quickly made sure that she was prepared for theatre and asked the clinician to find out if theatre staff could take her in immediately. Fortunately the anesthetist on duty Monday morning had just arrived. Our voluntary obstetrician from the UK was also present and surgery was commenced. It was a risky and complicated procedure due to the time that she had been obstructed needing the help of our German consultant obstetrician. Having extracted a dead baby they then went on to remove her uterus which had been on the point of rupturing with uncontrollable bleeding.
Today she is recovering in our high risk postnatal ward, she is not in danger of losing her life and that is a good.
Of course this is not acceptable. Of course this brings feeling of anger and frustration but we are in one of the poorest countries in the world. The whole health system is inadequate for its people. We are understaffed, under skilled and poor equipped in every way. As clinicians and midwives at Bwaila we are improving, the care and attention to the patient is rarely consistent and the infrastructure does not always support us but we must keep positive and enthusiastic as we aim for excellence.
The new Ethel Mutharika Maternity Wing has now opened at the central hospital. Bwaila will slowly change its function to becoming the District Maternity Unit. All the high risk patients will be sent to the new wing where they can be cared for by a larger medical team and backed-up with an intensive care unit and improved neonatal services.
We will continue to be extremely busy as we the care for the women and babies of the ever increasing and expanding population of the district of Lilongwe. We will still receive referrals from the health centres and villages as well as caring for the pregnancies, babies and young children of the area. Dealing with emergencies, stabilizing patients for transfer and maintaining our own operating theatres will continue to be a huge task. We will lose our doctors to the central hospital leaving the unit to be staffed by Clinical Officers and midwives. The need for more highly skilled midwives will be greater than ever. Midwives able and ready to use their knowledge, make accurate assessments, good decisions and follow through as skilled practitioners is my aim.
I continue to do classroom teaching twice a week and bedside teaching on a daily basis. It’s tiring and often frustrating but it’s slowly making a difference and I am proud of the way some of our midwives are responding.
At the beginning of the year I was able to find funding to present a ‘midwife of the month award’ as a means of encouraging good practice. At that time it was very clear who would win the award as those few clearly out-shone all others. I am pleased to say that we are now finding it very difficult to select just one person each month. This is a sure sign that there are now many outstanding midwives. I find this extremely encouraging…..and you should too!
Last week was a quiet week. Just 25 to 30 births each day. We continued to keep busy but without the sensation that many of the women were receiving less than adequate care.
Today is Monday. I arrived on labour ward soon after 7am. 18 babies were born before 12midday. Just 5 midwives reported for duty this morning. We then lost 2 of them to meetings which left 3 of us to cover the ward, admission room and theatre. There are always problems to solve from the night and also things left over from the weekend. Inductions, prolonged labours, fetal distress, referrals, all needing our time and skills. This generally means that the easy ones end up birthing alone, calling out for the midwife as they push their babies out onto the bed. We enter the room just to clamp the cord delivery the placenta and move on. The babies get weighed, later…. if we find time, the documentation is scanty and the after-care often non- existent. I must have delivered more than 10 babies myself but did not have time to take even one blood pressure. In an attempt to avoid un-necessary c/sections I assisted two women with vacuum extractions and successfully delivered a breech on a very young primigravida. The baby needed resuscitating and the mother suturing. The outcome was good for both, but extremely time consuming, meaning that other mothers just had to wait. The midwives seem tired and demotivated today which I always find distressing. We very quickly ran out of delivery packs meaning that for each and every birth I had to search the ward for some way to improvise. The cupboards were almost empty as they had not yet been restocked after the weekend. I could not find any suture material or cord clamps. It was a hard day for me both physically and emotionally.
Last Thursday we had a visit from a team representing the Nursing Council. They came to inspect the ward and the care and attention we are giving to the mothers and babies. The meeting this morning, which I would like to have attended but could not due to shortage of labour ward staff and heavy workload, was to receive the feedback from their visit. Later this afternoon I found time to hear from one of my colleagues the contents of the report. It was highly critical. The infection prevention standards are not being met. The documentation was poor. The care was not up to standard. The midwives had a very defensive attitude. I was angry and disappointed but not surprised. No account was taken of either the huge lack of staff or materials. This report in my opinion served only to decrease an already low morale. So much of my time at Bwaila is spent in raising morale, keeping the atmosphere happy and positive, giving praise for simple tasks done correctly and celebrating good outcomes. I truly believe that although some official appraisal and control of standards is vital it must be done in a realistic and positive way. I wonder how long it will take to get back the enthusiasm at Bwaila?
