Birthing a dream

JUST ANOTHER STORY TO TELL

2011-08-09T15:37:00.000+02:00

I want to tell you the story of Chikumado (meaning ‘Someone who is not happy’)
Chikumado’s mother lives in one of the many extremely poor villages about 20kms. outside of Lilongwe, the capital of Malawi. As far as I can find out she has had ‘psychiatric problems’ for some time. Her husband Cidy claims to have married her because ‘I had been without a woman for such a long time so I thought I would take care of her.’ I believe that he too is highly unstable. It is not clear as to whether her first child, a girl now two years old, is fathered by her husband or was the result of a violent incident.
I only met Cidy and his wife today.
I had arrived on labour ward at the usual time just before 7.30am. Checking for any problems that needed to be solved from the night I then attended the morning ‘hand over’ meeting. I then returned to labour ward where I take the daily responsibility of leading the morning round with the clinical staff, students and midwives. This is wonderful opportunity for teaching in the practical situation as we discuss each and every case in detail learning and planning care.
My mobile phone rang twice but it was not a good time to take the call so I let it ring. The third time it rang I answered the call. Beatrice is a nurse/midwife colleague who I have known almost since I first arrived in Malawi over three years ago. She is running a small charity organization set up 4 years ago by an Marican midwife (Joanne) with the aim of supporting the families of our orphans from Bwaila. That is to say when a mother dies in our care they will support and encourage her close family to care and raise the child in the village rather than take it into care(orphanage) We have worked together closely for all these years and I will call Beatrice whenever there is such a situation. She is caring and reliable and doing a much needed task which should be covered by the Social Services but as in many things here in Malawi is sadly lacking.
‘I am at the central hospital ‘she explained. ‘One of the babies we have been caring for has died and we have no way of return the baby’s little body to its village’
How could I resist? How could I deny this plea for help?
I agreed to help
Fortunately labour ward was not too busy and we were well staffed so I set off in my car to the hospital to find her.
What a sorry sight met me as I arrived. The small accompanying procession of women approached my car, the small corpse wrapped in a colourful cloth, the distraught father carrying his dead child and my friend and colleague Beatrice. They all climbed into my car and we set off on our sad journey home.
Whilst we drove Beatrice told me the whole story.
Beatrice had first become involved with the family when Chikcumado was five months old and weighing just 2.8kgs. He had been brought to the hospital by his father severely undernourished and extremely sick. After a short stay on the paediatric ward he was discharged home is the care of his father. The baby’s mother was not fit to care for him as was evident. Beatice continued to make regular visits to the village providing milk powder and nourishment and slowly Chikcumado began to gain weight. The situation was still precarious and when at 11 months he was still malnourished and failing to thrive he succumbed to pneumonia and severe anemia. His father once more brought him to the hospital. Treatment was given and after three weeks, during which time his father never left his side, Chikcumado began to make progress. He now weighed 7kgs. At the beginning of this week one of the ward assistants brought hot water to the father so that he could bathe his child. Unfortunately she failed to tell him that the water was straight from the stove thus allowing him to dip his son into boiling water sustaining severe burns to most of both his legs. This was too much for the small undernourished child to deal with. He died three days later.
We arrived at the village and were met by the village headman and members of his family. It seems they were unaware of what had occurred and certainly had not supported Cidy over the past weeks. The baby and the anguished father were taken into the family mud hut and a procession of women started to arrive to pay their respects as is custom. We enquired as to the whereabouts of the Chikumados mother but no one seemed to know where she was. They had not seen her for days. She was eventually located in a dilapidated hut next to where we were standing. How it was that no one knew or cared I fail to understand but it became clear that she had not been receiving any help from the village or her family. Yes…. now I began to understand clearly how it was that this whole situation had occurred. There are many superstitions surrounding people with psychiatric disorders which often results in them being outcasts in the village.
Entering into the hut I found Chikcumado’s mother sitting on the floor of what can only be described as a space fit only for animals. Her other small child lay sleeping in her lap filthy dirty and covered in faeces. A pan of beans was burning in a pan over a small fire made of sticks. I touched her face; I smiled and talked softly to her. I could do nothing. I left the hut and sadly walked away. We said our farewells to the father and the family respecting traditions and drove back to Lilongwe.
Beatrice will visit again and try to give care and support for the other little child, just 2 years old but with little hope for the future, with little hope for survival.
Lucas will return on Friday after seven weeks in Spain with his Papa. Lucas is privileged. Lucas is happy and healthy.
I thank God for Lucas.

LOW RISK

2011-06-22T14:41:00.002+02:00

Bwaila hospital plus fourteen health centers in the Lilongwe district rely on six ambulances and only one is functional at this time…..
Malawi is in the grips of a fuel crisis. Ever since I arrived here over three years ago there have been periods that it has been difficult to get fuel but none so much as during the past few months. The lack of foreign exchange in a country whose imports far exceed its exporting potential plus important political issues at this time is causing this dire situation. As you can imagine it affects all walks of life, all businesses, all people in some way, but here at Bwaila it means our ambulances cannot function and our women and babies are suffering.
This morning I was attending a young mother who had given birth to her first child in one of our health centers at 2.30am. At 5am. she had her first eclamptic convulsion. This condition, which is peculiar to pregnancy, but that may become evident even after delivery is one of the main causes of maternal death in Malawi. It was necessary to refer her immediately to the hospital so that she could receive the appropriate medications which are mostly not available in the health centers. It was impossible to find an ambulance with fuel. (diesel) At 7am. she had a second convulsion but still the ambulance did not arrive. Zione arrived at Bwaila at 10am.Now 5hours since she first became sick. On arrival she was semi conscious and needed immediate attention. Her guardian informed us that she had also convulsed in the ambulance on the way to us. Each and every convulsion leads her into a more critical condition. We immediately commenced her on the right drugs and management so that we could then refer her to the central hospital for admission to the intensive care unit. Working together with my colleagues we managed to stabilize her condition noting that her conscious level was improving. I sent a student to inform the switchboard operator that we would need emergency transport for the transfer. After 15 minutes I decided to check myself as to when the ambulance would arrive. I found the telephone operator sitting in the kitchen having breakfast. I asked him when the ambulance would arrive to which he answered that he couldn’t make the call as he had no ‘units’ for the telephone .I couldn’t believe what he was saying. Why hadn’t he come to labour ward to tell us this? Using my own mobile phone I called the District Medical Officer who promised to resolve the situation. 30minutes later, just as I was starting to make arrangements to carry her in my own car, the ambulance arrived and I accompanied her to the central unit to be further managed. Her condition on arrival had not deteriorated so I am hopeful that she will recover, although she may still have suffered some cerebral damage due to the convulsions that she had suffered. I will follow up her progress tomorrow.
The health personnel had cared for her well and adequately but the support services had failed. How long will this situation last? How many more women and babies will suffer and maybe die because the fuel tanks are empty? Or the telephones are not working?
This is yet another example of some of the challenges that we are facing when trying to deliver health care in Malawi. Challenges that are unimaginable in the developed countries but that are a daily reality here at Bwaila.

The first follow up HIV test after treatment was negative. I will repeat the test once more to be certain that transmission has not taken place but I am confident. I feel happy and positive. I accept the high risk situation in which I work but continue to known for certain that I am still in the right place, I am where I should be...for now.

SOME RISK

2011-06-22T14:30:00.001+02:00

Monday 30th May. It’s now one whole week since I completed the course of ARV’s (PEP) I feel so much better. I didn’t quite realize how much these drugs had affected me until I finished them. I feel so much stronger and far less tired. More importantly I feel so much more positive and emotionally stable. At the end of this week I will take an HIV test which will then be repeated again in two months time. It will only be then that I can be sure that the virus has not been transmitted. However, I am feeling very positive and believe that I will be tested negative.
Bwaila continues to be both challenging and rewarding. The in-service training that I set up within the first months of arriving over three years ago but that became irregular during last year due to the withdrawal of funding has now been started up again. I am pleased and encouraged to see how well this has been received by the midwives who are enthusiastic participants. My role in this has changed somewhat as I hand over the facilitation to my Malawian colleagues and take up my new role as mentor or teacher of the teachers. Since January I have taken on the leadership of the daily ‘ward round’ on Labour Ward each morning. This is an excellent teaching opportunity attended by all cadres including students and trained staff. We discuss each case at length particularly those that are more complicated or ‘high risk.’ The participants are encouraged to assess each case and make plans for actions necessary and care needed. I particularly enjoy this type of teaching sharing all my knowledge and experience with the aim of improving the outcomes for the mothers and babies attended at Bwaila.
We are specifically looking at improving our Neonatal death rates. Birth asphyxia, which is most often caused by lack of diligent care during labour, is the main cause of neonatal deaths on our unit. We need to prevent our babies being born in poor condition thus needing resuscitation and nursery care. Many of our babies born with birth asphyxia will be the result of obstructed or prolonged labour. I have been working tirelessly both in the clinical situation and in the classroom to address this challenge. I hope that this effort will be reflected in our statistics during the next few months but more importantly that our aim to discharge healthy mothers and babies will be achieved

MEDIUM RISK

2011-06-22T14:29:00.000+02:00

Twenty eight days of taking ARV’s and only two more to go!
It’s been a long hard month which has been an extremely testing time for me. I was warned very seriously from those that had taken these medications(PEP) that the side effects were many and unpleasant but in true Rachel style I was determined that this would not be the case for me That somehow I would be stronger, more resilient and not let them effect me. So I started out on a positive note as usual which I was able to maintain for the first two weeks. I was truly amazed to find that apart from slight nausea, lack of appetite and a general tiredness which I could overcome keeping myself busy I kept myself remarkably well physically. Emotionally it was a different matter and I found myself rejecting the medication each and every time I had to swallow those three huge pills. It felt as if I really poisoning my otherwise healthy body. After two weeks I came down with some sort of infection. Whether it was ‘flu or some weird virus I started to feel a sickness come over my whole body. It started by finding hugely painfully enlarged glands in my neck. At one point I tested for Malaria even though the symptoms were not typical and I felt sure this was not the problem. I began to worry that I was developing full blown AIDS. I was sufficiently worried to visit one of our specialist doctors who reassured me that it was extremely unlikely. The underlying doubts still remain. I spent three days at home determined to care for my health and fully recover. It took nearly a week to clear with just a few painkillers and anti inflammatory drugs. The week ended with a relaxing three days at the lake which always serves to renew and refresh me in body and spirit. I am not feeling good. However positive I try to be, the fact is, I still feel as if these drugs are poisoning me and therefore am experiencing the side effects more acutely. I am tired, just so tired. The one thing that keeps me going is to be on Labour Ward. Once I am there and involved in my work I don’t even notice the tiredness. When I stop, when I come home it is there again. Just two more days then I will be eliminating the drugs from my body and start to be Rachel, return to the enthusiastic, energetic Rachel that I know I am. Until then I will care for me, I will rest and I will find the strong positive Rachel which has pulled me through so many difficult situations so many times.
Am I still worried that I may still test positive in a few weeks time? Yes…. I guess I still have that niggling doubt, however small. The chances are very small the statistics assure me that it is very unlikely, but…..

HIGH RISK

2011-06-22T14:27:00.000+02:00

I’m confused but I’m not afraid, I’m strong but I need to feel comforted and supported.
It was one of those usual busy days on labour ward at Bwaila. Most of my time is now spent teaching students of all categories sharing my skills and knowledge so that others may learn. Clinical/ bedside teaching is what I love, what I do best. My role is well accepted and well established now and I am sought out by the students to supervise their work.
So it was that two weeks ago whilst supervising one of our students I received a needle stick injury. Having administered the injection of Oxytocin for the removal of the placenta I had carelessly left the uncovered syringe and needle on the bed. Later whilst wrapping up the cloths on which she had birthed the needle entered deeply onto my left hand. I removed my gloves (we wear two pairs for extra protection) and went to the sink to wash. The best thing in these situations is to squeeze the wound to make it bleed. Unfortunately as the entry had been deep there was little blood however hard I squeezed I knew this mother was HIV positive and that I should therefore seek assistance promptly. Alongside the maternity unit there is a busy and successful HIV clinic that supports our work. I hurriedly left the labour ward to visit their clinicians. I am working on the busiest labour ward in Malawi and possibly in the whole of Southern Africa, I am working at Bwaila. It is an extremely high risk situation in which we try to protect ourselves but inevitably accidents do happen. Since arriving here over 3 years ago I have been regularly tested for HIV as a matter of course. Small needle prick injuries whilst suturing have not alarmed me but this was different. After testing negative at the present time I was prescribed the usual medications to assist my body in rejecting the virus. Post Exposure Profilaxis (PEP) is a combination of Anti Retrovirals ( ARV) I will have to take these drugs for one month then be retested after three months to ensure that I havn’t been infected.
So how do I feel?
My first reaction two weeks ago was that of anger. How could I be so careless?
Every morning and evening I have to take the medication. This is the hardest for me. Consciously putting these powerful drugs into my otherwise healthy body to do all manner of harm to my cells and tissues whilst supposedly preventing transmission, which I may not even need, I find hugely distressing.
I was warned of all the possible side effects, nausea, diarrhea, weakness, tiredness etc. ‘you will feel sick for month’ I was told. I was having none of this I decided! I would be fine, I would feel fine, and life will go on as usual!
And to some extent it has. Sometimes I get a bit weepy, I am often very tired and weak but apart from the occasional wave of nausea, I am just fine.
I am not afraid; I truly do not think I will contract HIV
I won’t publish this now but wait for 3 months to share this with you all.

MORE MALAWI MIRACLES

2011-05-06T09:02:00.000+02:00

Yesterday was one of those busy days at Bwaila. Most of my time now is spent supervising the student midwives on Labour Ward, ensuring that they understand what they are doing that they become skilled at recognizing when things are going wrong not just ‘catching’ babies as they ‘pop out’ nor focusing only achieving numbers to fill up their books. Although we are now a District Unit and our most serious high risk women will be transferred to the new unit at the Central Hospital we continue to receive and care for many high risk situations. This is inevitable due to the huge number of women and babies we are attending and the fact that they are the most poor and disadvantaged Malawian women with all their underlying health problems. The day started badly when I realized that the women whose HIV status was unknown could not be tested due to the fact that no kits were available. This is a totally unacceptable situation in the light of the funds that are pouring into the country specifically aimed at preventing Mother to Child transmission. I took time out to visit the DHO in his offices next door. I found him in a meeting discussing the pharmacy issues. This was just what I needed. I interrupted the meeting to request that they please discuss this especially as we are approaching Easter. If this was not sorted out immediately we would be passing the whole Easter weekend in the same situation. What would become of those women? What would become of those babies? I was informed that this was a country wide problem but, as usual, mostly affecting the public hospitals…once more the private hospitals had their own supplies, once more the rich would win!
Since early morning I had been especially caring for a very young 18year old mother whose labour was progressing extremely slowly. When I took her over from the night staff I was told that she was ’hysterical and uncooperative’. She had been rolling on the floor in pain, had removed her IV line and was ‘totally uncontrollable.’ She was young and alone and very frightened. After assessing her situation I decided to administer Pethidine ( a strong pain killer) and instructed one of the students to take over her care to gain her trust and therefore her cooperation. As the drug began to work she became calm and sleepy, ceasing to cry out in pain with every contraction and rested on the bed. This new situation allowed me to then administer hormones to increase her contractions and therefore speed up her already prolonged labour. This she tolerated well .I would not leave until her baby was born. Slowly but surely her baby descended and her cervix opened to allow him to pass through. Once the baby was well down in the pelvis I took a vacuum extraction cup and with the help of the young student midwife who had gained her trust I slowly guided her baby into this world. It was wonderful teaching situation not only in the skills of assisting in the more difficult situations but how to really ‘care’ for women.
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We only have one ambulance at Bwaila. At present it is in the workshop being repaired after an accident so we are managing as best we can with totally unsuitable vehicles.
It was nearly 4pm when Kristine arrived on labour ward. She had been found in her hut in the village by some neighboring women. She had delivered her first baby totally alone .Kristine was 18 years old. The first thing that I noticed was that she was extremely ‘pale’ with a very high fever. That might seem strange to you. How can a black skinned person be pale? Well she can, and she was,’ pale.’ It feels good to be able to recognize this now! Reading her health passport from the two antenatal visits I found that she had been diagnosed with severe anemia over one month ago and had not been treated or transfused. She was weak but conscious and coherent. She was not actively bleeding but I had no way of knowing how much blood she had lost before arrival. With the help of one of my students we quickly erected IV lines took blood samples and sent them to the laboratory. It was her lucky day..…One pack of blood was available. We started to transfuse. She badly needed IV antibiotics, but we had none. After inspection it became clear that some parts of placenta were still in her uterus. This would continue to be a high risk situation for her until they were removed. We had no doctor that day and it was now 4.30pm. We decided that, once stabilized, she should be referred to the Central Hospital. Any blood loss now could prove fatal for her. I called for the ambulance only to find that it would not be available for at least 2 hours. Could Kristine wait for two hours? I decided to take her myself. I put down the back seats, covered the carpets with plastic and assisted Kristine, two IV lines, blood transfusion, two guardians, her baby (1.6kgs.) a bundle of firewood, plastic basins and cooking pots into my Honda CRV. We arrived safely. The next day I heard they had found one more bag of blood for her and she was doing well.

Agness gave birth to the first of her twins in an outlying health center at 12.30miday.the baby was born without incident but number two didn’t seem to want to come down. The inexperienced attendant diagnosed that the second was presenting with a hand which could not be delivered normally. She was taken by ambulance to one of our community hospitals. Unfortunately there was no clinician at this center and I presume the attending nurse midwife was neither confident nor experienced enough to assess the situation, so she was sent to us. She arrived at 4.25pm. Four hours later! Quickly reading the referral letter I knew we were dealing with a very delayed/retained second twin with a hand presentation. I had no idea if the baby was still alive so called for the ultra sound scanner. Meanwhile I examined her only to find a small foot in her vagina. I wasted no time and took hold of the foot bringing the second foot down and delivered the breech. I still didn’t know if the baby was alive and my first impression was that she had arrived too late for the little one. Feeling the chest wall I found a very slow heart beat! I ran with the baby to the resuscitaire and with the help of a colleague we brought the baby back to life. It took a long time but we were efficiently maintaining heart activity with cardiac massage and ventilation. After 20 minutes we decided to leave the baby to ‘go it alone’ I went back to the delivery room to check up on the mother. Ten minutes later one of the midwives called to me
’Your baby’s crying!‘ she said.
Another miracle at Bwaila!

MALARIA AND MORE

2011-04-13T16:13:00.001+02:00

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.

