MALARIA AND MORE

It’s nearly two whole months since I last wrote to you all. Fiona has been and gone. It was a truly wonderful time with her. Fiona is so easy to please and just slotted straight into our lives here in Malawi. I don’t think that it was always easy for her. Living and working in such a poor country inevitably needs a great deal of adaptation. She enjoyed her work experience at Lucas’ school as well as very bravely making regular visits to one of the local orphanages. The children all adored her and she made special little friends. She found it heartbreaking each and every time when she had to pack up the toys and leave. The little ones clung to her with tears in their eyes as she gave them a final cuddle. Lucas just loved having his big sister around. He too clung to her at the airport last week not wanting to say goodbye. The house is quiet now.
Bwaila continues to arouse in me all manner of conflicting emotions each and every day. It has been an exceptionally busy couple of months with totally inadequate staffing. We have had to rely on our students to ease the workload which is far from ideal as they have little experience or practical knowledge. My priority has been to work with all these students. Teaching supervising and mentoring on labour ward is essential as well as sorting out the more complicated situations as they arrive. It is very tiring work but hugely rewarding to see the students learning and improving.
I have been actively involved with our Quality Improvement Team for the past 3 years. Last month we put together a presentation of the data/statistics of the past 2 years. It was encouraging to see that although the number of deliveries has increased substantially (more than 2.400 births during 2010 compared to 2009) our Maternal Mortality Rate has reduced. Death due to hemorrhage was previously the main cause of death but this has now been successfully addressed and I am happy with the way that our permanent staff respond to this emergency as well as taking measures to prevent it.
We are still losing too many babies during the first few days of life due to Birth Asphyxia. This has mostly been caused by inadequate monitoring and prompt decision making during labour. We are now working towards reducing these numbers. These initiatives demand an important amount of more formal instruction as well as bedside supervision and teaching.
Since January both Dr Ibe Iwuh (our Nigerian registrar) and I have worked to ensure regular teaching on the morning round. This is mostly attended by intern doctors and clinical officer students but I continue to encourage the student midwives to participate. As the most experienced midwife on labour ward I take on this teaching role each and every morning. My work in this area is greatly appreciated by the students themselves.
But ‘incidents’ still happen only too often.
Yesterday we lost 2 mothers. It was a bad day.
Today we lost 2 babies. It was another bad day.
Catharine had been referred to us from one of our outlying community hospitals. They had already decided several hours earlier that she needed her second c/section due to a large baby and inadequate pelvis. They had not been able to perform the operation as they “had no anesthetist.” By the time she arrived with us several hours later the baby was severely distressed and her uterus on the point of rupturing. We quickly prepared her for theatre and advised the operating staff. Unfortunately they had just started another intervention. I ran to theatre to find out how long she had to wait. And found the place in darkness! The main theatre electric switch had ‘tripped.’ I found the switch but it would not move. Looking into theatre I saw that the c/section baby was being extracted by the light of 3 mobile phones! I am proud and continuously amazed by the resourcefulness of our staff. I ran to switchboard to ring the electricians. ‘msanga msanga’ (quick quick) I implored them. I managed to find a torch that was functioning on the Post natal ward and took it into theatre. By the time I had sorted all that out I went back to labour ward to see how Catharine was doing. The fetal heart beat was consistently low. Maybe it would be possible to open up the 2nd theatre as I knew we had a 2nd anesthetist that morning. So that is what we did. Unfortunately we had delayed too long and though I was present in theatre to receive the baby and ready to resuscitate, the little one was born dead. The uterus was on the point of rupture but with some good surgery was repaired. We saved the mother but not her baby.
Last week I visited this same community Hospital. The ‘road’ was almost impassable at times. Luckily we had taken a good 4* 4 vehicle and only got stuck once in deep mud. It’s the rainy season and many health centers and villages are almost unreachable. This particular Hospital has a 110 bed capacity. Of course there are many who will be on the floor. They have one clinical officer and 16 nurses in total to cover all the shifts. This is Malawi reality.
February saw the visit to Malawi of Annie Lennox as an ambassador of the Scottish parliament. She visited Bwaila and publically recognized the work that we are doing there. It was a huge morale booster for our staff. I was present at a reception given in her honour where my own work at Bwaila was also personally recognized. As a result of this I was invited to meet with the Malawian First Lady, wife of the president Bingu Mutharika. I felt rather nervous as I drove through the gates of State House and wondered how was it possible that I got here to this place It was a great privilege for me to be able to talk with her personally as a representative of the hospital. My first aim was to get her to promise to visit the unit. This I achieved and true to her word she visited us last Thursday. It was an informal visit at short notice, as she had requested, with little pomp and ceremony, but it was hugely important for our midwives who felt encouraged and boosted by her words of thanks and appreciation. How amazing it must be to be able to make so many people so happy just by one short visit.
Today was a quiet day for Bwaila but not without incident. Patricia arrived around 10am. She came from home. It was her 3rd pregnancy, the previous 2 had ended in normal healthy deliveries .She was being admitted by two of our junior students when I entered the room in my teaching/supervisory capacity. The young student was examining her so I asked her to tell me her findings. ‘Is the baby ok?’ I asked. She assured me it was .On checking her examination I failed to hear the fetal heart beat. Checking with the ultra sound scan I could see no fetal heart activity. During all this time she had no contractions but was fully dilated and therefore should be ready for the expulsive stage. Uterine rupture is extremely rare in the richer countries but here in Malawi we see it only too often. I immediately suspected that this had occurred and called for help from my colleagues. There was no doctor on the unit and our most experienced Clinical Officer was in theatre. We attended to her quickly and called the ambulance to transfer her to the central hospital as she would need an emergency hysterectomy ( removal of the uterus) and was at risk of huge hemorrhage. Whilst we waited for transport we were able to get 2 bags of blood for her and immediately started the transfusion. Our transport vehicles are far from adequate so we had to literally bundle her into the back of the 4*4 half on and half off the back seats. She arrived safely, was operated and is now in the intensive care unit in a stable condition.
Shortly after arriving home I received a phone call from a Malawian woman who said she had given birth with me. I have no idea who she is. She explained that her daughter, now pregnant had been admitted to our ante natal ward last Sunday with Malaria. Her voice was of fear and concern as she explained that the nurse had told her that her daughter could not be treated for the illness as the hospital didn’t have any Malaria medication. This morning in the hand over meeting it was reported by the nurses that they had run out of Malaria drugs and had been informed that they were not available. They had been told that Malaria drugs were not to be found anywhere in Malawi. I had listened but I had not taken in the true reality of the situation. Labour Ward has its own issues and Malaria drugs is not one of them .I immediately phoned the nurse on duty to ask about the situation. It is true, we have no Malaria drugs! Now what was I going to say to this mother who would have to spend another night not knowing if her daughter’s condition would deteriorate with no possibility of treatment. Her only possibility was to try the local pharmacies to see if she could buy the drug privately. Even if she was able to locate the drug this would probably economically impossible. I promised I would see her tomorrow. I cannot stop thinking about her…but what do I do? She is not the only woman on the ward who is being deprived of treatment, I can’t possibly solve this problem for them all….Tomorrow I will see her, I hope I am not too late? I must have been her last hope and I have failed her…. If this is really true, if Malaria drugs are out of stock country wide many women and children will die. We are still in the rainy season, which is the time of most incidents of Malaria, this is a terrible thing. Many will die, but mostly the poor, as the rich will always find a way.