Just to end on a happier note…..
Fiona has just celebrated her 21st Birthday in Leeds. I was sad not to be able to be with her but will have a special something with her in December when I am in UK.
Katy and Nick’s wedding is getting nearer (Dec.30th) Invitations are being sent and the dress fittings will start soon. It’s all so exciting I can’t wait!
Alasdair is on the lookout for a good job now that he is a fully qualified vet. He was recently interviewed but hasn’t heard yet if he has been successful …….
Lucas is fit and well again after having being diagnosed and treated for Bilharzia. (A nasty little bug picked up in the lake.) He took part in his 1st fishing competition last weekend. He was delighted to win 4th prize.
Sometimes we have to struggle…..sometimes not. The issue is not the struggle: the issue is who we are as we engage in it.
Tuesday, 24 August 2010
Pregnant with her second child she went into labour prematurely at only 7months. Before the first pains of labour began she started having convulsions. The local gulewamkulu (witch doctor) was called as it was presumed by her family and the rest of the village that she had been bewitched. Steps were taken to find the person who was bewitching her. Five days later, after numerous fits she gave birth to a small dead fetus. By now her condition had deteriorated to such an extent that on day 6 post-delivery she stopped talking and walking. They continued to use the services of the gulewamkula and local medicines still believing that this was the only remedy.
Agnes was brought to us on Monday morning at 8.05am. 8 days after giving birth and 13 days after her first convulsion though we presume she must have had signs of her illness well before that. I was asked to go and see a woman in room10 who had arrived in a critical condition. My first impression on seeing Agnes was that she was only just alive. She was deeply unconscious and only taking gasping breaths. I called for help and assisted by a midwife colleague and a student we started to resuscitate Agnes. It was difficult to find a vein in which to insert an IV cannula but we managed to fix 2 lines and take blood samples. We started her on oxygen and quickly catheterized her bladder to check her urine for proteins. At some point I ran to the telephone to call for medical assistance. Whilst the intern doctor tried to get some information from her family so we could get a clearer picture of her condition she went into respiratory and cardiac arrest. It was now 8.15am. I sent for the anaesthetist to intubate and started CPR. We continued to resuscitate for more than 20minutes but with no response whatsoever. Agnes was pronounced dead.
The conclusion was that Agnes had suffered from undiagnosed Eclampsia. Untreated for 11 days she suffered a cerebral vascular accident (CVA) Complicated by puerperal sepsis she finally suffered septic shock, respiratory and cardiac arrest and she died.
This was a totally avoidable maternal death. This condition can be treated.
Of course she came to us far too late. We did everything we could but it was already too late for Agnes. Her family cried and wailed. This was the same family that delayed in bringing her to us for more than 13days due to their local superstitions.
How can this happen? Why are these people still so poorly informed in 2010? Why are these superstitious beliefs still so strong to the extent of allowing their loved ones to die? Why do the women not come to receive care in our hospitals?
Agnes was eventually brought to the hospital which means her death will become part of our Maternal Death Statistics. In Malawi around 900 women in every 100.000 will die in pregnancy, childbirth or immediate post natal period. (In Europe it will be 5-10 per 100.000) But how many young women are being buried out there in the villages without any record being kept?
Agnes was a beautiful young Malawian woman. A mother, a daughter, a wife, a sister and Agnes was very, very, poor….could this be the reason why she died?
Lucas arrived back from Europe yesterday after having been away from Malawi for the past 7 weeks. What a joy, what a pleasure to have him back with me. A house should always be filled with that special something that only a child can give. He has obviously had a wonderful time with his ‘papa’ doing all those things that mummy doesn’t do……fishing, catching birds, shooting everything in sight, watching the football at the bar, buzzing around on his motor cross bike and the new mini bike doing incredibly dangerous things and staying up all night! He has also been able to spend time with his big brother and sisters. I am so happy that he has such a close relationship with them all, that they love and care for him and that he in turn is so proud to be their little brother. He talks of them constantly and I know misses their company.