BACK TO BWAILA

2011-02-14T13:09:00.001+01:00

Its 6.30am. Saturday 12th February. I am sitting in my lounge in the lovely house we have made home here in Lilongwe with the warm African sun blazing in through the window. The only noises I hear are the chirping of the birds in the garden, which due to the heavy rains at this time of year, is lush and green. Fiona is still asleep in Lucas’ room and I feel content. Fiona will stay with us in Malawi for 2 months whilst she carries out her experiential learning with the year 1 children at Lucas’ school. Lucas is thrilled to have her here. And me? Well I just feel so grateful for the opportunity she has given me to be her Mum ‘close up’ for a while.
Europe, Christmas and Katy and Nicks wedding seems lost in a different world, in the distant past, but of course it was only just over one month ago. Time spent away from Malawi and away from Bwaila was therapeutic and healing, just as imagined it would be. Flying back into my other world into my other reality caused me the same conflicts and confusion as it has always done. It always takes me time to adapt back to that huge sense of wealth and excess that oozes from the pores of European living. But I did and I enjoyed every minute. I was able to spend nearly 3 weeks in England in the loving and safe arms of my friends and family. It was good to see how my Mum was recovering from her recent stroke and on her way to resuming her independent life once more. Time spent in Yorkshire with Katy and Nick in the final weeks before their wedding was full of excitement and joy. I felt privileged to be able to share this time with them. Christmas was spent in Spain surrounded by the usual hectic rush and tumble of pre Christmas plans then the beautiful giving and receiving of presents. All my four children have acquired the ability to find the perfect gift chosen with such thought and given with great excitement and love.
Katy and Nick’s wedding on 30th December was a fairy tale. Everything was just wonderful and beautiful especially my daughter, the bride. My role as mother of the bride was just so special, I enjoyed each and every single moment. What a wonderful feeling, as a mother, to witness my own child moving forward into a loving relationship with the man of her choice with an unknown but exciting future ahead. As I read in the wedding ceremony from the words of Kahlil Gibram …..
Your children are not your children They are the sons and daughters of life’s longing for itself. They come through you but not from you. And though they are with you they belong not to you……. child You are the bows from which your children as living arrows are sent forth…

Ending my time in Europe I was able to enjoy 6 days in Norway with my eldest son Alasdair before he took up his first job in England since recently qualifying as a vet. I was grateful for this time with him as his possibilities for long holidays and ‘time with Mum’ are so much less now that he has left student life behind and embarks on his chosen career. I never cease to give thanks for my children each one so special in their own way.
And so I returned to Malawi. I must admit having felt rather apprehensive during the last few days in UK. I was ready to return, I felt strong and enthusiastic but leaving the comfort and security of family to return to the huge challenges of living and working in one of the poorest countries in the world left me feeling somewhat fearful.
Needless to say the sight of our dear friends and neighbors who were at the airport to meet us, soon chased away any feeling of doubt I had regarding continuing with my work and our life here in Lilongwe.
So I returned to Bwaila. Having played such a huge role in the setting up of the new Bwaila Maternity Unit it felt like going home as I walked through the doors of labour ward, that first day after nearly 6 weeks away, to be greeted with screams of welcome by my midwife colleagues.
It had been a difficult December as the unit had been without regular medical cover leaving the midwives and clinical officers to take full responsibility for the everyday running of what is probably the busiest maternity in the whole of Southern Africa. Despite predictions that the work load at Bwaila would decrease substantially after the opening of the new tertiary care wing at the Lilongwe central hospital ( Ethel Mutharika Maternity Wing) this has not proved to be the case and we continue to attend more than 1,000 births a month. The high risk mothers are now being transferred and the health centers are sending their difficult cases directly to EMMW. We still have many extremely sick women and emergencies to attend. I can honestly say that the past 6 weeks have been some of the busiest I have experienced since I arrived 3 years ago.
January sees the start of the clinical placements for our midwifery students. This year with an increase in students being trained it also means an increase in the number of students needing close supervision and clinical teaching in the ward situation. We have also had a new set of interns and clinical officer students on the unit all of whom need constant teaching. I quickly decided on my return that I should make my priority during this time the teaching and supervision of students of all cadres. It has been a pleasure to work with the interns, most of whom are highly motivated and enthusiastic learners. They are quick to learn and quickly become essential to the safe medical coverage of the unit. The student midwives are of varying levels of enthusiasm and competence. They have little input from the college staff due to shortage of tutors which means that their practical skills need to be taught by our own permanent midwifery staff. There is still some reluctance on the part of some of these to undertake this role. Others truly do not have the necessary skills to pass on their knowledge to students. I have spent most of my time this past month dedicated to this. I actually enjoy this part of my work tremendously and find that my own enthusiasm plays a key part in effectively creating greater interest and understanding thus leading to better and more adequate care.
As well as teaching I often find that I am the most experienced obstetric professional on the unit. This means that my expertise is being constantly sought to aid in difficult and emergency situations. I was very pleased to welcome a new Nigerian registrar onto the unit. We have already worked together in the past and are personal friends. We refer to each other constantly which gives vital strength to the medical and midwifery cover. I truly feel that together the possibilities to effectuate change are more than ever present.
This doesn’t mean that labour ward is without its distressing incidents.
I had decide to finish a little earlier last Friday afternoon to allow myself time to catch up on some of the more formal teaching preparation and administrative work that forms an important part of my work. It was 3.30pm and the ward was quieter and under control. There were 3 women still waiting for their emergency c/sections, one of whom had been waiting for more than 3 hours. The interns were operating which inevitably leads to delays as their inexperience means that the procedure takes much longer. I had already requested that a more experienced person took over for the 2nd patient as I feared that the outcomes of the waiting women and their babies would be adversely affected if they delayed further. The 2nd c/section was performed by one of our clinical officers but 2 were still waiting. A young 16 year old was just not progressing to delivery. She had been referred by a district health centre and despite all our efforts it became clear that the baby needed to be delivered abdominally. The other was a very small, very short young mother who had not been able to deliver her first child vaginally due to a disproportion between the pelvis and the fetus. There are many women in Malawi whose growth has been arrested during childhood and adolescence due to malnutrition or illness resulting in inadequate development of the bony pelvis which does not allow for normal delivery. Although a c/section is a life saving procedure for both mother and baby we are very reluctant to put a woman through surgery unless it is absolutely necessary. Once she has a scarred uterus she carries the added risk of rupture in any subsequent pregnancy. This is a real danger to our Malawian women living in the more rural areas with no adequate transport to a health facility and with the frequent use of local roots and herbs to induce or speed up labour in a very aggressive manner. I had collected my belongings and was walking out of the ward when greeted by a new referred patient with ‘a retained 2nd twin with fetal distress’, of course I could not leave. Calling for one of our clinical officers who just happened to be around I quickly took her into a delivery room to assess the situation. We performed a quick ultra sound scan on the baby and found a very slow irregular heart beat. This baby needed to be born fast! A c/section was not an option for at least 2 hours so I decided to attempt a vaginal delivery to save the baby. I called another midwife to help set up an IV line, empty the bladder and bring a vacuum extractor. It was not an easy procedure. The fetal head was high and the vaginal tissue, cervix and first umbilical cord were all in the way as I tried to place the vacuum cup on the baby’s head. It took almost 15 minutes to successfully extract the baby and I feared for its life. I have done this procedure before and it requires a great deal of cooperation from the mother and the medical team. At last the cup was placed and the baby extracted with ease. I was amazed and exhilarated when it came out alive! With a little resuscitation the baby was soon crying though still with breathing difficulties so I sent him to nursery for further management. Today he is doing well.
It was now past 4.30pm Before I left I went to theatre to make sure that the clinician on the night shift was aware of the 2 women still waiting for their operations. I could do no more and there was no time to consider administrative tasks. I arrived home after 5pm exhausted. It was Friday afternoon and the thought of the weekend, the rest and free time with Fiona and Lucas filled me with joy and hope.
Despite everything…..I love Bwaila!

When love beckons to you, follow him, Though his ways be hard and steep. . And when his wings enfold you yield to him, Though the sword hidden among his pinions may wound you…… For even as love crowns you so shall he crucify you. Even as he is for your growth so is he for your pruning…… All these things shall love do unto you that you may know the secrets of your heart… And think not that you can direct the course of love, for love, if it finds you worthy, directs your course.

TIME OUT

2010-11-28T09:27:00.000+01:00

Today I start my annual vacation. We will return to Europe for the month of December. I need rest; I need to recover, to find the renewed strength and enthusiasm vitally needed to face the ongoing challenges that will present at Bwaila next year. To put back, to replenish, to be in the company of my precious children, my family and old friends, to feel their love fill me and their support encourage me to continue to be able to give and to serve the very poor, very neglected, very under privileged women and babies of Malawi.
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.
‘

COMPUTER TECHNOLOGY

2010-11-15T15:46:00.001+01:00

There’s no denying that computer technology is the way forward. There is no denying that in the long term an electronic patient register along with accurate recording of hospital data will assist us in identifying our shortfalls and so technically lead to improved patient care.....but....
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.

SOMETIMES A STRUGGLE

2010-10-08T15:35:00.000+02:00

The back-up generator broke down and the power went off on Sunday morning from eleven am. until nine pm.
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.

GOODBYE TAREK

2010-08-24T14:41:00.000+02:00

Agnes was 22years old. She was married with one small child. She lived in a small, extremely poor village on the outskirts of Lilongwe.
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.
.

2010-07-22T21:25:00.000+02:00

AMAZING AND EXCITING TIMES AT BWAILA
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.

PLANS

2010-06-01T16:33:00.003+02:00

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.

LOOK AFTER YOURSELF

2010-03-25T16:55:00.001+01:00

Stress and exhaustion caught up with me this week making what should have been a simple cold and cough develop into a full blown chest infection. So here I am taking a ‘forced’ rest at home swallowing huge antibiotic tablets, cough mixture and copious amounts of fluids. The drugs make both me and my digestive system feel rotten but after battling away for over a week with a cold then cough then laryngitis then bronchitis I began to realize that things were looking serious and started the dreaded antibiotics. I am pleased to say that now 4 days into the course I am starting to feel the positive effects and although rather weak and tired I am on my way to recovery. I am surrounded by caring friends many of whom are also in the medical profession so have not lacked good advice and treatment. Unfortunately, in the end, it is me that has to TAKE the advice and that is where the problem starts!
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.

ONE PERSON CAN MAKE A DIFFERENCE AND EVERYONE SHOULD TRY

2010-01-23T13:21:00.000+01:00

I know it’s been a long time since I last wrote to you all. Gone are the days of writing every week. What has happened? Why is it I can’t find the time to sit down and write to you of my joys and my concerns, my smiles and my frustrations, all that goes along with living and working with the people of Malawi? Things have changed for us over these past two years as we have settled down to making friends, getting a home together, attending school, weekends away at the lake and all that makes up a busy life here in Lilongwe. Sometimes I yearn for the simple way I viewed things and approached situations when we first arrived. Without the inside knowledge, that I have now, the deeper understanding of the situation here in Malawi, the role of the aid organizations and government bodies, the immense poverty and oppression of these lovely people, it was all so much easier. But the very nature of learning and understanding brings with it the realization of one’s smallness, the stark reality that however much I do, however much I give, it will never be enough. It brings feelings of deception, of use and abuse, of sadness and sometimes of hopelessness. These people deserve more, they deserve what I expect for myself but it is not possible and finding my way to live with that is sometimes so difficult. Mostly they have few expectations and demand little. My expectations for them are much more, are much greater than theirs, which means that I am daily coping with conflict and confusion within myself that leads me to sometimes setting unreachable goals and unattainable targets. Maybe that is why I don’t find time to write? Does that all sound rather negative? Maybe sometimes I do feel like that but certainly not always. I have always felt that I was clearly led to Malawi, to Bwaila, to the work I am doing and as my role and responsibilities have developed I have been challenged and excited to continue. I was prepared and happy to give at least another 2 years to help develop the potential and possibilities given by the new maternity unit. However, since I returned from Christmas in Europe I have not only had to face the continued daily challenges, frustrations, traumas, sadness and sheer hard work of Bwaila but have been having a difficult time sorting out my contract and funding. I had thought that I was assured a further 2 years funding but it seems I was mistaken. So as I write nothing is sure, nothing is certain except my inner conviction that I should be here, that I still have much to offer and I will not give up.
‘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.

CHALLENGES AND ACHIEVEMENTS

2009-12-14T16:44:00.003+01:00

I am writing from the executive lounge, Nairobi airport. We very soon learnt that by paying 20usd we could make use of the lounge. Comfortable sofas to lie out on, drinks and snacks, internet access and a rather more peaceful atmosphere than the busy 'corridor' of duty free shops that makes up Nariobi airport. Any of you who have travelled through Kenya from Malawi will understand the how well spent are those dollars to achieve a rather less stressful 6 hour wait!
The past few weeks have flown by as I bravely struggled to achieve my three main aims before leaving for Christmas holidays. 1. The newly installed autoclaves would be up and functioning.
2. The oxygen supply would be piped to the resuscitation areas. 3.The 7 resuscitaires ordered several months ago would have finally be delivered. Well I didnt actually fully achieve any despite all my incredible attempts, phone calls, e mails, personal visits. I think 'frustrated' will be the word that describes how I have felt recently! Nothing went according to plan, delays due to shortage of FOREX or fuel were constantly cited as valid reasons for not delivering anything. True or false? I don't know but 'This is Africa' and therefore to be expected. Once more I am leaving having tried to 'organize' everything and leave all 'under control' How it will be when I return ? I dont know. No expectations, no disappointments! everything is promised and everything is nearly there!
Inevitably we are experiencing some minor problems with the constructionsince we opened. The contractors are not on site which makes it much more difficult to solve the daily difficultied which arise. The electric installation in Labour Ward seems to have some more serious underlying problem which I am hoping will be solved whilst I am away. The e;ectricians have been called on numerous occasions including nihts and weekends but don't seem to have actually found the root cause of the blackouts that we are experiencing all too often. I was amazed at the ability of the midwives to cope on the occasions that the electrics have failed in the middle of the night and they have failed to contact the electrician. During one of those occasions they were also without water as the tap had fallen off in the shower and the plumber had helpfully turned the water off to prevent the flooding thus leaving the whole Labour Ward dry. That night three midwives and one clinician delivered 28 babies, 4 c/sections, 2 breech births and twins all without electric or water. Unfortunately the night did not pass without incident and as often happens, whether to lack of staff or services all outcomes were not good.
Our in-service training program continues. We are loooking once more at very practical everyday situations that occur on our wards to keep the midwives updated and familiar with emergency procedures. I also set up a full day training on Neonatal Resuscitation which was attened by around 50 members of staff. We repeated the sessions 5 times during the day spending the greater part of the time on practicing on our special resuscitation dolls. This was well received, hopefully leading to better techniques on the ward.
Our results have not been good during the past two months. Birth asphyxia is an all too common occurance. Our nursery is overloaded with babies, up to 60 babies in a unit intended for 20. We delivered a record of over 50 babies in 24 hours last week with just 4 to 6 nurses on each shift. Lack or midwives continues to be a huge concern. The Malawian government are reducing funding in 2010 for midwifery training so we are wondering how we will cope and what the future will hold. Trying to get the Malawian midwives to openly admit that they CANNOT do their job well with so few staff is very difficult. When considering our staffing needds for the new unit we decided that we needed a minimum of 8 midwives on Labour Ward , day and night to be able to attend the women and babies SAFELY. This is not being taken seriously. Most health workers of all levels find it almost impossible to be seen to be criticising the government. I have been involved in negotiating for the funding of midwifery training for next year and so far we can sponsor 31 candidates. If anyone is interested in supporting this please contact me. It costs 2.000 euros to sponsor one candidate for the one year midwifery speciality.
On a personal note we moved into our new house on 1st November and have settled in well. What a difference it has made to us both to have a house and garden of our own. Lucas spends all his time collecting all manner of insects and reptiles and putting them in boxes. He has space to play football and run freely. The terrace looks out over the Lilongwe river and open fields so most of the day we feel a welcome breeze. I have had to take on the responsibilty of 'staff' which is a new challenge for me. Lucas' nanny is still with us but has taken over as nanny/housekeeper. I dont know what I would do without her. Alex and his wife live in the 'staff quarters' and serve as day guard and gardener. Actually he hasnt got a clue how to garden,nor much else either but he is friendly honest and always happy! We took over 'Mr.Phiri' as night guard from the previous tenant. Rather older, supporting 9 children (he apprently had14 but the rest died) he works 7 nights a week all the year round and apprently has done for many years ( who says babies are made at night!). He has taken quite a 'shine ' to me, washes my car daily, tells me when the curtains arent completely drawn, controls the outdoor security lights, and reminds me to set the alarm when I go out. I have increased his wages supplied him with tea and sugar and biscuits every night so in return he has taken to truly 'looking after me!'
We hosted our first party in two years for all our friends. I spalshed out on hiring a live band who really made the party a great success. I even stood up and sang some Simon and Garfunkel so it must have been good!
It has been an intense, tiring, challenging, frustrating but happy few months. Despite the huge challenges I have faced I believe much has been achieved. I am ready for a time of recovery and reflection before starting again in the new year. I am looking forward to our family Christmas of fun, laughter and lots of love.
Wishing you all the same....................