It’s been an interesting 7 weeks for me. Being on my own has been very different than usual both relaxing and liberating but sometimes lonely. I have been working hard and long. Arriving early in the morning and staying late without the worry and guilt of not being at home for my child is a feeling many working mothers will appreciate. I have also been playing hard. My social life has been rich and full. Starting with all the excitement of the world cup football which involved nights out several times a week to support whoever happened to be playing that day whilst remaining true to, first England, then when they ‘went out’ to Spain. We were only a small crowd of serious Spanish supporters which made us even more vocal and loud as we cheered them through to the final and then the championship. It’s amazing how nationalistic one becomes when away from ones origins! I have never been to so many farewells as I have during the past 2 months. This is one of the peculiarities of living in a developing country. Most of the ex-pats will be working on 2-3 years contracts which means making friends very quickly, enjoying them to their full and then moving on. I am lucky to also have very special friends who are Malawi residents which gives our life a little more continuity and stability. With no need of a ‘baby sitter’ I have seen the insides of the Lilongwe night clubs as well as playing a few rounds of Black Jack at the casino. There is really not much more to do in Lilongwe, no cinema, few nice bars or restaurants or places to dance so we make our own social life with private parties and ‘braiis’(BBQ’s) I have missed Lucas but I have been able to find my way without him too and that is good.
Tarek left Malawi last week. After working together in Spain for 3 years he left Acuario to take up his position in Lilongwe becoming head of Obstetrics and Gynaecology in both Kamuzu Central and Bwaila Hospitals. We have a very special relationship both in and out of work. His list of achievements during the 6 years he has been in Malawi is both admirable and extraordinary.
This is a part of what I wrote about him before he left:
……. Kamuzu Central Hospital is the main referral hospital for the whole of the central region of Malawi. It is the Teaching Hospital for the University of Malawi attending to the clinical placements of students from both the College of Medicine and the College of Nursing and Midwifery. Bwaila Hospital is the city of Lilongwe’s only District facility. Together they serve a population of over 5.5 million. Plagued by diseases of extreme poverty and social deprivation with all its incurrent and specific problems they carry a huge burden of severe pathology. Approximately 13,000 births are attended each year. The units are consistently understaffed and often deprived of essential drugs and equipment. Such severe working conditions are also exaggerated by poor discipline and low staff morale making the leadership such a huge undertaking. Dr. Meguid has consistently shown his full commitment
…… Teaching has formed a highly important part of his role. As an exceptional and experienced clinician himself, he has tirelessly shared his knowledge, teaching and guiding medical and nursing staff as well as national and international students
……With a vision for the future of the department, or more importantly, respectful and dignified care for the women of Malawi, Dr Meguid was the co-founder of The Chitenje Trust. Being its manager resulted in achieving the necessary funds for the erecting and subsequent opening of two new, modern, maternity units for both central and district maternal care at Kamuzu Central Hospital and Bwaila
…… It has been a privilege and a pleasure to have known and worked with Dr Meguid. His contribution to our hospital and more widely within the health sector in Malawi has been, without doubt, one that will be remembered for many years. His passion, enthusiasm, leadership, strength and persistence even in the most difficult of circumstances have all led to (this) list of outstanding achievements.
Tarek is a very special person. He has played a hugely important part in my life….because of him I am here. I shall miss him terribly.
Thursday, 22 July 2010
Bwaila is great! I am so encouraged by the way things are progressing. The atmosphere on labour ward is one of enthusiasm and fun. The feeling of team spirit is noticeable, even to an outsider, as the staff begin to respond to their colleagues and help each other out in the more difficult and challenging situations.
This may seem like ‘normal’ to you but I can assure you this is new and exciting at Bwaila.
We are attending an ever increasing number of women and babies. Sometimes up to 50 births in 24 hours! Word has spread around the district of the new unit and the women prefer to come to us than attend their local health center. We have started up our in-service training sessions again and are looking at the problem of birth asphyxia. That is, the babies being born in need of resuscitation to a greater or lesser degree. Our Quality Improvement Team is meeting regularly and putting forward new initiatives to address this. The results so far are positive.
July 6th was a public holiday (Independence Day) There were only 3 midwives on the ward and just 1 clinician so I decided to work that day. I started as usual at 7.15am. By midday I had assisted 9 births and by the time I left at 5pm. I had attended 13 deliveries. It was a crazy day. Had it all been straight forward and easy it would have been extreme, but as usual, Bwaila sees all the referral cases from the whole district plus our own often very High Risk mothers so it was far from normal. I counted 4 vacuum extractions, 2 breech births and 2 sets of twins amongst the women l attended, plus the usual prolonged labours, eclampsias and such like. A total of 52 babies were born during those 24 hours. I was the most experienced person on the ward. It was exhausting but highly rewarding.
I came home yesterday feeling good…..