5 WEEKS LATER

2009-11-23T20:08:00.000+01:00

It is now just over one month since the new unit became fully operative. Time flies by so fast and though I had hopes of being able to slow down a little once the unit was opened this has not been the case.
On Monday 19th October we started the big move from the old to the new unit. Although only 200m distance it was a huge job making sure that patients and equipment were transferred in the right order. We had planned for it to be done over three days but in the end we were able to complete in two. The last to move was the operating theatre and the sick babies on nursery. There was a period of 12 hours when we were operating two labour wards, two theatres and two nurseries! With an already depleted staff this was no mean feat. Most of the equipment and furniture had been supplied new or good quality second hand from a large container from Norway. This meant that only a few essential items that had not arrived or others that could be put to good use from our old wards, would need to be transferred. In practice that was not the case as we found that although basic needs were covered it was good to ‘double up’ on many items from the old and the new. Our 146 bedded unit soon became a 180 bedded unit as we pushed extra beds and cots into all areas. We are hoping that with the imminent opening of the new high risk unit on the Kamuzu Central Hospital site our numbers will reduce and we can use the buildings as intended. It is true to say that even with the extra beds we still have infinitely more space than we ever had at the ‘Old Bwaila.’
The ‘move’ didn’t all go exactly to plan but then it wouldn’t be Malawi if it had! By the end of day one almost everything was prepared but the resuscitaires for the babies had not arrived ( and still havn’t ...another long story...I believe they are somewhere between Brazil and Malawi on a container ship...if they havn’t been hijacked by pirates!) By 4pm. most of the staff were finishing their shift. There was no transport to be found. Refusing to allow the nursery and labour ward to be working without the necessary equipment Dr . Kind ( our new German obstetrician) and myself were to be seen pushing these machines over the bumpy ground all t5he way into the new unit tobe installed. The following day the same thing happened but this time with theatre equipment. Once again he and I manually transferred the anesthetic machine and huge oxygen cylinders into the new theatre. What a sight to see two ‘msungus’ (white people) pushing a huge oxygen cylinder on a patient trolley!
And so it was that at 8.50am.the first baby was born in our new delivery rooms. I just missed that one, arriving as the head popped out. But I was not to miss number two at 9.50am. I proudly assisted the birth of a boy to Ndaona Jonathan, weighing in at 3.600kgs.
Since then things have been totally hectic. All the usual problems heightened by the new environment which although completely superior, is, to most of the staff, totally unknown. Of course many building, electrical, plumbing faults became obvious when starting to actually use the buildings. Mostly these have been solved by the constructors whilst under guarantee, but others have been due to poor use of the services. We have continually found the drains blocked by bits of cloth and other debris. Many of our women are not used to mains drainage and flushing toilets, thus dispose of their rags, as they would at home, into the hole! We have had a couple of emergency runs for oxygen cylinders when the electrics failed in nursery and labour ward. We have an automatic generator which cuts in when the power supply fails. Unfortunately if it just ‘trips out’ in one area this does not happen. If I did not know before, I am now fully aware where the electric box is situated on every ward. I have assured that the ward staff know where to find the switches in an emergency and how NOT to lock the door to the room where it is situated and then not have the key available! Is has been good to see some enthusiastic and motivated midwives who are taking care and pride in their new work area.
Having spent the past months sorting out the buildings, equipment, training, etc. interacting on all levels with just about everyone involved it should not have been surprising to find that after the opening of the unit I continued to be called upon to sort out and solve everything! It soon became clear that many of these responsibilities could and should be taken on by others. In any case all I wanted to do was get back on labour ward where it became very obvious that the organization of the new environment was something of a challenge for the senior staff. With the new possibility of each woman birthing her baby in an individual room with intimacy and privacy came the probability of her birthing alone behind closed doors. The presence of a guardian/partner to accompany her HAD to be encouraged. But this too was a new concept.
Just at the right time appeared Brenda! She is British ICU nurse who had come to ‘help out’ She had no idea what she had come do but without her we would not have achieved the half of what we have during the past month. She became my personal assistant as well as using her ICU skills to train up some of the staff in the use of the new equipment. I shall be forever grateful to her. Realizing that I should off load man y of my more administrative tasks I set about meeting with the District health Authority senior managers and we were able to put together a new Organigram for the unit. This I presented to the staff on 12th November. Although this does not mean everything gets done, it does mean that there is some structure as to who is responsible for what and who is ‘in charge of what.
I still have many administrative things to clear up and supplies to chase as some furniture and equipment has still not arrived. Getting the telephone system working has been one of my biggest achievements and although now in working order some thought (and money) needs to go into supplying extensions to other areas. The oxygen instalment has been a constant head ache for me. The company that supplies this has a complete monopoly in Southern Africa which I guess allows them to do what they like, when they like and how they like! This is still not over but we are VERY near to completion!
On the Staff training side, it has been great to work with our partners CESTAS (an Italian NGO.) They have accommodated ALL the on- going in service training, that has been necessary, with very generous funding. This has allowed me to set up training for all different cadres. Midwives, ward clerks, cleaning staff and clinicians are all being covered. We are also continuing our weekly Team Leaders sessions where we are able to discuss the challenges that are occurring daily in the ward situation as well as recognizing the positive aspects and rejoice in them!
Finally on 16th November I donned my ‘scrubs’ and went back on labour ward. Just for the record, my name has been incorporated in the Organigram as one of the charge nurses on labour ward. This is hugely significant for me as I am formally accepted as one of the management team. Having worked my way into this role alongside my Malawian colleagues gaining their respect and trust I have now been rewarded with a formal recognition. The first week I seemed to be more off than on the ward but I guess that was to be expected. It would have been impossible to drop all my previous responsibilities so I am gradually handing over. Today I have spent nearly all day there and have been very encouraged to see the midwives respond to the new challenges. As time passes it has become evident where the short falls are and I have tried to introduce simple ways of dealing with them. These have been well accepted and mostly implemented.
Overall things are going well. We still have many challenges not the least to reduce our cases of birth asphyxia. We are approaching this in our training sessions and in the clinical areas. We will keep trying.
I have never been so in need of ‘timeout’
I believe our planned trip to Europe over Christmas will be beneficial both for me and for the unit. I will rest and recharge surrounded by the love of my children and family and Bwaila will learn how to be without Rachel!
As a footnote......I popped in to see my triplets last week and they are doing just fine. Strong and healthy a credit to their Mum and extended family.

OPEN AT LAST......WELL NEARLY!

2009-10-20T21:55:00.000+02:00

Today is Mothers Day here in Malawi. It is a national holiday. It is good that we celebrate the mothers of this country, their strength, their commitment and their love, even under the most difficult of circumstances. And circumstances are very difficult here for women. Being a mother in Malawi is dangerous. Over 800 in every 100,000 Malawian women will die in pregnancy or childbirth. Many women are already suffering from underlying medical conditions (chronic anaemia, mal nutrition, Hepatitis, AIDS, etc.) when the strains of pregnancy and childbirth are added to this, becoming a mother moves from the physiological into the pathological, from ‘normal’ to ‘dangerous.’ Lack of health care facilities, equipment and medication, huge difficulties in accessing the hospitals also adds to the problem. But of course the biggest challenge is the staffing. Never sufficient doctors and nurses to attend these women, overstretched, tired and demoralised the care is often far less than it should be and women die unnecessarily.
As I write I am looking out onto the waters of Lake Malawi. It’s a warm but windy morning. The sun is shining over the lake in front of me and I can see Lucas throwing his line and patiently awaiting his catch. Fishing is his passion. As soon as we arrive he sets up his lines and there he stays for hours. Yesterday evening was a great success, having caught more than 16 ‘little’ fish he is inspired and encouraged this morning! However, like any true fisherman, it doesn’t seem to matter that much if he doesn’t catch any!
I decided at the beginning of the week to spend these two days with Lucas at the Lake. This week is half-term holiday from school. The past weeks, since returning from Europe in August, have been totally hectic. I have been working 7 days a week and often 12 hours a day preparing for the opening of the new maternity unit at Bwaila. I have felt increasingly physically and mentally exhausted and so overwhelmed with the enormity of the task I have undertaken I sometimes become lost. Where is the way forward? Where do I start this morning? Which of the multitude of tasks is the priority? It is so easy to become frustrated, annoyed or angry. Things just take so long, are poorly done or not done at all. Promises are made and not fulfilled. Responsibility and accountability is hard to find therefore even more precious when shown. Recently I was asked by a Norwegian visitor if I was still positive, encouraged, enthusiastic, and energetic? The answer despite everything is quite firmly, ‘Yes!’
‘Let the fire in my heart, let the wind in my sails, let my reason to live......be love’ and if you want my definition of love you just have to look at the bible....1 Corinthians 13. Love is patient and kind. Not jealous, boastful, arrogant or rude. Love does not insist on its own way. It is not irritable or resentful. Does not rejoice in wrong but rejoices in right. Love bears all things, hopes all things, endures all things. Love never ends.
I’m not saying it’s easy, nor that I manage it all the time, in fact sometimes it’s very difficult and I have to keep reminding myself, but there it is and the closer I try to keep to this the easier it is and the happier I am. It’s about self becoming less important, about looking at the bigger picture. It’s about lots of individuals becoming truly more loving to make up a better world.
At 8am. 1st October, (Fiona’s birthday) after many setbacks in all areas, the Family Health Unit (Out Patient Department) finally opened its doors to the first mothers for their antenatal, family planning, postnatal, immunisation etc. care. It was a truly emotional moment for me. Up until 4pm. the previous day it was still not clear if we would open as some official checks were still not completed but we went ahead. The benches for the waiting area, promised the previous evening, had still not arrived at 7.55am.despite several frantic phone calls on my part. The matrons were eager to let the women in. ‘The lorry is coming through the main gate! ‘I shouted. Benches and women arrived together! Having arranged for the touch screen electronic registration equipment to be transferred the previous evening (I was still on the unit at 8pm.) I was horrified to find that it wasn’t working the next morning. A frantic phone call to the experts assured me they would arrive within the next hour. In the mean time the women were crowding in through the doors but with no way to register them! I decided to take a look. Now my knowledge of computers, as my children will tell you, is not extensive, nor of car engines, but I do know what a car battery looks like and I found two of them somehow linked to the system. Following the cables, as if I was jump starting a dead car battery, I noticed that one of them had become unattached. Red to red, negative to negative.....hey presto and it worked! The curtains came off their hooks, (more DHO workmanship!) the keys to the male and female toilets were identical, causing some embarrassment, the baby weighing scales got hung over the first available door frame, the painter was still precariously balanced on some stacked benches finishing off the health advice and pictures he was beautifully painting on the walls but still the women crowded in and still they sang and danced. More than 400 women and babies passed through our doors that day. It may have seemed like chaos, more or less organized, but all went well. (Malawi style!)
The next challenge was to get the unit ready for the official opening on 7th October. We had already decided that the inpatient side (Labour Ward, theatres and wards ) should not become functional until 19th October when Tarek returns from the FIGO conference in S. Africa. However the two were completely inseparable as the unit should be fully furnished and equipped for the ceremony just leaving a few final details and practicalities to be tidied up for 19th. It was a huge task involving many people, ministry and health departments, suppliers of equipment and services, on site workman, far too many to mention. Some were helpful, some unhelpful, some amazing. Some cared, some didn’t bother, some put themselves out, some did not respond. I pushed and shoved, nagged and pleaded, praised and hugged, laughed and cried as I desperately tried to pull it all together.(Officially known as the coordinator!)
I have never seen so much movement and so much achieved as in the final 3 days before the grand opening! Saturday 3rd saw more than 70 cleaning staff of the unit. Meetings with the MOH and the Vice Presidents Office resulted in numerous visits and checks during the next two days. Official protocols had to be applied to strictly for a full presidential event. Dr. Mary Robinson (ex president of Ireland and current UN Commissioner for Human Rights) was the honoured guest and together with the Vice President of Malawi (Hon. Joyce Banda) would open the unit. The flag pole was erected and the Malawi flag flew proudly at the entrance to our new Maternity unit. The dignitaries arrived early so that they would be in place to greet the Vice President. A grand tour was made of the whole unit led by our DHO Dr. Ndovie. It was an exciting morning, all comments were extremely positive both as to the quality of the unit and the success of the event. The plaque was unveiled and speeches made. Both the speech made by the director of TRP and that of Dr. Robinson were stimulating and challenging. The VP, in her words, showed her surprise at the scale and the quality of the project and its possibilities and potential for improving maternal and child health and addressing the high maternal and neonatal mortality rates. More importantly she pledged her personal and on-going support not only for Bwaila and maternal health but for the women of Malawi. It was a great occasion supported by singing, dancing and ‘Gule Wankulu’ in true Malawian style. You can read more about the occasion on the Rose Project web site. www.
It was a great honour for me to be personally greeted by the Vice President. It was also a huge privilege to be invited to spend some time with Dr. Mary Robinson not only during the ceremony but on other occasions over dinner. Listening to her speak of her international work on Human Rights and especially those of the mothers and babies in the poorest countries of the world I felt encouraged to continue to play my small role in Lilongwe.
The following day there seemed to be a general feeling of lethargy. I spent most of the day sorting out more than hundred and fifty keys that I had in my possession for ALL the locks in the whole unit. I was keen to get at least some of them handed over to the matrons so that I would not have to be solely responsible for opening and securing the buildings every night and morning. As you can imagine this has been very tiring and time-consuming. At last I handed over the keys to the matrons on the FHU on Thursday afternoon just keeping a main door lock and my office. On Friday Lucas started his half term holiday so I decided to stay a little longer in bed, arriving at Bwaila at 7.40am. Rather later than usual. To my surprise I found a vast number of people waiting outside the unit cleaners, nurses and many, many, women and babies. The keys had somehow got left inside the unit and they were all waiting for me to arrive. No one had phoned me, no worry, no rush......this is Malawi!
It was still difficult to get things moving again on Friday and I began to be concerned as to how I would find the necessary to motivate and build up enthusiasm, once more. Just one week before the women would be admitted, just one week before the babies would start to be born in our new labour ward and the place was empty of personnel. There was still much to be done, pharmacy supplies to be ordered and delivered, instruments to be sorted, packed and sterilised, oxygen cylinders to be filled, the wards had to be kept clean and the linen supplied and beds made among many other things. We had organized a ‘simulation’ to take place on the Monday afternoon. This is to ensure that we can respond to an emergency situation that everything is in place for the safety of the patient. How was I to get it all done? Here I must mention Audny. As the Norwegian hospital technician and procurement person she has been heavily involved throughout, though mostly from a distance. The times she has spent in Lilongwe have been a ‘godsend’ for me as she takes over responsibilities for the equipment and it’s functioning plus a many other things. I must admit to doing a bit of shouting and harassing that day which is not the best way and definitely wasn’t very loving or understanding! I decided to take the whole day off on Sunday. It was clear that nothing more was going to get done before Monday.
So here we are in the final days before the REAL opening. It’s exciting, it’s scary, it’s worrying, and it’s incredible! As I sit here and write to you from the peace and beauty of the lake I am thinking of how much more I need to sort out before Monday. I can’t believe we will ever be 100% ready but we WILL be safe. The transfer of patients will take place over three days. That will mean that the first baby will be born in the new Bwaila maternity unit on Tuesday 20th October (Alasdair’s birthday)I can't wait

100% CHALLENGED

2009-09-10T10:11:00.002+02:00

Lucas left Lilongwe at the beginning of June travelling to Valencia with his cousin Abigail to spend five weeks with his 'Papa' I was able to make full use of the following two weeks to concentrate fully on the coordination of the furnishing and equipping of the new Bwaila maternity unit. The procuring, ordering, confirming and delivering of each and every item necessary for the setting up of a unit of this size is a huge task. It has been and still is a challenging and often very frustrating process but I feel confident that it is now all 'coming together' and we will be ready for its opening during the month of September. I left Malawi on 18th July for my planned holiday break in Europe. After spending five wonderful days with my eldest daughter, Katy, in Leeds, UK, one of which was spent relaxing and being pampered in a health 'spa,' I flew to Valencia, Spain, to meet up with Lucas and my other two children, Alasdair and Fiona. Needless to say I have enjoyed every minute in the company of my children and friends. The love and support of these people, who are so important to me, reaffirms my conviction that my decision to stay in Lilongwe to continue the work I’m doing with the women babies and midwives at Bwaila is correct. Being in a first world country during these past weeks has not always been easy. It is difficult to completely forget the poverty and conditions from which I have come. It is especially difficult for me when I am in one of the many large, busy, shopping centres. My mind strays back to the villages, the hospital, the people of Malawi and it just all seems too much. How can some have so much and others, just a few hours flight away, have so little, have nothing? How can some people be so preoccupied by material trivialities when others are struggling to feed, clothe and educate their children. How lucky you are that you were born into a rich world that your worries are mostly about the extras and not about the basics, about luxuries and not about survival. I wrote the above soon after arriving back in Lilongwe at the beginning of August. Since then I have often thought about you all and needed to communicate with you but have quite seriously not had the time nor the energy to do so. These past four weeks have probably been some of the most challenging of my life. On my return to Bwaila I was hugely disappointed to find that, despite the huge efforts I made before leaving to assure that outstanding work would be finished or at least well underway for my return, practically nothing had been done in my absence. The jobs that needed to be done ‘on site’ and that I expected to be finished had not been touched and the suppliers of various pieces of equipment and furniture had achieved very little. It was then I decided to dedicate myself full time to pushing and shoving, nagging and pestering, phoning and visiting with a determination that all those who know me will understand. The official opening date of the unit has already been set. October 7th.The unit has to be up and running before that date and I for one was prepared to move heaven and earth to achieve it. And that’s what I have and I am still doing. Moving heaven and earth! Or at least it feels like that. If you’ve never lived in Malawi, though they tell me other African countries are the same and to be honest I guess pulling together this sort of project anywhere in the world would not be easy, maybe you wouldn’t understand, but the Spanish ‘manana, manana’ takes on a whole new meaning here in Lilongwe. I remember back more than 15 years ago when I was involved in setting up a new business venture with my (ex) husband, Andrew. New to Spain and with very little of the language and less knowledge of how the Spanish system worked, the job of sourcing and procuring every little piece of equipment, nut, bolt and curtain hook, for the farm, was my main job. I still remember the huge frustrations of never finding anyone when they were needed, of waiting days and weeks for things that were promised for the following day and finding that many items were just not available. I think that experience has helped me infinitely for the challenges I am facing now. My knowledge of building work, bricklaying, guttering, plumbing, electrics, drains, sockets, taps etc. increases daily. Not to mention the more specialized areas of autoclaves, theatre lights, piped oxygen and anaesthetic machines. Then there’s the procuring of furniture and equipment. I mean, just how many chairs are needed for a 146 bedded maternity unit? And stainless steel trolleys? And why does all the locally made equipment, beds, swab racks, bed pan racks have to be ‘epoxy coated’? and anyway what the heck is ‘epoxy coating’? Just ask me any of this now and I have the answers!I was very happy when the District Health Authority agreed to take on some tasks such as the building of concrete wash tubs for the women to wash their ‘chitenges’ The making of ‘curtain boxes’ for all of the windows and the building of a new road. The unit has been totally funded from outside of Malawi. Mainly from Ireland through The Rose Project but also with Norwegian partners. It will be given to the Malawi government to be run as a public, non paying District Hospital. It was therefore encouraging to see them show their interest in this way. My enthusiasm was somewhat dulled after the new entrance way collapsed and had to be remade. During that time we could not let any vehicles on site for 7 days. I started to panic thinking that I would have to cancel the delivery of materials and equipment which could delay everything. Silly me! The delivery trucks continued to arrive. They parked at the entrance and as if from nowhere there appeared more than ten very fit looking guys who carried the boxes, bags etc. sometimes on their heads, into the unit making several trips with often very heavy loads. But this is Malawi and I shouldn’t have worried. Then when finally they could drive in the lorry carrying the bricks and materials veered off the road onto the pavement smashing the recently laid paving slabs. Not once but twice! I had always been a little Sceptical of the driving skills or lack of but this was just amazing! However I think the best example of the hospital maintenance standards was when I passed by to see how they were getting on with the construction of the wash tubs. Now I am really not an expert but I do know that the water and drains are normally laid before and not after the concrete base. I respectfully enquired but was assured that they knew what they were doing. It was only once the tubs were built that it became clear that the plumbing would now have to be with external piping! It doesn’t look so good but I am assured it works! But that wasn’t the end of the story.... The following day I ’caught’ them on the point of connecting the permanent water pipes to the contractor’s temporary water supply. (An over ground piping that will be removed once the builders leave.) At least I got to that one in time and the proper connections were made. These are just a few stories of the many I could tell you which have caused me to laugh and despair. There are also many more that have been so very encouraging. We have a wonderful site foreman (George) who has always been at my side, listening, understanding, organizing, laughing, despairing, building up and knocking down, putting in and taking out, but always good humoured and willing to help. I have built up a lovely relationship too with many of the workers on site. The only female brick layer, who does a beautiful job, greets me every morning by name and with a huge smile. The gardeners who brought roses to plant just because I wanted them. Not to mention Fyson,the guy who holds the keys. There are more than two hundred keys, two for every door and cupboard on the unit but somehow he knows them all. Actually he’s the second guy to hold the keys and only since July. The story of Andrew, who I have known for over a year since I first started became involved in the new unit, is a long one which is definitely worth telling. This is part of a mail that I wrote to Tarek, soon after the incident, that I thought I’d share with you.... ‘’It’s a huge job I’ve taken on for The Rose Project and I often just wish I was back on labour ward. So much just doesn’t depend on me so I have to cope with the frustration of not getting things right because of someone else. As you said, I can’t change anyone else I can only change me. So I’m having to learn how to cope with so many things that are totally out of my control. I know that’s what you have to do and I am appreciating how hard that is. I have so much more to learn. But that’s not why I sat down to write at this hour. Maybe I’m putting off the moment as I’m not sure if I did the right thing. When I went on site this morning I couldn’t find the guy with the keys. He’s a young lad, always very friendly helpful and we have struck up a relaxed and fun relationship over the past year. I don’t know much about him but I have always had a good feeling about him. I eventually found out that he had been taken to the police station yesterday having been accused by the security guards of stealing a bag of second hand clothing whilst the Norwegians were sorting it all out. ( A huge amount of sheets, material and clothing came over in the Norwegian container.) I was surprised and horrified that he should be locked up in jail without any official charge against him. They also told me he had been beaten up. The charge had to be made by the DHO or myself. I couldn’t do it. I couldn’t bear to think of this young lad in the cell now for nearly 24hours and I couldn’t bring a charge for ‘possibly’ taking a bag of second hand clothes. I think I did the right thing? My instincts told me that I couldn’t leave the country knowing he was still locked up. So I went and got him out. I tried to do it the right way. I went to the security firm, I phoned the DHO to get his support and the guy from the security firm came with me. So I got him released. It wasn’t too difficult. I was so naive that I didn’t realize until I was told afterwards that the police officers were probably waiting for me to give them money, so they didn’t get any! Well, Andrew is out of jail. I spoke to him briefly. He is just so young and was very quiet with me. He thanked me but he could hardly look me in the eye. I felt very sad as I have no idea if he is guilty or innocent. Of course he shouldn’t steal, but it was a bag of second hand clothes! He probably has nothing and the temptation was too great. God knows what I would do if I had so little. Would I steal too? Would you? The foreman says they have always trusted him and will probably put him on another site to work. I hope so. I said he shouldn’t come back to Bwaila. So why do I need to write this down? Why do I feel so unsure? It felt so right at the time.’’
Andrew has been to visit me twice since my return. Both his parents are dead, he lives with his only living brother here in Lilongwe. He is now unemployed as the contractor fired him due to the allegations made against him. He calls me ‘mama’ and seems to be waiting for me to sort things out for him. At present I am not sure what I should do. He thanks God daily for the love I have shown him. How will I continue to show him that love?
You can tell that I haven’t written for two months..... I have so much to tell.
An important part of my work is with the nurses/ midwives and now especially with the matrons. Recognizing the huge differences that will be encountered by all the staff when we finally transfer to the new unit I consider that some training and especially team building is vital. Along with the matrons, who are now taking a very active role in facilitating the groups, I am dedicating our weekly ‘in service’ training sessions to this end. On returning from Europe and taking up the sessions again (which by the way continued extremely successfully during my absence) I became overwhelmed by the task of successfully ensuring team leadership. This is going to be vital in the new unit as we start off with an almost totally new team. Before leaving for Europe I had already discussed the situation with a Malawian led NGO who specialize in Quality Improvement and leadership training. The head of this initiative is a very inspiring Malawian guy whom I felt really understood the unique situation at Bwaila. I contacted him soon after returning and was thrilled and extremely relieved to hear that he had already found funding for us and was prepared to become wholly involved in our leadership training. These sessions have now started and the staff are making weekly visits to the unit with their leaders, sorting out work plans, equipment needs, patient flow, as well as practical details of ordering and storage of materials etc. We will be visiting the public hospital in Blantyre next week to discuss and learn from them. As you can see it all sounds very busy......well it is! It is still a race against time to get the unit up and running before the end of the month but I am determined to do all I can to achieve this. The DHO, who has been away for the past five weeks, is now back and becoming involved. He is/will be ultimately responsible for the new unit. We have a good relationship and I am convinced that he will do all he can to make a success of it. (Taking into account the very limited resources and budget he has to work with.)
On a different note I experienced a rather violent attack on my person a few weeks ago. Being in the wrong place at the wrong time my car window was smashed with a machete knife and my hand bag stolen. Fortunately I only received scratches from broken glass and bruising to my arm. It has not had a lasting effect on me. I don’t feel as if I am in any more danger than I did before and continue to ask myself whether this type of violence is due to extreme poverty or greed? On a more positive note we have some great friends over here who can be relied on for love and support as well as practical help. Lucas is back at school and after a difficult first week as he adapted back to the constraints of being in school is also finding his way and happy to be here. The contact I have with my older children, though never enough, makes me very happy. They are all doing fine, finding their way in life with all its ups and downs, growing and learning, continuing to develop into wonderful young people and I am so proud of them. Both for you and for them I encourage you to find your dream and have the courage to follow where it leads.

100% CHALLENGED

2009-09-10T07:26:00.008+02:00

Lucas left Lilongwe at the beginning of June travelling to Valencia with his cousin Abigail to spend five weeks with his 'Papa' I was able to make full use of the following two weeks to concentrate fully on the coordination of the furnishing and equipping of the new Bwaila maternity unit. The procuring, ordering, confirming and delivering of each and every item necessary for the setting up of a unit of this size is a huge task. It has been and still is a challenging and often very frustrating process but I feel confident that it is now all 'coming together' and we will be ready for its opening during the month of September. I left Malawi on 18th July for my planned holiday break in Europe. After spending five wonderful days with my eldest daughter, Katy, in Leeds, UK, one of which was spent relaxing and being pampered in a health 'spa,' I flew to Valencia, Spain, to meet up with Lucas and my other two children, Alasdair and Fiona. Needless to say I have enjoyed every minute in the company of my children and friends. The love and support of these people, who are so important to me, reaffirms my conviction that my decision to stay in Lilongwe to continue the work I’m doing with the women babies and midwives at Bwaila is correct. Being in a first world country during these past weeks has not always been easy. It is difficult to completely forget the poverty and conditions from which I have come. It is especially difficult for me when I am in one of the many large, busy, shopping centres. My mind strays back to the villages, the hospital, the people of Malawi and it just all seems too much. How can some have so much and others, just a few hours flight away, have so little, have nothing? How can some people be so preoccupied by material trivialities when others are struggling to feed, clothe and educate their children. How lucky you are that you were born into a rich world that your worries are mostly about the extras and not about the basics, about luxuries and not about survival.

I wrote the above soon after arriving back in Lilongwe at the beginning of August. Since then I have often thought about you all and needed to communicate with you but have quite seriously not had the time nor the energy to do so.

These past four weeks have probably been some of the most challenging of my life.

On my return to Bwaila I was hugely disappointed to find that, despite the huge efforts I made before leaving to assure that outstanding work would be finished or at least well underway for my return, practically nothing had been done in my absence.The jobs that needed to be done ‘on site’ and that I expected to be finished had not been touched and the suppliers of various pieces of equipment and furniture had achieved very little. It was then I decided to dedicate myself full time to pushing and shoving, nagging and pestering, phoning and visiting with a determination that all those who know me will understand.
The official opening date of the unit had already been set. October 7th.The unit had to be up and running before that date and I for one was prepared to move heaven and earth to achieve it. And that’s what I have and I am still doing. Moving heaven and earth! Or at least it feels like that. If you’ve never lived in Malawi, though they tell me other African countries are the same and to be honest I guess pulling together this sort of project anywhere in the world would not be easy, maybe you wouldn’t understand, but the Spanish ‘manana, manana’ takes on a whole new meaning here in Lilongwe. I remember back more than 15 years ago when I was involved in setting up a new business venture with my (ex) then husband, Andrew. New to Spain and with very little of the language and less knowledge of how the Spanish system worked, the job of sourcing and procuring every little piece of equipment, nut, bolt and curtain hook, for the farm, was my main job. I still remember the huge frustrations of never finding anyone when they were needed, of waiting days and weeks for things that were promised for the following day and many items were just not available. I think that experience has helped me infinitely for the challenges I am facing now. My knowledge of building work, bricklaying, guttering, plumbing, electrics, drains, sockets, taps etc. increases daily. Not to mention the more specialized areas of autoclaves, theatre lights, piped oxygen and anaesthetic machines. Then there’s the procuring of furniture and equipment. I mean, just how many chairs are needed for a 146 bedded maternity unit? And stainless steel trolleys? And why does all the locally made equipment, beds, swab racks, bed pan racks have to be ‘epoxy coated’? and actually what the heck is ‘epoxy coating’? Just ask me any of this now and I will let you know!
I was very happy when the District Health Authority agreed to take on some tasks such as the building of concrete wash tubs for the women to wash their ‘chitenges’ Making of ‘curtain boxes’ for all windows, building of a new road. The unit has been totally funded from outside of Malawi. Mainly from Ireland through The Rose Project but also with Norwegian partners. It will be given to the Malawi government to be run as a public, non paying District Hospital. It was therefore encouraging to see them show their interest in this way. My enthusiasm was somewhat dulled after the new entrance way collapsed and had to be remade. During that time we could not let any vehicles on site for 7 days. I started to panic thinking that I would have to cancel the delivery of equipment which would delay everything. Silly me! The delivery trucks continued to arrive. They parked at the entrance and from nowhere appeared more than ten very fit looking guys who carried the boxes etc. sometimes on their heads, into the unit making several trips with often very heavy loads. But this is Malawi and I shouldn’t have worried. Then when they could drive in lorry carrying the bricks and materials veered off the road onto the pavement smashing the recently laid paving slabs. Not once but twice! But I think the best example of the hospital maintenance standards was when I passed by to see how they were getting on with the wash tubs. Now I am really not an expert but I do know that the water and drains are normally laid before and not after the concrete base. I respectfully enquired but was assured that they knew what they were doing. It was only once the tubs were built they realized that the plumbing would now have to be with external piping! It doesn’t look so good but I am assured it works! But that wasn’t the end of the story.... The following day I ’caught’ them on the point of connecting the water pipes to the contractor’s temporary water supply. An over ground piping that will be removed once the builders leave. At least I got to that one in time and the proper connections were made. These are just a few stories of the many I could tell you which have caused me to laugh and despair. There are also many more that have been so encouraging. A wonderful site foreman (George) who had always been at my side, listening, understanding, organizing, laughing, despairing, building up and knocking down, putting in and taking out, but always good humoured and willing to help. I have built up a lovely relationship too with many of the workers on site. The only female brick layer, who does a beautiful job, greets me every morning by name and with a huge smile. The gardeners who brought roses to plant just because I wanted them. Not to mention Fyson,the guy who holds the keys. There are more than one hundred keys to every door and cupboard on the unit and he knows them all. Actually he’s the second guy to hold the keys and only since July. The story of Andrew, who I have known for over a year since I first started became involved in the new unit, is a long one which is definitely worth telling.
This is part of a mail that I wrote to Tarek soon after the incident that I thought I’d share with you....
I
It’s a huge job I’ve taken on for The Rose Project and I often just wish I was back on labour ward. So much just doesn’t depend on me so I have to cope with the frustration of not getting things right because of someone else. As you said, I can’t change anyone else I can only change me. So I’m having to learn how to cope with so many things that are totally out of my control. I know that’s what you have to do and I am appreciating how hard that is. I have so much more to learn.
But that’s not why I sat down to write at this hour. Maybe I’m putting off the moment as I’m not sure if I did the right thing.
When I went on site this morning I couldn’t find the guy with the keys. He’s a young lad, always very friendly helpful and we have struck up a relaxed and fun relationship over the past year. I don’t know much about him but I have always had a good feeling about him. I eventually found out that he had been taken to the police station yesterday having been accused by the security guards of stealing a bag of 2nd hand clothing whilst the Norwegians were sorting it all out. ( A huge amount of sheets, material and clothing came over in the container.) I was surprised and horrified that he should be locked up in jail without even any charge against him. They also told me he had been beaten up. The charge had to be made by the DHO or myself. I couldn’t do it. I couldn’t bear to think of this young lad in the cell now for nearly 24hours and I couldn’t bring a charge for ‘possibly’ taking a bag of 2nd hand clothes. I think I did the right thing. My instincts told me that I couldn’t leave the country knowing he was still locked up. So I went and got him out. I tried to do it the right way. I went to the security firm, I phoned the DHO to get his support and the guy from the security firm came with me. So I got him released. It wasn’t too difficult. I was so naive that I didn’t realize until I was told afterwards that the police officers were waiting for me to give them money, so they didn’t get any! Well, Andrew is out of jail. I spoke to him briefly, he is just so young and was very quiet with me. He thanked me but he could hardly look me in the eye. I felt very sad as I have no idea if he is guilty or innocent. Of course he shouldn’t steal, but it was a bag of 2nd hand clothes! He probably has nothing and the temptation was too great. God knows what I would do if I had so little. Would I steal too? Would you? The foreman says they have always trusted him and will probably put him on another site to work. I hope so. I said he shouldn’t come back to Bwaila. So why do I need to write this down? Why do I feel so unsure? It felt so right at the time.
You can tell that I havn’t written for two months...I have so much to tell.
An important part of my work is with the nurses/ midwives and now especially with the matrons. Recognizing the huge differences that will be encountered by all the staff when we finally transfer to the new unit I have considered that some training and especially team building is vital. Along with the matrons, who are now taking a very active role in facilitating the groups, I have dedicated our weekly in service training sessions to this end. On returning from Europe and taking up the sessions again (which by the way continued extremely successfully during my absence) I became overwhelmed by the task of successfully ensuring team leader ship. This is going to be vital in the new unit as we start off with an almost totally new team. Before leaving for Europe I had already discussed the situation with a Malawian led NGO who specialize in Quality Improvement and leadership training. The head of this initiative is a very inspiring Malawian guy whom I felt really understood the unique situation at Bwaila. I contacted him soon after returning and was thrilled and extremely relieved to hear that he had already found funding for us and was prepared to become wholly involved in our leadership training. These sessions have now started and the staff are making weekly visits to the unit with their leaders, sorting out work plans, equipment needs, patient flow as well practical details of ordering and storage of materials etc. We will be visiting the public hospital in Blantyre next week to discuss and learn from them.
As you can see it all sounds very busy......well it is! It is still a race against time to get the unit up and running before the end of the month but I am determined to do all I can to achieve this. The DHO, who has been away for the past five weeks, is now back and becoming involved. He is/will be ultimately responsible for the new unit. We have a good relationship and I am convinced that he will do all he can to make a success of it. (Taking into account the very limited resources and budget he has to work with.)
On a different note I experienced a rather violent attack on my person a few weeks ago. Being in the wrong place at the wrong time my car window was smashed with a machete knife and my hand bag stolen. Fortunately I only received scratches from broken glass and bruising to my arm. It has not had a lasting effect on me. I don’t feel as if I am in any more danger than I did before and continue to ask myself whether this type of violence is due to extreme poverty or greed?
On a more positive note we have some great friends over here who can be relied on for love and support as well as practical help. Lucas is back at school and after a difficult first week as he adapted back to the constraints of being in school is also finding his way and happy to be there. The contact I have with my older children, though never often enough, makes me very happy. They are all doing fine, finding their way in life with all its ups and downs, growing and learning, continuing to develop into wonderful young people and I am so proud of them.
Both for you and for them I encourage you to find your dream and have the courage to follow where it leads.

ilongwe

2009-07-08T12:34:00.000+02:00

YESTERDAY IS HISTORY, TOMORROW ‘S A MYSTERY, TODAY IS A GIFT.
THAT’S WHY IT’S CALLED PRESENT.
Tomorrow Malawi celebrates 45 years of independence. 45years since the end of the British Colonial rule and this is its motto of the day. It somehow sums up how life is lived here, with little provision and planning for the future. Yet another conflicting message for me to try and sort out within the context of the immense poverty and suffering I witness daily. It so makes sense to savour and appreciate the beauty of today. To give thanks for the meal I am about to eat, the friends I spent the day with at the side of beautiful Lake Malawi, the sunset across the African sky as I drove back to Lilongwe, for the fact that I am alive. I love and feel loved. But at a political level where is the grand plan for the future that gives hope to the poor and underprivileged? Hope to the women and babies who continue to die in childbirth due to lack of doctors and midwives to care for them. Hope to the uneducated children, the hungry, the homeless and the sick. It is obviously a mystery. The ruling party was re elected recently with a huge majority. The new budget was announced on Friday. The civil servants will receive a 15% pay rise.( ALL civil servants.) The rich continue to get richer and for the nurses, 15% of very,very, little still remains at very little! Malawi is moving on but Malawi has a long way to go.
My niece Abigail and her friend have been staying with us for the past 3 weeks. They are both medical students and were able to accompany me on labour ward a few times observing and learning basic procedures. They also took some trips out into the villages to follow up some of my babies. The triplets are doing extremely well and we are continuing to support them with the provision of formula milk powder to supplement breast feeding. They live in a particularly poor village suburb of Lilongwe just 20 minutes drive from the centre. When we arrived for the first visit we were appalled at the number of very drunk men who came out to greet us. This was not like any other village I had been to. The feeling was not good. We immediately became aware of the lack of community spirit and family support groups that are present in most villages. I will continue to visit for as long as they need our support.
Lucas left with them last Friday. He will spend a month with his daddy in Valencia. He was really excited to be seeing all the family both in UK and Spain. The house is very quiet without him. I miss his happy chatter and his cheeky face.
However it is a good time for me to be alone as the organizing and planning details for the new maternity unit are taking up a huge amount of my time. To such extent that I have left labour ward for a while and am dedicating myself to help ensure that the final ordering and delivery of the furniture and equipment is taking place. I am also involved in the orientation and adaptation of the new staff for the unit. I am leading a weekly team building session for these nurse/midwives, part of which is making visits to the new buildings to try and familiarize ourselves with the totally new environment before we move in. These are important sessions which are also about creating enthusiasm and excitement for the project and helping the staff to feel prepared for change. The new labour ward is a totally innovative concept here in Africa. Each woman will have her own individual room for labour and birth. The potential for this unit is vast as we become more woman centred. Concepts such as privacy, freedom of movement, birthing options, male involvement, presence of guardians or family members, informed choice leading to increasingly empowering women, are all new and will need to be sensitively approached and gradually implemented. I feel very fortunate to be able to be involved at this time and help to lead the way to change.
Staffing, or should I say lack of it, is still our biggest challenge. To this end we are trying to find ways of attracting more staff to the new unit. One of these ways is through the sponsorship of student midwives who would then bond themselves to work on the new unit for a period of 2 years after training. If anyone is interested in this type of support please contact me.
Yesterday I received the first delivery of equipment. 20 new beds were put into the new labour ward rooms! It was an emotional and exciting moment. I have become increasingly involved in this project during my 18months here at Bwaila but the congratulations must go to those who initiated and believed in it from its conception over 4 years ago. Their dream of providing the poorest women and babies of Lilongwe a decent, respectful place to birth will soon become reality. We who have moved in since will help them to achieve that dream.
As I drove to the hospital this morning I noticed that the large signs for Independance Day displaying the above message had been painted over to read FROM POVERTY TO PROSPERITY . Maybe someone else wondered if they were putting the right message across?