It was after 4pm. when I was called loudly and urgently to Room 2 to assist a newly arrived, referred patient with ‘cord prolapse.’ The woman had been accompanied in the ambulance from a local health center by one of their midwives. She informed me that the cord was presenting in front of the baby’s head but that the bag of waters was still intact meaning that as yet there was no pressure on it and therefore it was still pulsating. The baby was still alive! The protocol for’ cord prolapse’ is inevitably cesarean section, but in our circumstances, with only one theatre and less highly qualified staff the decision has to be ‘which is the quickest way to get the baby out?’ It was her 3rd delivery which makes the situation a little easier as she would be able to push the child out more rapidly. I assessed the situation a found that although the head was high, in this case it is what had saved the baby from hypoxia due to cord compression, the cervix was fully dilated. The contractions were coming hard and fast. The baby and the mother pushed down with each and every one. I knew that it would not be long before the bag of waters broke bringing the baby down onto its lifeline...its umbilical cord. I made a fast decision to deliver the baby vaginally as I believed this would be the quickest and safest way. It is not easy, but I know that I can knowledgably and instinctively follow my decision once I have made it. It was so amazing to see how the other midwives and students responded to my decision. (Apart from the midwife from the health center, who doesn’t know me!) The IV line was placed, the bladder emptied, the vacuum extractor and delivery pack brought and the resuscitaire prepared. Just in time as the membranes broke spontaneously with a huge contraction and the head came down. Trying to fix a vacuum cup onto the head of a baby rather high up in the pelvis with a long loop of umbilical cord in the way is not an easy task but I had done this several times before so I knew I could do it again. Several attempts and time was passing, I knew I needed to do this quickly to avoid oxygen deprivation. At last I got it well placed, the oxytocin was in the IV line to increase the strength and effectiveness of the contractions, another midwife aided by pushing down on the top of the uterus and in one big long push/pull the baby entered the pelvis rotated into the correct position and was born. The student clamped and cut the cord and I rushed the baby to the resuss. area leaving my colleague to attend to the mother. With some quick and effective resuscitation management the baby began to breath. Around me there had been 5 student midwives, 2 clinicians, 2 young interns and 2 of my fellow midwives. The team came together and the result was excellent for both mother and child. The smiles and enthusiasm of each and every one was a joy to behold. This is what I will remember and will keep me going in the tough frustrating times. Yes… I had done the vacuum extraction but it was the true team work that saved the life of that little one.
This is probably the sort of response that you would expect in your well staffed, well equipped, well qualified, well organized hospitals over there…but I can assure you that this is new and amazing for us here at Bwaila.
And what of my darling and amazing children…….
Lucas has been away in Spain visiting his Dad, Fiona and Alasdair for over 1 month. He will return on 10th August which is still 3 weeks away. I miss him a lot but am happy to hear that he is very much enjoying his time there, experiencing some of the luxuries of being in Europe such as the cinema and McDonalds!
It has been wonderful to be able to spend some real quality time with Fiona during her two visits here in Lilongwe during the past three months. She would have liked to stay longer but had to fulfill her obligations as a teacher in a summer school in Valencia during the month of July so it was a sad goodbye for us both. I miss her too!
Katy keeps me updated as she and Nick prepare for their wedding at the end of the year. I shall be saving all my holiday for that time and am so looking forward to spending some time with them in December before celebrating their marriage on 30th. What a wonderful way to end the year.…Happy times ahead! Imagine me…. The Mother of the Bride!
Alasdair needs to be well congratulated for graduating from university. He is now a fully qualified Vet. I am very proud of the way he has ‘stuck at it’ even through the long, hard times when I think that even he wondered if he would ever get through. I never doubted his determination nor his ability….
It’s so good to read back over what I have written and realize how positive I am feeling . I am happy here in Malawi, I am challenged and rewarded and full of energy to continue. Thank you all for your support and love.
Tuesday, 1 June 2010
I wrote this almost three weeks ago but it has taken me all this time to be able to get a decent internet connection in order to send it to you Hopefully the next one wont take so long!
Plans? Future plans? Where am I going? What will I be doing?
Do I need to know? How far am I able to plan anyway? How much control do I really have? Things can change from one day to the next, from one moment to the next and all those plans go out the window and we start again.
Life is an unknown journey that leads us to places we never expected and the directions change along the way. The excitement, the possibilities are all out there waiting for us as we make our plans and follow our dreams knowing that at any time it may all change.