THREE AT ONCE

2009-06-13T07:49:00.000+02:00

This month I had triplets! Can you imagine the challenge and the joy to receive not one nor two but three babies into this world? Of course in the developed world this would most likely have been the result of assisted reproduction methods and most certainly be delivered by elective c/section. With an operating theatre full of medical staff, technology and equipment you would have missed out on the miracle of mother nature who reminds me time and again of her incredible capacity to get things right. A twin pregnancy had already been confirmed but we weren’t expecting number three! After the first little girl had been born weighing 1.7kg. with no problems and a healthy cry we listened and examined for number two. I commented that her abdomen seemed quite large and was therefore a little nervous of number two who was presenting as a breech( bum first) “ I suppose there could be three!” I exclaimed jokingly. We decided to have a look with our portable scanner. We were all surprised to find two heads and not one but most of all the mother! She would pass from being mum to 2 directly to mum to 5! Number two was soon out, a little more complicated and in need of some resuscitation, but a healthy 2.5kg. So where was the last one? With the two girls out little brother put his head down and was easily pushed out by his very strong and capable mum. At just 1.4kg I wondered how he would fare. Two hours later mum was up and in the shower to wash both herself and her dirty linen. I called for her ‘guardian’ (her mother) to come and help though I’m sure she would have managed quite well on her own! Through a translator I was able to make her understand that I would support her to raise these children under the condition that she spent some days in our ‘kangaroo care room’ until the littlest one was beginning to gain weight and become strong. She agreed. And so it was that both mother and grandmother spent 10 days carrying the little ones on their chests ensuring then warmth the close physical contact most needed for them to thrive. Eventually the women started becoming anxious and impatient to get home. I finally discharged them last Tuesday with the little boy now weighing 1.550kg. It was necessary to supplement her breast milk with some formula milk ( after all we women only have two breasts!) It is rather expensive and totally unaffordable for most of our women. I promised we would visit 2 days later and bring more milk. So we set off this afternoon to try and find them! Linda from MUM’S RECIPES,(one of my present sponsors) came too as she has been closely involved over the past months in following up the orphans and needy babies from our nursery. Doreen (Lucas’ nanny) was there as our reliable translator so that meant that Luki came too. As usual for first visits it proved to be much further away than we thought! After passing through the densely populated outskirts of the city, almost slum conditions, we ventured into the more rural area. Eventually we picked up a local guy who knew where they lived. I guess that there are not so many families around with three new babies! It’s not uncommon when asking for directions, especially in the more outlying districts, for some totally unknown local (or two) to jump in the car to show you the way! It took some getting used to on my part, especially the smells that often accompany them! We arrived at her mud hut. It was very obvious from the start that this was one of the poorest areas. Accompanied by what seemed like the whole village both adults and children we entered in side to greet Agness and her babies. I am pleased to say they were all looking remarkably good. Wrapped up in a huge number of brightly coloured local cloths they felt warm and snug. She was looking after the babies well. We watched how the tiny boy suckled strongly at her breast,( In Europe he would probably still be in and incubator) and I checked that she was mixing the milk powder correctly and with some level of hygiene. Whilst we were there a young girl who looked about 8 but was actually 11 years old entered the hut carrying a small baby on her back. We were informed that it was her baby brother, that she could not go to school as she had to look after the baby since their mother died of Cholera 2 months ago. And so it goes on. Everywhere you go, everywhere you look there is need . So much need. Real genuine need. Linda will organize a visit to the family to find out the whole situation and assess how we can help. We cannot turn our backs for Malawi is full of orphans, Malawi is full of poverty but we can do our best.
Having written so long and so detailed of my triplets I will just try and summarize other events....
Labour ward is still busy, happy, sad, frustrating, squashed, smelly, fun, challenging, depressing, dramatic and unacceptably dirty....but I love it!
The new unit at Bwaila is almost finished so we will very soon be handing it over to the District Health Authority.
The container of equipment has arrived from Norway. The furniture and other materials are ordered. Some is being made here in Malawi.
I will begin the training and team building of the new staff next week. I have been encouraged by the enthusiasm shown by midwifery colleagues recently.
There is only one more week of school for Lucas before the start of the long holidays. He will be in Spain for 5 weeks with his Dad in that time.
I will be coming to Europe at the end of July for a break before returning for to Bwaila for the opening of the new unit
Having ‘lost my way’ for a time last week, with profound feelings of confusion and hopelessness I am now more positive and balanced.
.....This is the first challenge, to keep ourselves up. To stand upright for a reason.

LEARNING TO LIVE WITH LESS

2009-05-25T16:45:00.001+02:00

I have not been motivated to write my blog these last weeks. I’m not sure why that is. My days are full to the brim there are never enough hours in the day. There’s so much to do I sometimes find the task overwhelming. After a second visit by the director of The Rose Project and afterwards the Norwegian person responsible for procurement of equipment and furniture for the new unit I was left with the task of finalizing these orders assuring that what is needed is actually the correct specification and readily available. Some will be imported from Norway, others from South Africa or Kenya and the rest made locally. The buildings are now almost completed except for some last minute changes that have still to be finished.
Apart from these practicalities I am also working on the identifying and training of the members of the new health team. Due to the huge shortage of nurses/midwives in Malawi, staff will be brought in from many different areas. Some from the health centres, others from administrative positions and others will be nurses that have left the profession and are now being encouraged to return. In practise this means that the new unit will be staffed by a whole new team who have never worked together. This is a daunting task. The nurses and midwives, the colleagues I have been working with for the past 18 months will not form part of this group but will be taken to the other new maternity wing at the Central Hospital. I somehow feel I will be starting all over again . Starting once again to build up the relationships, the trust and the confidence which is vital for my continued work. This overwhelms me at times but I believe I am strong enough to do this.
Daily I am faced with conflicts and confusions within myself. I continue to find that life in Africa and here at Bwaila takes me to my limits and beyond. Not only practically, where my increasing experience in the area of obstetric complications allows me to respond to emergency and often life saving situations, but also emotionally as I try to empower my colleagues in their work and develop their own skills, often in the light of an almost generalized apathy, lack of urgency, responsibility or accountability. I remind myself frequently of Tarek’s words: “ Rachel, we are not looking for ‘Super Midwives’, just normal midwives who do their job.” So I endeavour to live with less, rather than more. I don’t accept it as right but I do have to learn to live with it. Less care, less caring, less vigilance, less ability, less accountability, less possibilities, less opportunities......... How difficult it is to stand back and let things be, let things take their course, allow change to happen slowly, give time. If we always do it, if we always point out that it’s not quite right, if we always make the decisions, if we can always do it better, little by little we are reducing confidence, we are undermining ability we are disempowering. I am here to empower the women of Malawi, to empower their health workers, to teach them skills, to give example but also to love and respect their differences. Not to want to make them like us but to accompany them in their journey towards a better and fairer future.
May has been a Spanish month with the arrival of Teresa a midwife from Valencia and Carmen and Carlos from Zaragoza. Teresa has been staying with us speaking only Spanish to Lucas. This has been wonderful for him as he prepares for a months’ holiday with his Dad in July. Bravely adapting to life at Bwaila with the usual conflicts and traumas that accompany the first few weeks of work here, she has been able to give some very special care to the mothers and babies she has attended. Those women and babies she has touched will know of something better because of her and she will grow and learn and love because of them. The Zaragoza team arrived full of expectations for their proposal to aid our work here at Bwaila/KCH. We soon encountered the recurring challenge of time commitment. Although understanding the huge potential out there of professionals wishing to give of their skills and knowledge to our work we find it extremely difficult to get them to commit to anything but short stays. We truly believe that a six month period is the minimum needed to be able to really contribute successfully. Adaptation takes time, understanding of the bigger picture in that whatever we do must lead to maximum sustainability, empowerment and confidence building cannot be achieved in a few weeks. It was therefore difficult to find a way to fit their plan to our needs. It will be good to find a way forward for these type of offers.
Lucas keeps well and keeps me on my toes. He ‘Ran for his Life’ ( sponsored run for wildlife!) last weekend. I was so proud of him as he completed 12 laps (12kms.) Running non stop for an hour. Needless to say , for those that know me, I encouraged him loudly from the side line without joining in! This morning I watched him run the 1,500m ‘open.’ Racing against boys of up to 12 years old he came in 10th of 12 runners. He was the only boy in his year that gave it a try which says something for his determination. Tomorrow is Sports Day, then only 3 more weeks until end of term. My niece arrives next week which we are looking forward to. Friends continue to love and support us and life in Malawi is good. My wonderful children keep us up to date with their busy lives and although we miss them so much it’s good to know they are happy and healthy. I will be back in Europe for a short stay at the end of July before returning for the opening of the new unit to face the difficult but exciting times ahead.

OK FOR AFRICA STUFF

2009-04-23T22:23:00.000+02:00

I am just not going to apologize any more for writing so infrequently. I really don’t find the time as my work here continues to diversify. From catching babies on labour ward, to teaching both in and out of the classroom, co-ordinating for the set up and running of the new maternity unit and a mountain of others areas in which I seem to have become involved, writing my blog seems to have dropped very low on my list of priorities. I know it is the only way that some of you manage to keep in touch so I will continue as often as I can. I do think of you all often even though you don’t hear from me.
Wednesday was a particularly busy day on labour ward. I am finding it increasingly difficult to find a day when I can spend my whole time on the ward without the interruptions of my other responsibilities. I do enjoy it very much and am therefore reminded where my true love lies. It was one of those days when nothing seemed to go normally. I attended more obstetric pathology in that day then many would see in a month or more! I continue to be reminded of the awful situations that women are facing daily through lack of money, education and resources. At one point in the afternoon we had 4 women queuing up for their emergency c/section. There was great debate as to who should go first. The woman who had arrived with us in such a critical state we just didn’t know how we could save her life. Her 30 week fetus had been dead for some time. She had started to labour a few days ago in her village. The labour became obstructed and her uterus ruptured spilling out the infected necrotic matter into her abdominal cavity .The only answer was surgery to remove the baby and the uterus, but her condition was so critical it would be dangerous to operate. We had no choice, so she went to theatre. As I prepared her, pumping her full of antibiotics, I talked to her and caressed her poor distended semi conscious body hoping she would at least understand the tone of my voice or the touch of my hands if not the words that I spoke. It still amazes me that women can reach such a severe state before finding their way to our doors. Another mother had arrived at the same time. Her labour had been obstructed for many hours. She was exhausted and the baby was severely distressed, but it was alive......so she went first!
My priority on labour ward at this time is the clinical teaching of our midwifery students. There are many students and few trained staff. It is difficult to ensure that they are always supervised and mistakes occur due to their inexperience. I spend my time passing from bed to bed watching over them, asking questions, giving explanations, teaching, showing, guiding, repeating the same things over and over again, but I never tire as I see them respond and improve and learn. This particular woman had been labouring all day. About the same time as the 2 emergencies arrived she was showing signs that she may not be able to deliver vaginally. We had been watching the baby carefully and were starting to think of sending her for a c/section. This was now out of the question. She would have to wait her turn which as things were looking could be more than 3 hours. I waited as long as I could but the baby’s condition continued to deteriorate. I decided to try a vacuum extraction. Thanks to my years in Acuario where I had truly been learning the ‘art’ of midwifery and learnt to develop and trust my instincts as a midwife, I had become able to judge whether a baby could be born vaginally even in some of the most difficult circumstances. (There are still times when one never can be sure so would therefore opt for a c/section, just in case) But I had no choice. It really wasn’t easy and there were moments when I felt like giving up but that would be condemning the baby to certain death, so I slowly, very slowly continued. I should also say that our equipment is not the best. Parts are missing and pumps don’t work. It’s all manual no machines and no modern stuff. ( Do you realize the amount of second rate, out of date, what no one else wants things we receive......it’s not good enough for the rich but it’s OK for Africa stuff!) Eventually the little one was born. My colleague resuscitated the baby and I took him to nursery. This morning he was off oxygen and suckling at his mother’s breast! Amazing! Yes it feels good, but no, it’s not good. They should have had the possibility of a c/section.
The director of The Rose Project will arrive in Malawi on Monday. Discussions will take place to finalize the details for the handing over of the new unit to the District Health Authority. The buildings are nearly ready and the equipment and furniture is starting to arrive. These are exciting but scary times. Staffing, or lack of, is still a problem. Adapting to the new environment is going to be a huge challenge. I am spending much time confronting these issues on all levels and in all aspects.
Lucas returned to school after his Easter break. He was happy to be back. This term his after school activities include athletics, chess, cross-country running and kick-ball (whatever that is?)When we arrived last year he found it difficult to express himself in English. Now there’s no stopping him! We have a deal whereby at least 2 days a week we only speak Spanish and of course Aragorn, Legolas and Gimmle only speak Spanish!

QUIET TIMES KEEPING BUSY

2009-03-31T17:22:00.004+02:00

I can't really believe it has been so long since I last wrote to you all. Did you think I had forgotten you?Its nearly Easter and school holidays. I am hoping to take a few days off to go away to the lake with Lucas.Labour ward has been remarkably quiet this past month. This means that we have been attending around 25 births a day instead of the usual 40 and above. In many ways that is good as it gives the midwives a chance to rest and breathe but as we have around 10 midwifery students on the ward doing their practical placement it some times feels as if they are fighting for deliveries! We also have 4 midwives who are in training for obstetric emergencies they are also desperate to gain experience. I wonder how many vacuum extractions have been done just so they could learn? All these students need close supervision and bedside teaching so it has been a pleasure for me to spend time with them, to share my knowledge and experience. I am continuously reminded as to how much I enjoy clinical teaching.This morning I was contemplating the decreased number of births in the month of March and wondering what could possibly be the cause? Remembering back to this time last year this was not the case. I wondered if it could be a much needed drop in birth rate? the greater use of condoms? increased education in birth control? Are things beginning to change? But then as I thought more I realized that we are still in the rainy season and the month of March has been particularly wet. Roads and bridges have been washed away. Many villages have been unreachable. Access to the more remote areas is now only by foot or ox cart. So I began to wonder, could this be the reason that the hospital has been so quiet? I hope not. What would this mean? The reality of the situation began to dawn on me. If the villages are inaccessible and the rain has prevented the women from coming to receive our care, who has been attending them? Where have these babies been born? What has been the outcome? These questions are almost impossible to answer. Most of the births and deaths that occur in the rural areas, unless they have been referred to a health facility, will never be registered. So we will never know how many have been born and how many have died.
Two weeks ago I was called from labour ward to nursery twice in one day. I was introduced to an old ( or at least she looked old) woman cradling a small baby in her arms. Her daughter had died in childbirth and she had no money or means to buy formula milk to feed the child. I was able to reassure her that through our feeding program to aid the orphans from Bwaila nursery we would be able to support her. She took her tins of milk and we promised to visit her the following week. The second call was a grandmother with twins of nearly one year old. These babies had been born in our hospital, prematurely and been cared for in our nursery. All was well until her 20 year old, unmarried, mother died suddenly. The grandmother could not look after the twins so came back to the only place where she had found care and attention. We were also able to help her, at least for a while. March is a particularly difficult time of the year for the poor people of Malawi as some of the maize is not ready to harvest and the rains are causing crop damage. This is the time that many are starving. There are so many people who need help the task is overwhelming.
Luiza was brought in to labour ward one morning, on a trolley, from an outlying health centre. Her baby had been born at home, in her village, assisted by a TBA. (traditional birth attendant) The birth had taken place without incident but the placenta was still inside her uterus. She had been bleeding profusely. When I first saw her I thought she was dead. She was so thin and gaunt I wondered how she could possibly be alive. My immediate reaction was to wonder how on earth could she have carried a baby to full term? Why had she stayed in her village to birth her baby when she was so obviously seriously sick and how was it she had not found help earlier? But those were questions for later, first we had to resuscitate her, but even if we did, would she really live more than a few hours? We started to care for her. We decided not to remove the placenta, at this time, as she was not bleeding more importantly we needed to stabilize her condition. I took blood samples and sent then to the laboratory. We slowly rehydrated her and awaited blood to arrive for transfusion. It didn't come. Eventually I was told that the centrifuge machine was not working so the blood could not be matched. The samples should be taken to the central hospital in the ambulance. By now it was almost lunch time and lunch time is sacred. Not an ambulance was to found and no driver answering his phone. Leaving Luiza with my colleagues I got in my car and drove the 5 kms. to fetch blood. I was lucky to find a technician in the laboratory who could process the samples and supply the blood. It also helped to mention that my good friend and neighbour, Bibiana, is a quality control supervisor in that department! I rushed back with a bag of blood (only 1 bag not 2) and started the transfusion. Slowly Luiza started to regain consciousness and began to talk to her guardians. I cared for her the rest of the afternoon. Later I was able to successfully remove the placenta with no further bleeding. When I left that evening the 2nd bag of blood that I had been promised had still not arrived. I phoned to check.'Yes they would send it'Her baby was small 1.9kg but strong and healthy. I went to nursery to get formula milk as Luiza was still critically ill and could not breast feed. I couldn’t stop thinking of her that evening wondering how it was possible and what were the beliefs and customs that allowed that young woman not to seek help for her illness. Yes she was HIV positive but testing and treatment is readily available, free of charge and often very successful. Despite our care and attention I didn’t think that Luiza would last the night. The best I hoped for was that my fellow midwives would care for her well in her last hours.Luiza was still alive the following day but still critically ill. The blood that was promised arrived at 9am. Whilst it was still transfusing Luiza died. Her baby was taken to be cared for by her family. That is the best we can hope for as so many are abandoned to be cared for in orphanages.
Do you remember the story of Laureen? Or maybe I didn’t tell you? She was the 2nd child of a educated mum. Her grandmother was also present at her birth as she is a midwife in Zomba. What should have been an easy 2nd birth turned into an emergency when Laureen, who weighed over 4kgs. got her shoulders stuck. The head was born with a huge effort and then no more. It didn’t matter how much her Mum pushed or I pulled she wouldn’t come. I quickly performed the appropiate manouvers for a shoulder distocia but she was truly stuck. I managed to get her Mum into another position and tried again. Eventually I got her out but in the process I managed to break her right arm. Well you can imagine how bad I felt? OK, so I had saved her life but I had BROKEN her arm! In the following days I managed to get her arm x-rayed and seen by an orthopaedic specialist who assured me all would be well and she would heal perfectly. I'm not sure I believed him at the time, but he was proved right and Laureen is now 6 months old bonnie and beautiful with no sign of the trauma she experienced at birth. Last Sunday I was invited to her baptism, I even bought her a frilly dress to wear. I was the only white face in a congregation of over 300 but what the heck!
So, as usual, its ups and downs, good and bad, happy and sad.Last night I read love described as 'agony and ecstasy'That just about sums it up.