As I plan for the next few months I am aware how much happier I am and how much easier I feel when I put away the anxiety of ‘future plans’ and allow life to guide me in the correct path. That doesn’t mean I sit back and do nothing; I try and test all the doors to see if they are open for me but am aware that the path will become clear as I go along. It’s not always an easy path and needs a good dose of positive thinking and faith but it is there in front of me and I will follow where it leads.
Plan 1. I will sign a contract to stay here at Bwaila for the next 2 years. I truly believe that the commitment and continuity I can offer to the maternity unit is my best way of serving the women and babies of Malawi.
Plan 2. I will be spending the month of December in Europe to celebrate the marriage of my eldest daughter Katy. What a pleasure and what I joy this will be. What a privilege, as a Mum, to be involved in this wonderful occasion, to be part of the excitement, the plans, the love, the sharing and caring as Katy and Nick commit themselves to each other and a future together.
Plan 3. Lucas will travel to Spain in June to spend the long holidays with his Daddy in Spain. I shall surely miss him for those 6 weeks but his Dad will have the pleasure of being with him and strengthening their relationship.
So that’s it for now…I wonder what else will come my way this year.
I slept and I dreamt that life was JOY
I awoke and I saw that life was SERVICE
I acted and behold SERVICE WAS JOY.
I think that this sums up how I am feeling at this time.
Life goes on at Bwaila with all its challenges, upsets, difficulties and conflicts. It is impossible to run our unit safely with the constant shortage of staff in all areas but especially midwives and clinicians. I can continue to tell you the stories of the women that have to wait more than 3 hours for their emergency c/section putting either their life or the life of their baby at risk .We find us constantly in this situation.
The woman had been referred from one of our Health Centers. It had already taken more than 3 hours to arrive from the moment of referral, due to distance and transport issues. When she arrived I quickly summed up the situation and realized she needed an emergency c/section. The baby was severely distressed and I was not sure how much longer it would cope. Unfortunately we had just taken another mother to theatre so she would have to wait. The surgery complicated which meant she would have to wait longer. I decided to attempt a vacuum extraction as she was fully dilated and it was her fourth child. It didn’t work and maybe I made the situation worse but I just couldn’t stand by and do nothing, I had to try something. She was still waiting 90 minutes later when another woman was admitted. At 34 weeks pregnant and actively bleeding the baby was alive but she continued to bleed. Placenta Previa was diagnosed (the placenta lying in front of the baby’s head) this was a priority as both the baby and the mother were at risk. Mother’s life takes priority over baby so she was taken first. By the time that operation was completed my original baby was dead. How to explain that to a mother who had been prepared for c/section nearly 3 hours before and told it was to save her baby’s life? More than 40 births in 24 hours and just 4 midwives on night duty. Little wonder that when I arrived at 7am. Many babies had not been monitored for at least 5 hours. I continue to spend the first 2-3 hours in the morning trying to sort out the problems brought over from the night. The labours that have gone wrong, the babies that just won’t come, the women that are totally exhausted. With so many births to attend there is little time to sort out the problems as just attending to those who push them out on their own will take up most of their time.
Let me tell you the story of the woman who set off walking, on her own, from her village more than 15kms. away to give birth at Bwaila. She had been told it would be safer as she was carrying twins. The labour progressed quickly and she found herself by the side of the road with no money for transport and the birth imminent. She tried to stop the few passing cars but nobody heeded her. Fortunately 2 local women assisted the delivery, in the bush, of triplets. They then left her by the side of the road. This was now 9am. At 4.30pm she was picked up by a passing motorist and brought to Bwaila. Both she and ALL the babies were alive and well although she was dehydrated and exhausted. The babies had all been breast fed. We took her into the ward and the babies to nursery where they continued to do well. She is now at home back in the village and being supported by a small organization that try to follow up our orphans and needy mums and babies .I will personally be visiting them over the next weeks.
Or maybe I should tell you of another woman who was accompanied by her mother. She too birthed her twins on the side of the road with the help of the grandmother then caught a minibus to our hospital straight after.
These are amazing women, worthy of our love and respect, our care and support.
I stand humbled in their presence. Just imagine this happening to one of our European mums?
Improvement is our aim and as such I have played an active role with our Quality Improvement partners to this end. It’s not easy to find the time just to meet and discuss these issues as time and midwives away from the ward means women less attended. We have rejuvenated the team and now have some enthusiastic members. Our goals for the next few months are to reduce Neonatal deaths due to Birth Asphyxia. (Especially related to prolonged labour). We have designed some posters for our delivery rooms reminding the staff to monitor closely the baby during labour.