SOME CHANGES BUT SAME DIRECTION

2009-03-10T23:23:00.000+01:00

It’s now over 2 weeks since I last wrote to you all. Life just gets busier and busier. I remember someone saying to me many years ago with reference to my Mum, “If you want something done, ask a busy person!” It was true then and still is now!
Since I arrived over 1 year ago I have been following the progress of the new maternity wing at Bwaila hospital. As I have explained before we are at present running a high risk, centrally run unit on a district site. The buildings are old and dirty. Conditions are bad and back up services are mainly at the Central Hospital several kilometres away. The initiative for the building of our new wing plus a larger one on the central site was taken by Tarek several years ago. The central unit is being funded by The Hunter/Clinton Foundation whilst ours by The Rose Project from Ireland. During the past months I have become involved with their work becoming their representative here in Malawi. Over the last 2 weeks I have been working closely alongside the director and members of the board during their visit to Lilongwe. As the buildings near completion there are a huge number of details to be checked on ground level. As my input is as a midwife I am able to see things on a purely workable basis which is important. I will be helping to organize and aid a smooth change over to the new wing. It is a hugely challenging task into which I have thrown myself. Trying to co ordinate the various parties that are concerned has turned into a largely administrative and managerial task which has taken me away from labour ward for the time being. I must admit I really miss the contact with the women, babies and my colleagues but I know I will get back to that later. I am still closely involved in the workshops/teaching twice a week and am taking this opportunity to introduce the new working conditions and hospital lay out to the midwives. The delivery rooms have been built on European based designs. Each woman will have her own individual room. This is totally innovative here in Africa. It may be found in a few private maternity hospitals but never in a public service. Our ‘poor’ mothers will have a greatly superior environment and they deserve it! Being with Mary Donahoe (Rose Project) has introduced me to other areas and given me new contacts. I was particularly interested in our meeting with the school of nursing and midwifery. They are hugely short of tutors and clinical teachers which only comes second to the fact that many midwives cannot be trained due to lack of funding. Recently one of the training courses was delayed as the government funds were not received. The school was closed until such time as the money became available. This is now a problem for the integration of these graduates into our new units. We are relying on these new midwives as part of our team. The most challenging area to be faced is that of staffing. Everyone seems aware of this crisis but nothing seems to be effective. Short term, we need midwives from ANYWHERE and long term, we need to train more midwives here in Malawi. There are many reasons for this tremendous shortage. Those that go overseas, those that move into the private/NGO sectors, where the pay and conditions are better, and not least, the high number of nurses who are dying. Believe me not a week seems to pass when they are not burying a colleague. Life expectancy remains under forty in Malawi and this is seen equally in the nursing profession. This morning I heard that one of our ‘old’ midwives had died. On enquiring as to how old they thought she was I was seriously told “In her fifties!” The Rose Project is also sponsoring a clinic for health workers in Lilongwe. This centre will serve all health staff. They will be attended in confidence and counselling and treatment will be given. This is especially important for our HIV positive nurses who find it difficult to visit a public clinic as they will be seen by their patients and possibly thereafter be unable to work due to stigma and lack of knowledge of the condition and its implications. There is much to be done and few to do the work but there are also many trying to help from afar. Aid to Africa has and is suffering due to the global economic crisis. I ask you please not to forget us. However difficult it may be for you over there it is not comparable to the poverty and suffering in Malawi.
Lucas and I keep strong and happy. We have much to be grateful for. Compared to the many in Malawi we are extremely fortunate. We sometimes miss our European roots especially our family and friends. My lovely children so far away, Lucas’ Dad his brother and sisters and Branston Pickle!
But for the moment we are in the right place doing the right thing...at least that’s how it feels at present. We send our love and thoughts to you all.

CHIMWEMWE MU'BEREKI

2009-02-22T13:05:00.000+01:00

Chimwemwe mu’bereki means ‘joyful motherhood’ It is the name that Joanne my American midwife friend gave to the small charity she set up whilst working here at Bwaila. Its purpose is to provide support for the needy families whose babies have been cared for in Bwaila nursery/neonatal unit. Some will be premature or HIV positive babies others orphan babies whose mothers have died in childbirth at our hospital. We try to support and encourage other family members to take on their care. This may be a grandmother or an aunt who may already have other dependants. Breast feeding is recommended for all babies irrespective of the mothers HIV status. It is the best protection against gastro intestinal infections which kill many neonates and children under five. But these orphans have no mother and therefore no breast milk. The cost of a tin of formula milk powder is around 800 MK (about 4euros) The small baby will need at least one tin a week to start with. This cost is totally outside the possibility of many of our families. As the child grows the cost of artificial feeding increases and the babies begin to starve. I have become involved in Joanne’s work and am seeing ‘first hand’ some of these problems. The families will either return to Bwaila on a monthly basis to collect milk powder or will be visited by a nurse/midwife who works for the project. The baby’s weight and progress will be documented and the family will be educated in health and hygiene issues. It is difficult to insure that the feeding cups are kept clean and the milk prepared in the correct way. I was concerned that these babies were not getting the possibility to suck, neither at the breast nor the bottle. We know this an important part of a child’s development. I had to learn that the risk of becoming infected by dirty bottles and teats outweighs the lack of sucking stimulation. Our most recent orphans are... a set of twins. These are the youngest siblings of a family of 3 sets of twins! The mother died on our unit after a problem with her blood transfusion. ...Triplets all weighing under 1.600kgs. The grandmother is staying in the hospital and learning to care for them. We hope that with our financial help and support the little ones will be able to stay with her so as not to be separated into the care of the already overcrowded orphanages. On Friday I was called to nursery see Flora and her grandmother. Born in November of last year, prematurely, her young mother died of Eclampsia during her birth. She weighed 1.400kgs. at birth and now 12 weeks later she weighs 2.500kgs. Last month we had supplied 8 tins of milk which should have been more than sufficient for this month, but she had travelled for more than 2 hours to receive more. When I saw Flora her face was pinched and thin. Her eyes seemed to stick out of her head, a round bloated belly and no surplus covering of fat. Anxious and crying she was desperately searching for food. I prepared some milk which she gulped down furiously. Afterwards she lay contented in her grandmother’s arms. Where had all that powdered milk gone? I presume that while the little one went hungry the other children of the family were being given her food. Or maybe they were sold to buy maize so other mouths could be fed? And how can I blame that grandmother? These are some of the dilemmas we confront daily. I said to just give her 4 tins this month and meanwhile we would visit her home to assess the conditions and the number of dependants that were being cared for . My role in this project was just to be supportive of the Malawian nurse and in an advisory capacity but I see myself getting daily more involved. Is there no end to the desperate needs of these people

Friday was the usual busy day on labour ward. My feeling of dread as I arrived early in the morning was justified. Prolonged labours, distressed babies and a queue for operating theatre. Who needed their emergency c/section first? The pre-eclamptic who could convulse any moment with a blood pressure of 210/140? The woman with 2 previous c/sections who had been in labour for many hours and was in danger of rupturing her uterus? Or the baby with fetal distress ?
All got their c/sections and all mothers and babies are alive!
Later that day I attended a surprise twin birth. I noticed that the mother had fever and the baby showed signs of infection. Its heartbeat normally at 120-140 per minute was consistently 200. I treated her infection with intra venous antibiotics and began to prepare her for a c/section. It became obvious by her behaviour that she was a victim of aggressive sexual practices and probably her pregnancy a result of rape. Although she tested negative for HIV at her last test she certainly had a severe STD. ( sexually transmitted disease) I was not keen to send her for surgery due to her physical condition but I feared for the life of her baby. I re-examined her just before taking her to theatre and found that she was almost fully dilated. I judged the situation and opted for an assisted vaginal delivery. It wasn’t easy as she found it very difficult to co-operate. It wasn’t easy as a vacuum extraction requires maximum co-operation from the mother. The baby was born and was taken to be resuscitated by another midwife. As I turned to assist the delivery of the placenta I noticed that the uterus was still rather large. “There must be another baby! “ I exclaimed. And sure enough there was. I quickly ruptured her membranes as I felt the 2nd head engage in the pelvis. The mother was reluctant to push. I called for someone to explain to her that she had another child to push out. I don’t think she was very pleased to hear this! I applied the vacuum cap once more and quickly extracted the 2nd little girl. This one cried loudly as if complaining about having been forgotten! 1.500kgs. and 1.650kgs. were reasonable weights for these twins. I sent them to nursery to be treated with antibiotics to prevent neonatal sepsis. I will check on them on Monday morning.
I will end by sharing two quotes from this week.......
As I wandered round the Ministry of Finance building trying to find my way out, after an unsuccessful visit to procure an extension to my visa. I enquired from an employee as to how to find the exit and commented that I was lost. “ No! ” he told me. “You can never be lost where there are people”
Each morning we listen to BBC Africa whilst having breakfast. There is always a moment called ...wise words. “ Great success comes from great belief “ we heard. “That’s you mummy” remarked Lucas. I didn’t quite understand what he meant so enquired as to his understanding of the quote? “ Great success comes from great BELLY!” he exclaimed.
Now that one needs thinking about!

CARING FOR THE CARERS

2009-02-12T21:32:00.000+01:00

What a privilege it is to be here! To be working in a place where amongst all the pain and suffering the appalling conditions, the dirt and poverty, miracles happen! How many of you can say that? Not a week goes by when I cannot say “ I HAVE SEEN A MIRACLE” Could it be that in the affluent world everything is so controlled, so much technology and knowledge , so many answers and logical explanation for everything that you wouldn’t recognize a miracle even if it slapped you in the face?
I believe in miracles more than ever before in my life. Why is that? Because I see them!
Let me share them with you........
Having been attended at a Health Centre several kilometres away from the hospital this mother was referred to us at Bwaila with a prolapsed cord. Those of you who have read my other blogs will understand that this is an emergency situation. It means that the baby’s umbilical cord, its life line, is coming first and is in danger of being compressed by the presenting part either the head or the breech( bum!)This will cause its death before being born. Apparently no ambulance was to be found so she was brought to us on the back of a bicycle! It is a common form of transport as most people will not have a car and the minibus may be too expensive or not available. When she arrived she was examined and taken straight to theatre for a c/section. The operation was performed and the baby was extracted alive and well! The baby was badly positioned in the uterus, meaning that as there was no presenting part in the pelvis there was no cord compression! Mother and baby are doing fine!
Yesterday another cord prolapsed. Yes, it is not uncommon to see this and many prove fatal for the baby. On examination she was found to have a foot and head presenting plus a long loop of umbilical cord. The doctor and midwife rushed to attend. The cord was still pulsating! What should she do? The head would compress the cord but was still high up. Quickly she made her decision and caught hold of the foot. Then with the help of abdominal palpation she was able to catch the other foot. It wasn’t easy but it was worth a try. It took some time, the baby was delivered, they feared it was dead, it looked dead. But no.... there was just a small sign of life. The midwife rushed the baby to the resuscitaire and began work. It took a while, but 30 minutes later it was sucking contentedly at its mother’s breast. Today it’s doing fine!
Now do you believe in miracles?
It’s not uncommon to hear the recently delivered mothers praising God for a safe birth. Mother and baby alive, hallelujah! “ Thankyou Jesus “ they say. I have to agree, but thanks to US, just a little, I say!
These last few days there have been more than 25 births overnight with just 4 midwives. The night shift starts at 5pm and finishes at 8am. This is of course much too long for any person to work continually. This means that they have to take turns to sleep for a while thus leaving the ward covered by 2 or three midwives only. There is one clinician on duty who may be operating or attending patients on the ante natal or post natal ward. It is not difficult to see how some women or babies will be missed and tragedies occur.
Arriving on labour ward early in the mornings is still a difficult time for me. Having greeted the night staff I always ask if they have any particular problem cases, prolonged labours or any referred patients. These I attend first. However very often the problems have not been recognized and a quick assessment shows women exhausted from labouring too long and babies struggling to resist. Although these situations continue to frustrate me it is also rewarding to solve the problems, perform the appropriate interventions and give the correct care. My knowledge and experience is increasing as each day presents a new challenge.
The work on the two new maternity wings is progressing well. Some of the buildings are already finished. It’s an exciting time but also full of worries and concerns as to how the change over will take place and particularly as to staffing matters. Malawi has a huge deficit of health workers especially nurses and midwives. We will be opening two units simultaneously with just one skeleton staff. This is our biggest concern. Malawi is not training sufficient nurse/midwives to cover its needs. Many of the more highly trained are being taken up by the private hospitals or NGO organizations and others are leaving the country for greener pastures. How to make working in Bwaila hospital attractive to the nurses and midwives is proving to be a huge challenge. The new buildings and working conditions will of course be tremendous but will that be enough and for how long?
Last week I attended the launch of an iniciative to lobby politicians to commit to reducing the enormously high maternal and neonatal death rate here in Malawi. It was well attended and an appeal was made to government , in light of the impending presidential elections, to increase funding and resources to this end. A young mother told her story of how she nearly died in childbirth. This woman had been attended at Bwaila hospital. According to her story she was badly treated and neglected. The blame once again was aimed at the midwives. It is true we must be accountable, it is also true that women and babies don’t always receive adequate care but it is also true that the midwives are working under great pressures and stress. Appalling conditions, huge lack of staff in all areas, miserable wages not to mention the vast personal problems and loads that many of the midwives carry .Many are responsible not only for their own family and children but also that of their extended family after the death of a sister, cousin or family member. Life expectancy is still less than 40 years. HIV AIDS, malnutrition, hunger, TB and many other illnesses are killing off the poor people of Malawi and leaving vast numbers of orphans to be cared for by others. These sort of public attacks do nothing to raise the moral or encourage the nurse/midwives. CARING FOR THE CARERS is the motto of the National Organization of Nurses and Midwives of Malawi.
I will be an advocate for the midwives of Malawi. We must find ways to support and encourage them not to criticise and demoralize. This is our only way forward.

MUM AND MIDWIFE

2009-01-29T08:54:00.000+01:00

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 4.30pm.one 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!

THERES NO HIDING THE TRUTH

2009-01-18T16:09:00.005+01:00

"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.......

,

DIFFERENT WORLDS

2008-12-14T21:42:00.003+01:00

As I sit here in the comfort and warmth of my brothers home in England I am thinking of Malawi . I want to write to update you with news of my women and babies, left behind, so far away in a different reality to that in which I now find myself. We arrived this morning after a long and tiring flight through Lusaka and Nairobi. With just 30 minutes left before landing we were told that due to intense fog conditions at Heathrow airport we would likely have to divert to Amsterdam. At that moment it just seemed too much to bear! I confess I sent up a word to the Almighty for a safe landing...preferably at Heathrow!
After circling for 20 minutes we were told we could land a Gatwick....that was better, at least we would be in England! With 5 minutes till landing another announcement told us we would be turning round to land at Heathrow as planned.. the fog had lifted! Joy of joys we arrived only 40minutes later than scheduled. What a priviledge to have that feeling of somehow being "looked after"
I went to visit Flora twice before I left. I took her some more food and some of my daughter Fionas old clothes. She was so happy to receive them especially a pair of pink shoes that I had no need of. On the first visit her investigations had still not been done nor had she been transfused the prescribed blood. I insisted that this be done and they assured me they would attend to it. I was not confident but could do no more. The second time I visited she had already been discharged home. I went to see the attending clinician and together we examined her file, She had been given 2 bags of blood, her Hb had risen to 6.2. The investigations revealed her to be suffering from a common parasite found in the waters of Lake Malawi( Bilharzia) This had been adequately treated. As chronic condition this had been the cause of her severe anaemia . There was no reason to think that she should not now recover fully. I left the hospital feeling happy and content. Although I did wonder what would have happened, if the outcome would have been different had I not taken a special interest in her? I hope that one day when I visit the lake I will be able to find her and see how she is progressing.
The day before leaving I took a trip out to the villages to follow up my twins, Edward and Alex. Pilirani had called me two weeks ago saying that they were starting to go hungry. Last years maize was finished and they were now planting for a harvest in March of 2009. I took with me a 50kg. sack of maize which should feed her family for a month. As usual all the children came running out to greet me. They all want to watch over my car or carry my bags as they know this will result in a 20mk or 50 mk payment. I sat down to talk to the ladies of the village. Looking round at them all especially the children I was overwhelmed by such a strong feeling that whatever I brought, however much, it would never be enough. This is how I have been feeling these last days . Never, oh never enough!
After a short trip this afternoon to a local shopping centre I find myself with all sorts of confusing feelings and emotions and cant stop thinking about my life in Lilongwe so different, so far removed from what I will be seeing and experiencing during the next few weeks. I look at the busy people rushing around doing their Christmas shopping seemingly totally unaware of what it is like for my poor women and babies in Malawi. I want to scream and shout and tell them to stop buying un necessary things, to stop spending their money on trivialities, what importance have they? dont they realize that just a plane journey away the people are suffering, are hungry, have nothing, no presents, no chocolates, no pillow to lay their head, no shoes on their feet. Different countries, different realities.
As I passed through labour ward on Friday to bid farewell to my colleagues a young woman called to me, her arms outstretched, " Nursey, nursey come and help me, please come and help me! " I could see that the babys head was close to being born. I could not attend her. I had other things to do. I had no uniform or gloves. What excuses I gave! I called to another Malawian midwife to attend ..the birth was imminent. " No, no, no the young woman pleaded with me " You nursey..., asungu, asungu, asungu......" ( She wanted this white woman to care for her, not anyone, just this white woman) I had to leave, the other midwife went to her. I can still see her arms stretched out to me and hear her voice " asungu, asungu!" and I left...
And here I am in England, doing my Christmas shopping along with all the rest.........

MAKING A DIFFERENCE

2008-11-26T14:48:00.003+01:00

Today I want to share two of my many stories with you.
The first time I met Flora she was lying on a bed in labour ward her mum was standing alongside her. I was suprised at how young she looked and immediately noticed the worry and concern reflected on her mum's face. Maybe that was how I identified with her in that moment, somehow not as a patient and guardian, of which I see many, but as a Mum with her precious daughter. It is unusual to find mothers on labour ward except with very sick patients so I immediately presumed that her condition must be critical. I inspected her file to familiarize myself with her case and found that indeed she was a very ill girl/woman. Flora had been referred from the health centre in Salima, more than an hours drive from Lilongwe and situated on the side of Lake Malawi. She was around 30 weeks into her first pregnancy but was carrying a dead baby. She had last felt her baby's movements over one week ago. But that was not her only problem. She was suffering from severe and chronic anaemia. Her Hb. (normally 12 to 14) was 3.1 .The clinician who had admitted her described her appearance as "paper white" This may seem a strange way to describe a person with black skin but certainly makes you realize the seriousness of her condition. Flora is 20 years old, but looks 15! Apart from the pregnancy she had also been vomiting blood for several days. The reason for this was not known at that time but was an important contributing factor to her anaemic state. The hospital at Salima had transfused 3 bags of blood but could do no more. It was now extremely important to deliver the dead child but her critical condition made this very dangerous so she was referred to us at Bwaila.
By the time I arrived she had been transfused one more bag of blood and induction of labour had been iniciated. I decided to take over her care. I quickly made friends with her Mum, even though she spoke very little English and was grateful for her presence throughout the day. I soon realized that they had arrived in an ambulance from Salima with no posessions, money or food. I gave her Mum 500mk(less than 3 euros) with which to buy some basic food and essentials. It quickly became obvious that Flora had been sexually abused and therefore it was very difficult to perform the necessary examinations and procedures. However, I refused to do this by force ( she had been forced too many times) and though it took a great deal of time and effort, talking and explaining, and being as gentle as possible, I slowly began to gain her trust and confidence. She laboured quickly during the day and by early afternoon she was ready to deliver. I had been able to transfuse 2 bags of blood and also blood extracts during the morning and hoped that would be enough. It was all that was available. We had been promised more later. I was concerned as to how she would cope during and after the birth and did all I could to ensure minimum blood loss at that time. The fetus and placenta was expelled easily without haemorrage but she continued to ooze afterwards. When I left her on Friday afternoon she was on the way to operating theatre for an exploratory procedure to establish the cause of bleeding. It was just too difficult to examine her properlywithout sedation or anesthetic. My last words to the clinical officer was " Please look after Flora I want to see her on Monday"
" I'll do my best " he replied. I could ask no more.
I spent most of the weekend thinking of her.
My first call on Monday morning was to post natal ward. I was delighted to find Flora alive. Not healthy, not strong, but alive.
The same day she was transferred to the gynae.ward at the central hospital for further investigations. She was still vomiting blood.
Today I went to see her and took her some boxes of milk, nutricious cereals, a bar of soap and some washing powder. I found her sitting up in bed, still ' paper white' but still alive.
When I enquired of the clinicians as to her condition I found that the investigations were still not done and they were not aware of her most recent blood results. Her Hb. post delivery is now 2.9.
I do assure you that in the developed countries 2.9 is considered nearly dead!
I requested that they ensure she receives more blood and that the investigations be carried out as soon as possible. I will return in 2 days to make sure.
Now I must quickly tell you about Larson.
My friend and fellow midwife Joanne, now living in Ghana, but who spent 3 years working at Bwaila, is here on holiday. It has been great to spend time with her, she's a remarkable lady.
On Saturday she sent me a message telling me of a Malawian family that she knows. Larson was desperate to find work. Did I know of any opportunities? At the time I didn't. Later that day I was talking to my neighbour who informed me she would be moving to a new house. It would be a good thing as there would be a big garden for her boys to play in but unfortunately being the other side of town she would need a driver to shuttle her sons back and forth to school and their various activities. I immediately thought of Joanne and her friend.
The interview was arranged for Sunday morning. Joanne arrived with Larson and I introduced them to Rose. We sat on the verandah and Larson began to talk. A married man with 3 children his wife was expecting the 4th. He had been out of work for 2 years and during that time had trained and gained a licience to drive taxis. He started his own business as a taxi driver but a year ago he was attacked at gun point and his taxi was stolen.He is lucky to be alive. Understandably, he will not drive a taxi again.
We asked how he and the family had survived during the past year? He explained that by doing small jobs he could earn some money so the family could eat and if not they just had water. It was shocking to hear this type of story first hand. We all know how many families here in Malawi live this way but it was disturbing for us to listen to his words and hear the emotion in his voice. The voice of a good man who so often could not provide for his family.
" I promise I will work hard, madam. " he said. " You can trust me. I will look after your boys as if they were my own. "
Rose decided to offer him the job. She was concerned that it would not start untill January.
" That's OK, madam, I have been waiting so many months I can wait one more"
The tears in his eyes and the smile on his face as he left to walk the 6km home to tell his wife the good news were a joy to behold!
What an incredibly humbling experience it had been for us all.
" You have just employed a driver " I said to Rose " But you have turned his whole life round"
Larston would go home to tell his pregnant wife that the future was brighter. 2009 would bring food on the table, clothes for his children and who knows maybe schools and medicines too.
" There was always much love in that family." said Joanne.
" Now there is hope"
How little we really had to do to make a difference. How little YOU really have to do to make a difference.

BLOODY MATTERS

2008-11-11T12:41:00.004+01:00

A new blood bank is being built in Lilongwe. Until this is finished the blood comes from a central supply in Blantyre., more than 3 hours drive from here. It is ordered and received daily but invariably there is never enough. Most of the donors are young students which means in holiday times there is a marked shortage. Iam sure that the particular lack of supply two weeks ago was the cause of many tragic incidents all over the country but I can only tell you of those in which I was involved. The lady that I talked of last time was eventualy delivered of a still born infant later in the day. A normal delivery saved her from a c/section. Her life was not put at risk by operating with out the necessary blood supplies but for her baby it was too late. The following day I was attending a very young girl, just 17 years old, having her first baby. She had been suffering from severe malnutrition and chronic anaemia for some time. (Hb 4.2) As her labour progressed I prepared myself and her for possible complications. An IV line was inserted and the appropiate medications were prepared and ready for use as soon as the baby was born. Her blood loss should be minimal if she was to maintain her condition. I aided the last part of her labour by assisting with a vacuum extraction. Such severe anaemia brings with it an overload on the heart and inability to cope with extreme effort such as pushing out a baby. The placenta was delivered quickly with minimum blood loss. It was then she started to haemorrage. I knew that I would be lucky to find blood for her but had send off a petition earlier. It was still not available. After following all the procedures in event of severe haemorrage she still continued to bleed. We were begining to get worried. As with any wound or area of blood loss, compression of the site willreduce bleeding. It was the only thing left to do and for the time necessary to stem the haemorrage or untill the arrival of the blood so that she could be taken to theatre for a hysterectomy.The poorly contracted uterus was the cause of the haemorrage with the underlying chronic anaemia. This meant that removing the uterus would be the only option. So it was that I found myself performing bi-manual uterine compression for more than 30 minutes. This means that I had to compress the uterus between my two hands, one externally and the other internally, in the vagina. It is a procedure that we are taught in our training and that I continue to teach for emergency situations but is rarely needed as by this stage the woman should be in the operating theatre. The senior obstetrician was called to review the situation. She decided to go ahead and operate. The anaesthetist was not happy. "She can die here from her bleeding and we do nothing or we can try and operate and she dies in theatre.... we must give her a chance. Some things we just have to leave to God" the obstetrician remarked encouragingly. I found myself in operating theatre with this young girl. At worst she would not survive and at best she would be 17 years old with no uterus! I waited by her side for the surgeons to get ready and the theatre to be prepared. I was continuously checking for the contraction of the uterus and signs that the bleeding had ceased. All was ready. "Please can you check the vaginal packs once more " I asked, " I think she has stopped bleeding ,her uterus is contracted " And it was! There was no need to operate, I couldn't believe it! She was taken to post natal ward where later that night she received 5 packs of blood. When I went to see her the next day she was sitting up feeding her baby!
Maybe I should end with that story so that you can all feel better and happy? But no .... I cannot, you need to know the whole truth, all the stories. The following day the situation was still the same. Little or no blood to be found. The lady who was brought to us from the health centre was already in a poor state as she had started to haemorrage in her home, in the village. The placenta was lying low down, in front of the baby's head (placenta previa)as the cervix began to stretch it was pulled away from the uterine wall and began to bleed. She had already lost a huge amount of blood when she arrived in the early hours of the morning. The treatment for this condition is emergency c/section. She was unstable and there was no blood available. The anaesthetist decided her condition was too precarious to operate.The young clinician could not contact his superior and the woman bled to death one hour and a half after arriving at the hospital. Her baby was still inside her. Should she have been taken to theatre in any case? without any posibility of transfusion! Maybe yes? Maybe no? Would any doctor like to be faced with that decision? would you like to be faced with that decision?
Don't worry you won't have to ! You'll always have blood available for transfusion. Your blood banks work, your donor schemes work. You are rich, you can protest and complain! The women...especially the women...the poor women of Malawi have no voice, will not be heard, so they die because there is no blood to give them.
The new Bwaila hospital is well underway and nearing completion.It should be ready March of April next year and I'm getting involved!
The Rose Project from Ireland (www.roseproject.org). are funding the building and equipping. It will then be turned over to the Malawian district health authority to staff and run. So thats where I fit in. I will be co ordinating and advising to help to achieve the vision and aims of the donors and sponsors. To create a maternity hospital of excellence here in Lilongwe.
More about that next time.Suffice to say its all very exciting for me and a whole new challenge. Keep supporting me, please, I'll need it!

HOW LUCKY WE ARE

2008-10-28T15:40:00.003+01:00

The workshops that I started up several months ago for the midwives at Bwaila and Kamuzu Central Hospital continue to be enthusiastically attended. Sometimes I wonder how much of what we share and learn is ever taken back into the clinical situation but that is on my more negative days. As requested by the midwives, in the evaluations, we have been covering topics that are directly linked to their everyday practise. Skills and knowledge that I inicially took for granted would not be necessary have been well received. Many of these topics have covered actuation in emergency obstetric situations. I was priviledged to have attended an excellent course last year before coming to Malawi on these same subjects which has helped me to prepare a more structured presentation. Todal we were looking at post partum haemorrage. This is profuse bleeding after delivery.This is one of the main causes of maternal death in our hospital. Prompt and acurate dignosis and attention really does save lives. After learning the basic theory I set up a clinical situation in which they could practice. As I lay on the conference table pushing out my baby and then fainting from blood loss the midwives practised how to call for help, organize the team and methodically go through the process of attending to this simulated emergency situation. As you can imagine much fun was had by all and amoungst shouting a laughter I hope we all learnt something. I did, however, draw the line at having medication inserted in my rectum!! I have also been using case histories as a means of looking crictically at our work. We were not suprised but were concerned by what we discovered.
After I had finished teaching I returned to the labour ward positive and encouraged. Unfortunately I was met by an alarming situation. The woman was 34 weeks pregnant with here 4th child. She had been suffering from severe anaemia during most of her pregnancy this is not uncommom due to extremely poor diet and hunger. She had been regularly attended in the antenatal clinic as well as being an in-patient for some time. Her membranes had ruptured spontaneously several days ago with no other signs of labour. It was decided to incuce labour. The procedure is to insert medication in the vagina to ripen the cervix. This was done earlier this morning. At 1pm when she was being assessed it was noticed that the baby had an irregular, slow heartbeat. A monitorization showed severe fetal distress. She would need and immediate c/section to try and save the baby's life. We prepared her for theatre and called the clinician. It was noted that her anaemia was still severe ( her Hb was now 5 having been increased from 3.9 with blood transfusion, a normal healthy Hb is around 12 to 14) Blood samples had been taken during the morning to prepare blood for her to be given as soon as possible. We contacted the laboratory who told us that there was no blood available. They would be processing blood at 2pm but it would not be ready untill later in the afternoon. It was not that there was no blood for her, she has a very common blood group, the situation was that in the biggest hospital in Lilongwe, the capital of Malawi, there was NO BLOOD AVAILABLE. I went to theatre to talk to the anaesthetist who confirmed that it would be too risky to operate without blood, that she would have to wait. I walked slowly back to labour ward to give the news my heart was so heavy. The young Irish midwife, who had been looking after her, cried out" This cannot be happening! " But it was true. I told her to remove the fetal monitor, there was nothing more we could do and listening to the baby's slow heart beat was not going to help. She cried. I tried to console her and felt resigned. I did notweep as I would have done a few months ago. Am I starting to harden to these situations? am I accepting them? I hope not.
The lights have just gone off, there is a powercut in this place that I come to talk to you all. How strange that the computer still works! Here I share my highs and my lows, my laughter and my tears. I let you into my life and my work, into the lives of the poor women of Malawi. Why? Just so you know how lucky you are! Just so you realize how much you take for granted! Just so you think again when you complain of the health care you receive! Just so you appreciate every day and moment of your comfortable lives! Just so you love and care!
My midwife friend Joanne sent me this ( she was working at Bwaila before me) I thank her for her insight and her continued concern for Bwaila.
"If we are lucky, we will suffer a taste of powerlessness in our own private lives. Because then things change. Then we begin to see with a gentler, broader vision and talk with a kinder tongue and feel with deeper feelings for those for whom powerlessness is a way of life." Joan Chittister

TIME PASSES BUT WHAT CHANGES?

2008-10-17T17:15:00.002+02:00

I really can't believe that nearly three weeks have passed since I last wrote to you all of my life here in Lilongwe Malawi. Time passes so quickly and I am already starting to make plans for our return to Europe in time for Lucas' birthday and for Christmas. These are special times for us as a family and it will be good to be together again. My mum has be operated on recently and although she seems to be recovering it has not been without its difficulties. I am grateful to have my brothers and especially my sister available for her as I am really not much use to her being so far away. I sometimes question my dedication and availability to the poor, the women and babies of Malawi when I am not even able to care for my own mother. Still ....I guess life is full of confusing and conflictive thoughts ....nowhere more so than here in Malawi, one of the poorest countries in the world. It is evident that huge amounts of donor money is being poured into this country. Many projects covering a huge multitude of different areas of health, education, agriculture, etc.etc. Conferences and congresses. Training programs and education to improve knowledge and skills. But yesterday we found ourselves with no gloves. Just for 15 minutes whilst someone went off to find the matron and replenish supplies, but during these 15 minutes nothing could be done! Well not quite true... I managed to deliver a baby and resuscitate another without gloves... much to the horror and disgust of all my colleagues. On our busy labour ward many things can happen in 15 minutes it is not acceptable to be without gloves. Proper suture material has been absent during most of this week. Yes, women are being sutured but not as well as they could. But this is normal at Bwaila hospital this has become acceptable ...at least to some. So all this money pouring into the country and we have no gloves and no suture material. Not to mention scissors, forceps, curtains, vacuum extractor, beds, sheets, lights, soap, syringes, needles, washing facilities, showers, hot water...........do you want me to continue? But I'm not saying that the answer is to keep donating these necessities. I just want to emphasize that these are necessities for dignant care.
I have heard that large sums of money are being spent on courses and training on how to deal with a major crisis or disaster. Earthquake, floods, tsunami or the likes. I'm sure it is very relevant and important but hunger, poverty, lack of decent health care and education are here with us now. Crisis and disaster are here with us now and we are not managing to deal with it effectively.
The twins that I wrote of in my last blog were able to go home after just 5 days in the nursery. They returned one week later for a check-up and were looking fine and healthy both having gained weight. Before discharge their mother had asked me to give names to the two little girls. This is a great honour and one becomes as if a god-mother. I shall have to be careful not to take on too many of these adopted children! I decided to call them Ruth and Rachel ( My elder sister and I) When she came to show me the girls they were dressed in the clothes I had given them and wrapped in the little blue Ikea blankets that Katy had brought out. She proudly told me in broken English that Ruth and Rachel were doing well and would like me to visit them. I shall put aside a day next week to do just that.
Some days are more chaotic than others. Very often labour ward is full of staff. Students of all types mill around with what seems like as a total lack of direction. Many times that is so. I continue to try and teach as much as possible. I move from bed to bed trying to keep aware of what is happening ask questions and discuss care plans. I am always particularly vigilant to make sure that the referred cases are assesed promptly. This is still a problem. This past 2 weeks my in-service training sessions have been looking at case studies to try and pick up any mistakes made and learn from them. I was suprised to find that most of the midwives were quick to spot the delays in giving the appropiate care and could easily present the case and make the corrections. They also could appreciate the evident lack of record keeping. They found the sessions stimulating and helpful...or so they said... I was dissappointed to find that the following days showed that this knowledge was not being put into practice. They were not able to perform the care that they knew was correct. Or they were too busy or tired or complacent. This ended in two particularly sad cases where the result was two dead babies. If they had acted quicker or made a more responsable decision instead of waiting these babies would not have died. Much of the delay is in getting to the hospital but we need to confront the obvious delays that are occuring in our own labour ward.
I will try not to leave it so long before writing again.
Many times I just don't feel like writing it all down as its too upsetting or just too repetative.
My moods change and swing each day and sometimes many times in a day. Today I am not so positive and just a little tired and angry. I am sure it reflects in my writing.
Lucas has been on half term holiday this week. We were so lucky to be invited to spend a long weekend at a cottage on the lake shore. It was a fun and peaceful few days. We feel very fortunate to have such good generous friends.
I remain with the image of the sun rising over the lake. A huge fiery red, orange and pink circle changing the colours of the sky as each minute passed and a new day began. I crept out of bed quietly and wandered down to the lake for a morning swim in its calm sweet waters. I have so much to be grateful for. Sometimes the contrast from that to my work with the women is too much to bear.

MANY BABIES AND NO BEDS

2008-09-25T15:17:00.004+02:00

We have 14 beds on labour ward at Bwaila hospital. It is the traditional ' nightingale ward ' which allows little or no privacy for the labouring women as more often than not the curtains hanging round each bed ar either torn broken or not present. The beds are about 1.5m apart which does not allow much freedom of movement for the woman or the midwife. However this ' layout ' does have its advantages as it allows the understaffed midwives to, at least, be aware of what is going on in most of the ward. If you can't see them you can hear them. " Nursey! nursey! nursey! " they cry to attract our attention., very often when the babies head is emerging, so all we can do is run to catch the little one coming out. However it doesn't always work. I should tell you of the birth on night duty, I wasn't present. The woman cried out alerting the staff that the baby had been born. The midwife approached the bed with her equipment but there was no sign of the baby. On closer inspection the newborn was found dangling by the umbilical cord over the side of the bed! Both mother and baby are fine.....now!

We are attending around 40 to 50 births a day so, as you can imagine, it is not unusual to find that we have no spare beds. Labouring women will stand beside the bed of a recently delivered mother just waiting for her to get up and go to the shower so she can claim her bed! ( It reminds me of people waiting in restaurant queues for the next available table. Trying to judge if the diners on table one, who are taking coffee, will then ask for a liquor after or just go straight for the bill and what a relief when you see them putting on their coats and getting up to go!) No spare beds means that women will birth on the floor. This can be an advantage as she will rarely lie down but be in whatever position she finds most comfortable but the disadvantages are that the cement floors are extremely dirty, hardly ideal for receiving a newborn and most midwives would not get down on the floor to assist. And so it was on Monday morning when I arrived. " A full house! " I was told. I enquired as to where I should start? Who was pushing? Any problems? I was asked to attend bed 8. " She was fully dilated at 6am. but we've been so busy we told her she would have to wait " And she had! As I went to her bed I passed a woman crouching on ' all fours' on the floor. She was moaning loudly, obviously in advanced labour, but as there was no bed and I had another to attend I left her on the floor. It was her first baby and the head was low. I got her out of bed and onto the birthing stool. " Can I push now" she enquired and was happy and relieved that she didn't have to wait any longer, that she had someone to care for her and so she started pushing. Ten minutes later, with much encouragement I started to see the head, the fetal heart was fine and she was doing well. I had been looking over regularly at the woman on the floor to see how she was doing and shouting words of encouragement. " We'll have a bed soon, don't worry " I dont expect she understood me but then again my words were not only for her, but for the other midwives standing around. Its a dangerous time to give birth as the night nurses have finished and the day staff have not yet started. " Can someone attend that woman please I begged" Too late! The cleaner shouted out " Baby born!" Still no one seemed to move, so I left my young first timer and rushed to her side. The baby had been born by the breech ( bum first) and was hanging by its head while she stayed on all fours position. This is a great position for normal births but absolutely NOT for breeches. I got on the floor and quickly managed to help the head to be born, it was not easy, even with my experience in attending in all sorts of positions. The baby needed immediate resuscitation which I did. Still no movement from my colleagues! " Please will someone get her onto a bed " I cried. " Can you check if there is a twin as the baby is quite small. " I asked. It took about 10 minutes to get another woman off to the shower and wash the bed. In that time I continued to work on the baby all the time asking for them to hurry up and please check if there was a twin. By the time she was on the bed and being attended by 2 students the baby was breathing spontaneously so I left her with oxygen and approached the bed. They had confirmed a 2nd twin but still had not listened for the fetal heart or determined the presentation. I continue to be amazed by the total lack of a sense of urgency amoung my fellow midwives. I could not bear it, so I just took over. "She has one nearly dead baby by god we're going to save this one " I exclaimed. They had not heard a heart beat! I examined her, determined a head presentation, ruptured the membranes, applied a vacuum extraction and as she pushed I pulled that baby out. It was not difficult but it was urgent. The baby's condition was poor so I left the students to attend to the woman and resuscitated the 2nd little girl. Both babies responded well and are now in nursery. The students working in Nursery have taken a special interest in them and I have visited them everyday since. I am happy to say that they are doing well. Both are breast feeding, they have lost weight and are being treated with antibiotics but after the first 24hours on oxygen are now maintaining well. I was able to take them some of the clothes and blankets that Katy brought over given by very generous donations. I hope to continue to follow their progress when they are discharged.