‘Please listen to my heart beat every 30 minutes to make sure I’m OK’
Although our Maternal Death Rate, due to bleeding post-delivery, has reduced we have also decided to address the monitoring of the women in the first hour post- delivery to prevent this type of hemorrhage going un-noticed. We have designed a check list for this purpose and hope that these initiatives will bring results.
So labour ward remains incredibly busy. Time just flies past and there are never enough hours in the days. Each and every procedure I perform, each and every birth I attend I use as a teaching opportunity for someone. Whether it is a student midwife or clinician or one of our trained staff the purpose is to share knowledge. If I know something then it is my obligation to ensure I pass this knowledge on to someone else. What use is it to keep my knowledge and experience for me?
Little by little, small steps, don’t expect too much, keep positive and ENJOY!
If anyone wants to donate a music system to labour ward this is my next plan!
NEXT PLAN: Getting the women off the bed, out of their pain and suffering, dancing with the midwives and hopefully achieving a better birth.
Thursday, 25 March 2010
I truly find it incredibly difficult to be away from the hospital and even more difficult to REST.
I have had time these past days to reflect on the above statement and to be honest I have even been avoiding doing that. How easy it is to give the right and correct advice to friends and colleagues.....’Take time off, look after yourself, make a full recovery before going back, you’re not getting any younger, take care of your body, you’re no good to anyone if you are sick, your health is important, just stay home and rest, they can manage without you...........etc.etc. We say them so easily and so lightly but how many of us really manage to take our own advice?
As I write I am thinking of all the things I could be doing at Bwaila. The women and babies to attend to, the midwives to mentor, the matron to support, the student midwives to supervise, the new Spanish midwives to orientate and more and more and more. As I sit here at my laptop biting my nails and writing of my dilemma I ask myself once more, ‘Why Rachel, why?...why can’t you switch off and rest ? Why can’t you switch off and recover?’ Where is the peace when I’m not doing enough, today, I’m not doing anything today? I’m resting...I’m recovering!
How arrogant of me to think myself so needed, so irreplaceable! Do I really lack so much in humility? The reality is there is SO much to be done and so few to do it. But I can’t do everything, I can’t be everywhere? What a conflict in my head, in my heart! My world is so small, just Bwaila, just Lilongwe, just Malawi. And what about the rest? Such a tiny part of the whole! Oh how I wish I could change it all make it better for everyone. Where is the justice in this world that means these poor people in Malawi are not and cannot expect to be cared for and attended to in the same way and to the same level as you do back there? How naive, how immature..... just my thoughts.
What if we all really loved enough, cared enough to make things better? Ok, so it doesn’t mean we all have to dedicate ourselves to the poor and the under developed countries but with each and every person we come in to contact with today. Our family members, our work colleagues, the person in the shop or restaurant anywhere, everywhere.....How many times this has been said by how many people? Is it really achievable? Is it really sustainable? So let’s go back to me, in my little world here in Malawi and think small then it becomes achievable for me, it becomes sustainable for me and that is enough.
If I am sick I cannot do this, if I am weak it is not possible. So I must be healthy and I must be strong. I will search for the peace that is not in the physical not in the ‘being there’ but in the spiritual, being here in this moment.
‘We are not a physical body with a spirit but spirit with a physical body.’
I will rest and I will recover so better I can serve others once more.
I am now fully recovered and back on labour ward. The past week has been exceptionally busy as I continue to make the supervision of students a priority. They are only with us for 4 weeks and during that time they have so much to learn and must become competent in all areas of normal physiological birth. Finding sufficient ‘normal’ births so that they all may reach their quota has proved to be extremely difficult. We are attending so many complicated births and seeing so many pathological situations that would never be seen in the first world. Foetal abnormalities that would have been picked up on scan but are not diagnosed until labour, premature births, dangerously high blood pressure are just some of the many situations we encounter daily. So I try my best to teach, to repeat, to show and to encourage the students so that they too in the future will teach others.
My days start at 6am. After dropping Lucas at school I am at Bwaila by 7.15am. This is always a difficult time as the night staff are very tired after their 15 hour shift and keen to get home often leaving many problems to be sorted out by the first day staff to arrive. And that is usually me! After a quick handover when I try to take stock of the situation I start to prioritize. On many occasions I find that there are a least 3 or 4 women who need immediate attention. The day staff have still not arrived and I find myself alone. A grand multipara (8th baby) in room 6 has been pushing for 3 hours, A primipara (1st baby) in room 2 has been fully dilated with foetal distress since 5.30am. In room 3 another primipara has not progressed in 6 hours and Room 4 has been waiting to go to theatre for 2 hours for a c/section but the theatre is busy. I am not exaggerating....this is the reality of Bwaila almost every day. The next time I look at the clock it is nearly 11am. Deciding which to attend myself, which to delegate and which to teach can be difficult. I try to look at the bigger picture and share my knowledge and expertise but very often it just seems so much quicker, easier and more effective to do it myself. The hours and days fly past and the weekend comes round again. How I love to spend time with Lucas, my friends and in my home for those 2 short days before going back to the never ending succession of needy women and babies at Bwaila. This still remains the hardest part of working at Bwaila. Never finishing, never doing enough, always with the feeling that there is so much more to do, so many more women and babies to attend.
Although the new unit has 2 operating theatres we have not been able to open the smaller one due to lack of staff. It would need a totally separate team of nurses, doctors and anaesthetist and this we do not have. As a result we are daily having to make choices as to which mother or baby should go first. The choice is often extremely hard as taking one may lead to the death of another. We have found ourselves in this situation many times this past 2 weeks and women have been waiting for up to 4 hours or more for their ‘emergency’ c/section.
As the main referral unit for the whole of the Lilongwe area, which can stretch up to 80kms away from the hospital, we are daily attending the mothers and babies sent from these outlying areas. The road access to these centres is almost inaccessible especially now in the rainy season. The journey to the main road may be as much as 20 to 30 kms. thus delaying the arrival of these women to our unit. I was horrified to receive 2 women both in the last stages of labour after a delay of 6 hours. The referral was made at 8.15am.... they arrived at 2pm. I always treat these referrals as a priority. On examining the first women I found her to be fully dilated and ready to push. She had been referred as her labour was not progressing. ( at 8.15am!) I could not hear the foetal heart, I quickly scanned here to confirm my findings. Just 10 minutes later she pushed out a dead baby.The second woman had been pushing for many hours.The theatre was busy so I decided to try and assist with vacuum extraction. I tried and I failed. Already prepared for theatre she was taken at 3pm. The baby was extracted alive but died minutes after birth. Two transfers two dead babies. I needed to know why? Why had it taken so long to bring these babies to us?
The ambulance had to negotiate more than 20kms. of dirt road full of pot holes and mud. It had crossed two rivers. The ambulance broke down on the way. The women were waiting for 4 hours on the side of the road for another ambulance to arrive. This is the care that the poor women of Malawi are receiving. They have no voice to complain and their cries of sorrow are not heard.
The problems with my funding are still not totally solved but I have been promised that it will be sorted this week. Things are getting a little tight as I wait for the money to be made available but I remain positive and confident that I am still in the right place, I am still where I am most needed and will therefore continue to love and care for these women and babies as best I can
Thanks to the amazing generosity of our good friends and neighbours Zaida and Vincenzo we were able to spend a beautiful weekend in their cottage on the shores of Lake Malawi. This is just what I needed to reflect, rest and prepare myself for the following week. A trip out in their boat to a small island where we could swim and snorkel in the clear fresh water of the lake, appreciate the beauty of nature and remind myself once more how much we have and how rich our lives are... for that I am grateful.
Saturday, 23 January 2010
‘Ever tried. Ever failed. No matter. Try again. Fail again. Fail better’
As has happened in the past I had left instructions and had been given promises that outstanding works and deliveries would be completed whilst I was away. I don’t know why I was surprised to find on my return that very little progress had been made. There are still some items that havn’t been delivered and poor workmanship in the building and installations that needs to be followed up. Unfortunately the DHO who are now responsible for the new unit have very little government funding for administration and maintenance. The new unit is at least 4 times bigger than the old needing 4 times the maintenance. There is much more equipment meaning many more machines that can breakdown or go wrong. The fact is that they were unable to cover these areas in the old unit (much smaller and much less) so it is not surprising to find that the new unit is proving to be a huge challenge.
I will continue to hunt for funding to assist with the maintenance issues. Since returning I have worked on completing a list of outstanding repairs and damages and poor installations. I was horrified, but not surprised, on inspection to find many areas in need of important repair work only 3 months after moving in. The constructors will cover most, but not all, of these things during the first year but after that....what?
We had been waiting, since the opening, for the delivery of 7 new neonatal resuscitaires for the labour ward, theatre and nursery. The delivery had been finally promised for 18th December. They had not arrived when I returned in January. One of my first tasks was to check up on these. Can you imagine my joy when I finally unpacked and installed these last week? I felt as if someone was bringing me a personal Christmas present! The brand new photocopier was still sitting in the office, not yet unpacked. After 2 e-mails and 2 phone calls the Minolta agents for Malawi arrived informed me of the missing items and the cost of installation and left to await my call. The DHO are now responsible for this but as usual funds are not available. Fortunately I still have some money that I have been given by kind donors and will get it set up and working next week. The new anaesthetic machines are causing problems. Having been supplied from Germany it is not altogether straight forward when needing to find replacement parts. The old machine is still in use, it has half the possibilities but it’s familiar and comfortable to use! 2 of the 6 suction machines were not working. The Autoclaves for sterilizing instruments, installed just before I left, are functioning sporadically. Fortunately the representative for the suppliers ( a Brit.) once informed, does his very best to solve the problems. Unfortunately the general habit is to leave the non functioning items in a corner collecting dust and continue either with the old or make do without.
The on-going in-service training that I have been leading for the past 2 years was stopped just before I left to be taken up immediately on my return. This forms an extremely important part of life at Bwaila. It has become, over time, not only an important time for building practical and theoretical knowledge and training in life saving skills, but also for team building, motivation and moral boosting and generally keeping the staff together. Helping to maintain a team spirit is a huge challenge, hence the importance of these regular meetings, discussions and teaching sessions. Unfortunately there has been some mix up with the funding from UNICEF due to a duplication of projects. This has meant that the sessions have not yet been commenced. The staff enquire daily as to when we will start again. They too realize its importance. As I have commented before it is difficult to get people to attend any sort of training or meeting without receiving an allowance. This has become an integral part of Malawi life in all sectors. Invented by some NGO at some time to ensure good attendance it has become the nightmare of any person who is trying to encourage personal and professional growth without the need of economic reward. Last Thursday I was absolutely thrilled to lead a meeting of our Team Leaders/charge nurses without any allowances. I could not have done this without the help of the matrons who encouraged the midwives to attend. I did but them all a Fanta or Cocacola though which was greatly appreciated. This was a huge step forward and made me feel very good. These are the small things that continue to occur daily which give me the courage and strength to carry on.
I am trying to get back onto Labour Ward full time or as much as possible without completely dropping the other areas of higher management, administration and other responsibilities that have become part of my work and to which I am looked for to support the management team. I do just love being with the women and babies and being there this week reminded me of that. I hope you will be getting a few more stories from there in my next blog.
Until such time I will end by telling you that Lucas has settled back happily into school and social life. He is now in the junior squad swimming team and the junior football team. Time flies by, the rainy season is well underway and the maize is growing in the fields. Some areas of Malawi are not so fortunate and already having problems with their crops. This time of year is always a difficult time for the most poor as last year’s maize is running short and the harvest will not be for several weeks. The prices rise and many people in the villages become hungry. I am still supporting 2 lots of twins and the triplets who come to visit me regularly at the hospital. Pilirani’s twins will be 2 years old on 14th February I will drive out to the village to visit them and take some gifts.
I cannot end without telling you that on Friday we were presented with details of the Bwaila maternal deaths for the month of November 2009. I knew already that the numbers had been high. When auditing the case histories it became clear that the majority were young, had chronic anaemia, arrived very late at the hospital for assistance, had suffered severe haemorrhage, blood was not available and if so not enough to save their lives. These women had died in childbirth due to POVERTY. In 2010 this is a harrowing thought, with all the money and aid that is being poured into the developing countries this is still a reality.
I hope this blog has not been too negative. I find it thoroughly therapeutic to write down my thoughts and feelings. Those of you who know me well also know I am strong and determined. When I compare myself to my Malawian Mums I am very fortunate. Think of me often......for me I ask no more......but for them?
PS. Christmas with our family and friends was just wonderful. Just thinking of them and their love and support makes me feel good. My children are just such a joy to me. From Alasdair’s exams in his final year of Veterinary Studies, Fiona’s rollercoaster life and love and trying on wedding dresses and planning weddings with Katy who will be married next winter, I am kept busy and entertained with much to think and worry about as a mum. My Mum who shows no sign of her age or giving up on her hectic life (guess I must get it from somewhere!) continues to worry about me as if I was a teenager. I am looking forward to seeing her plans in the Spring if her plans work out. It will be a big challenge for her but I know that being able to see for herself the life and needs of the people she has been supporting for most of her life will be a real thrill for her. Not to mention visiting me and Bwaila.