Just to finish I should tell you of our visitors to labour ward this week. We have received a large group of senior midwives, tutors, matrons, clinical instructors etc.from all the different university training centres in Malawi. They are on a 3 week goverment course funded by an NGO specifically to revise and refresh their practical knowledge so has to improve their teaching both in the classroom and in the clinical situation. Part of their updating is to look at different birthing positions, freedom of movement in labour, spontaneous pushing and instinctive birthing behaviour. They had been told that in Bwaila maternity unit we are already practising this type of care. Hallelujuh ! Its just what I have been teaching and trying to implement, but how much better that it now comes from official ministry sources and encouraged by their own people. I have had the opportunity to work with these midwives this week and we have had more vertical births than ever. Women were seen crouching, standing, moving around and generally off the bed. Yesterday I was able to demonstrate how to attend the delivery of twins with the woman sitting on the birthing stool.

I am happy and extremely encouraged.

HORRIBLE AND HAPPY

2008-09-18T15:52:00.006+02:00

I was glad to be back on labour ward on Monday. I spent the weekend missing my girls and feeling a bit sorry for myself.
It was as busy as ever and we had a new set of student midwives who had started whilst I was away. Their time is to be spent attending high risk women so this is a very important part of their clinical training.
These midwives will soon be out on their own in the district health centres and hospitals so I am quick to point out to them the district referrals that we receive so as they can become aware of the dangers of waiting to long before sending these women to us. We had an especially busy morning on Tuesday when we received up to 10 referred cases. I was appalled to find one woman, labouring her 5th child, who had been pushing "since yesterday"
Her whole lower regions were swollen beyond recognition. I quickly and easily diagnosed a posterior prestentation ( the baby looks up instead of down) a huge full bladder that obstructed the descent of the babys head and severe fetal distress. Examing her I felt sure that we could assist a vaginal delivery, though difficult. I made a quick decision that the childs life was already compromised that a c/section would take at least 30 minutes to get the baby out and that her other 4 children needed a fit healthy mother. She has more chance of this with a vaginal delivery. Any operative procedure carries a very high risk for the mothers here in Malawi. From haemorrage, underlying conditions such as Hepatitis or HIV,severe and chronic anaemia and sepsis due to little personal hygiene, no clean or running water, not to mention the deplorable state of the operating theatres and the sometimes very inexperienced clinicians. I referred to the clinician on duty and the senior midwife. Neither were too sure but I have now built up a good relationship with them all. They trust me and will refer to me in many difficult situations where decisions have to be made. So we worked together and the baby was born with the assistance of a vacuum extraction. Leaving the clinician to care for the mother I rushed the little one to the resuscitaire and commenced profound resuscitation. I did not feel confident that my efforts would be successful but at least I could try. The baby responded slowly so I continued to work on him. When I had achieved spontaneous breathing , though still with difficulty I transferred him to the nursery. I handed him over to the nursery nurses telling them that I was not hopeful that he would survive. It was a long hard morning. I had intended to leave at 3pm having worked non stop since 7.15 am but just had to help sort out 2 other situations before I left. Sometime around midday a young woman having her 1st baby arrived. A very late referral for prolonged labour. We could only find a slow heart beat. My Norweigian midwife colleague called me to assist a vacuum extraction, she felt sure the baby would come with a little help. She was not successful with her first pull so asked me to take over. The baby would not come even though it was very close. I felt that there was some other reason for this difficulty.. it didn't make sense.. I tried to find the babys heart beat before continuing but it was not to be found. When a baby has died in the uterus it is much more difficult to birth. Babies also play a part in facilitating their own birth. My colleague agreed that she had probably been hearing the mothers pulse. This we confirmed on ultra sound scan. Sadly we explained to her that her baby had died, she had been pushing too long.We decided to leave her a while to see if she could birth with less violence as now there was no hurry to get the baby out. I gave her some sedation so she could rest and would feel less pain.At 3pm she was still no closer to birthing her dead child. I enquired of the clinician on duty as to when she would come to assist the woman. She was the only clinician left on duty. Where the others had gone I dont know . She had to do an urgent c/section and possibly another after. I could not go home and leave this woman. It was likely that she could not be attended for several hours. Her uterus was still contracting.she was still being forced by her own body to push her child out. I called to another midwife and a student to assist me. A c/section in these circumstances would be unforgivable. The only other option is to destoy the baby. I had to try. I pulled and she pushed
my fellow midwives encouraged her to use all her strength. I sweated and manipulated untill at last the little one came. What a relief ! Not nice, not at all pleasant, never to be done in your rich and well developed world where clean and safe operating theatres are the norm. Where anesthetics and anaesthetists are readily available but the best option here. Today she was discharged home, without a baby but alive and well and with the possibility of other pregnancys, of other babies...I hope.
I eventually left at 4pm!
Arriving on Wednesday morning I was greeted by a call from a fellow midwife who was having problems. I don't know how long the woman had been pushing but the baby was not coming. I could see a large part of the fetal skull so suggested an episiotomy (cut in the perineum) might be helpful. This she did . The head was born and the shoulders got stuck. Following the correct manouvers of which I have now had plenty of practice the baby was born. I immediatley realized that this baby was severely distressed so quickly carried his floppy body over to the resuscitaire. I found a slow heart beat but nothing else. It was 7.15am. I had just arrived. Hardly time to put on my apron and I found myself resuscitating a nearly dead baby. As I stood there doing all I could. Giving my best . Inflating his little lungs suctioning the mucous from his throat, I began to wonder when this would all stop? How much longer would the rich world let this carry on? Its not as if they don't try .....millions of dollars are being poured into Malawi so why is it not working? Why am I still finding these hopeless situations daily? The baby was pink, the chest was rising I was inflating his little lungs the heart was beating strongly but he just would not breath. I could see that his pupils were already dilated, he was already brain damaged the respiratory centres in his brain were not functioning but I carried on. At 7.40am the students started to arrive. I had been breathing for him for 25 minutes but he still showed no signs of improvement. How long do I carry on? Can I really stop? When? I asked a student to take over, we would continue a while longer. I went to look at the mothers file and give her the news that her baby would not survive. The labour graph told me that niether she nor the baby had not been attended since 12midnight, when she was found to be 8cms dilated. That means she would have expected to give birth between 2 and 4 am. the baby was born at 7.15 am! I went back and told the student to cease resuscitation. It was nearly an hour since the birth. The baby was making a few gasping sounds so I left him under the warm heater with an oxygen supply. The doctors and clinicians came to make their grand "round" It was commented by a white visiting doctor as to "why had that baby been left there and abandoned? " I just cried. My Malawian midwife colleague held in her arms andgave me a big hug and reminded me we can only do so much, we can only do our best, we cant do more. The baby died in nursery during the afternoon. Later I went back to check the labour graph and found that the times had been changed that the graph had been manipulated. It is not the first time that I have witnessed this but this is still too big for me to confront.
Most afternoons I call by nursery to see 'my' babies. I found the woman I had attended the day before sitting on the floor with her baby in her arms. I asked the staff how he was as I had expected him to die. " Improving" they assured me. I knelt on the floor and the mother started talking to me. "What is she saying?" I asked.
" She says she has no milk for him" I gently squeezed her breast and out came those precious drops of calostrum which I put onto his lips. He began to respond so I squeezed out more. Bringing the baby close to the breast I carefully put her nipple into his mouth. He sucked! There was no hesitation, he latched on beautifully and wouldn't let go! His mum gave me a huge smile and the students working in nursery looked on in amazement. I still wonder if he will be brain damaged and if so, how severely but at the present he is happily sucking away at his happy mum's breast.
Yes that will keep me going for a while!

MY GIRLS IN MALAWI

2008-09-12T13:30:00.002+02:00

I have just returned form leaving my two girls, Katy and Fiona at the airport. I am sad.
They have been with me for 9 days and we were able to take a short trip to the lake and the game park and thus introduce them to a little of Malawi, of Africa.
It has been a wonderful time for me. I have enjoy their company, their love and their interest in everything.

During the first few days I was able to take them to Bwaila hospital to show them where I am working and the conditions under which the poor women of Lilongwe are being attended. They were both amazed and saddened to experience, first hand, some of the things they have been following in my blog and our regular phone calls. They were particularly interested in our nursery and the tiny babies that are being cared for. Just 900 grams and very premature it was difficult for the girls to hear that these babies have very little chance of surviving as both the facilities, the equipment and the medical expertise are not available.

Katy had been busy collecting money, clothing and toys, crayons, books and note pads for the past months. The response to her call was wonderful making it possible for her to bring not only a large number of these things but also more expensive items such as a doppler for listening to fetal heart rate, and weighing scales much needed by the Traditional Birth Attendents in the villages. We were able to visit an orphanage, a small mission clinic by the lake, two TBA's as well as distributing to the many women and babies "camped out" in the grounds of Bwaila hospital.

We visited my twins in the village and also one of my "miracle babies" These were both wonderfully enriching experiences for the girls who were able to appreciate true Malawian village life. We we received by the head man of the village which was a great honour.
We were entertained to homemade doughnuts sitting inside a cool mud hut and much time was spent blowing up and playing with balloons with the numerous children many of whom had never seen nor touched a balloon. We warned them that it may pop making a loud noise but it still suprised them!
The twins were looking big ! They are now nearly 8 months old. Unfortunatly they were suffering from vomiting and diarrhoea so we took them all, in my small jeep, to the clinic and left Pilirani with money for medicine and transport home. It was quite a squash... 6 adults and 2 babies ...but nobody seemed to mind!

The girls soon became aware that wherever we went there was poverty and need. They were able to give small gifts to the children as we travelled and were rewarded with dancing, with obvious joy and huge smiles. But they too soon found that there was never enough to give. Where they thought there were just 2 or 3 children, suddenly, out of nowhere, dozens of little ones appeared. At times it was very frustrating. They too felt the conflict and confusion of bargaining for every small wooden carving or craft that they wanted to buy. How much to pay ? Was it enough ? Maybe they could pay more? Should they pay more?

I am looking forward to going back to labour ward tomorrow after a week off. I know it continues to be very busy and there are many new students. I feel strong and positive. There is much to do...

MAKING A DIFFERENCE

2008-08-28T16:40:00.003+02:00

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!

ANGER TURNED TO HOPE.

2008-08-20T16:35:00.007+02:00

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 bed...to 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 September...wow 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?

TOTALLY CRAZY

2008-08-06T16:24:00.005+02:00

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?

WITHOUT MY HEALTH I AM..........?

2008-07-12T12:14:00.003+02:00

Its been two weeks since I was last able to have access to my mails and to my blog. Its been one week since I was able to work on labour ward. I have felt frustrated, out of touch and very low.
As can be seen by all my writing over the past months Malawi is not the place to be in need of health care. I am strong I am healthy. I have a natural capacity to look for and find the positive side of even the most difficult situation but during the past week I have been severely tried and tested. I have entered a Malawi operating theatre, as a patient, only minor surgery but how much better it feels to be wearing the nurses uniform and not the patients gown. As a nurse and midwife for so many years the familarity of the hospital feels like home, the ward my bedroom, the operating theatre my kitchen. Its not strange, not worrying, its known, its familiar at least untill I became a patient. What a lesson it has been to me to have this insight into how these uneducated village women must feel as they confront the unknown sights and sounds of the labour ward and especially, of the operating theatre. I think I am mending though the process will be slow and I will need a great deal of patience... this will be another lesson for me. With the help, support and love of my family and of my good friends I will achieve this..

Alasdair arrives with Lucas on Tuesday.... at last! Just what I need at this time. I had already decided to take some time off work and had planned a small trip so it will be a wonderful convalescent period for me. I need to be fit and well, I need my health restored my strength so that I may continue to give of myself, to love and to care for the women and babies at Bwaila.
I have recently informed my employers in Acuario (Spain) that I will be staying here untill the end of the year. My work here is still not done, I feel I have more to do/to share, it is too soon to return, I search and pray for guidance. In the same way that it became so totally clear when I made my decision to come to Malawi I am confident I will know when it is time to leave.

Today I will share with you the experience of my Norwegian midwife colleague.
We are continually receiving referred cases from the outlying health centres, it is the first place the woman will be taken when things go wrong with the attention of the TBA ( traditional birth attendant) in the villages. Nina decided to spend a day in one of these places. We know they are extremely understaffed very often without a doctor or medical cover. There have few materiales and only the minimum of emergency supplies.
The mother was carried into the centre by her husband accompanied by the TBA who was attending the birth of her twins. Twin pregnancy is considered high risk and therefore one of the reasons that they are advised to have a hospital birth. She was stiff and unconscious. She was having and eclamptic fit. The two nurse/midwives on duty began life saving tasks with the limited equipment and drugs available. They phoned for an ambulance for immediate transfer to Bwaila. This would take a minimum of one hour. On examining the woman they realized that the child had already been born, though the placenta was still in place. When? Yesterday.....and... the 2nd twin was still inside the uterus! More than 24 hours had passed! Why hadnt she bought her before? Because she will not be paid if she doesnt deliver the child!
Eclampsia demands the immediate delivery of the baby as it is the only way to save the mother. In these cases mothers life is always considered before the child. But it was not possible to deliver the 2nd twin . At last the ambulance arrived, the mothers condition had not improved, No one even thought to listen for a fetal heart beat ..what was the point? Did she live or die?
We dont know, as she was taken to a mission hospital that was closer. We shall try to find out. But no one else will. The mission hospitals are paying hospitals so many women cannot afford to go.They do attend emergency cases without payment. Nina came to see me that evening at home. She was noteably distressed. She said she will not go back again to the health centres as although she knew Bwaila hospital was not always adequate she could not cope with feeling so utterly alone and unsupported with not even the basic necessities for life saving tasks. We talked, we hugged, I was able to support her and give her the assurance she needed that she had done all that she could. Yes we are doing all that we can...not enough..never enough ... but all that we can.

ZIMBABWE AND MORE

2008-06-29T11:27:00.004+02:00

Zimbabwe is a sad place to be at this time. That was my feeling after spending 4 days there. I did not feel threatened or afraid but there was a noticeable tension and fear in the eyes and the behaviour of its people. There was little chatting in the bare, half empty shops as we queued to pay for our kilo of carrots costing billions of Zim.dollars. Yes, I became a billionaire overnight, though when I paid 5 billion dollars for a postcard and stamp I realized it wasn't worth much!
Life in Harare continues as best it can, the city people going about their business and everyone wondering what will happen next. There was a definite state of insecurity and those that would talk with their conjectures of what may happen but not really knowing what tomorrow would bring.We heard many distressing stories of torture and violence and many rumours which all led to a sense of the fear and the unknown.The people feel intimidated and controlled but by what and by whom? Who might be listening who could be trusted? The people are tired of living this way. They just want a normal life but they dont know how it can be nor who will find the way to create this change. They are looking for help .From where? from whom? They are praying to God, they are asking for help, to the rest of Africa, to the rest of the world, they dont know when this will end but they still have hope. I too hope and pray that the world and its powers will not desert them, that a way will be found to ease their pain and their fear and change this totally unacceptable situation that is life in Zimbabwe.

The long road to Harare was a wonderful experience for me. As I was not driving I was able to really take in the beautiful changing scenery as we passed over the Malawian border through Mozambique and down to Zimbabwe. We were able to break our journey with an overnight stay in Tete boths ways. We were wonderfully entertained by friends and I was able to enjoy a truly Mozambique experience as we climbed up high in the evening to watch sunset over the Zambezi river. It was interesting to see and feel the differences between the 3 countries their dress, their villages and their cultures. I was suprised to find the city of Harare so much more of a developed city than Lilongwe with its tall buildings, good roads, lighting etc. The infrastucture is still there, very obviously still present and that is what the people rely on to bring it back to prosperity, as and when this dire situation resolves.
My visit to Zim.was made possible by my good friend Sandy who invited me to accompany her on this trip. She was able to take food and provisions to her family and staff whom without this trip would have been sadly lacking in basic food stuffs and as in the case of the staff become very hungry. They were the lucky ones. As we crossed the border on our return journey we realized that we were the lucky ones. There are many Zimbabweans in the surrounding countries who have not given up hope of things coming right and are just waiting to go home. I hope that will be soon for them.
My best story from my visit is as follows...
When asked "How are you?" doesn't everyone answer "Fine thankyou"
Well it was the same in Zim.
Untill one day I asked the Zimbabwean housemaid at a families' residence.
"I'm not good " she replied.
Full of concern I asked as to what was her ailment.
" My body is fine thankyou" she said, " but my country is not fine, my country is sick and I pray for it to become well"

On Friday I was back on labour ward. My first task was to assist at the birth of triplets. It was a great experience for me and more so as I was able to team up with a young Norweigian obstetrician and work together to achieve a positive outcome for both mother and babies. Just 32 weeks pregnant so the babies would be small and premature. After a quick scan we confirmed they were all presenting breech. (or more acurately feet first) This shouldn't be a problem as it was her 3rd pegnancy and they would be small. As I got to work to deliver the three babies the doctor was scanning and checking heartbeats and positions. We soon had a audience of young Malawian clinical officers and interns looking on. It was great to show, by our example, how to actively manage safely this type of siuation. First a girl weighing 1.400kgs. Then 2 boys both weighing 1.500kgs. I checked up on them yesterday in nursery and they seemed to be doing ok. Its early days yet so I am not being too optimistic but at least they have a chance of surviving. I will continue to follow their progress and offer to help out with clothing, blankets and formula milk, if it becomes necessary.
Due to lack of medical staff and experienced clinical officers I have now learnt and am becoming capable of performing assisted birth with vacuum extraction. I have spent many years assessing the conditions and safety of performing this intervention so have now moved on to take this extra responsibility.
I was particularly pleased with yesterday's events. When taking the decision for an urgent vacuum extraction for fetal distress and finding that the only clinical officer available was involved with an eclamptic mother, I was able to
to perform quickly and safely this procedure and save the baby's life. Alongside me was a young Noweign midwife who had been caring for the mother and recognized the problem. We both felt good after that!
When things are difficult and black we can pull on these moments to keep our spirits up and know that what we are doing is worthwhile.

I have been feeling rather sad and lonely these days.( though my friends are great) I am missing all my children and my family. Its been 6 months now since I last saw them. I know it feels more exaggerated by not having Lucas around but I can't help wondering if I'm doing the right thing being so far away?
How difficult it is at times to see clearly where we should be and what we should be doing. How torn between our responsibilities and our needs. Responsable to who? Needing who and what? I feel I have so much to give so much love to share. Whose needs are more important? I have gifts, we all have gifts, I am enjoying using those gifts but its confusing ......I look for clarity, I pray for guidance. I am thankful for what I have and for where I am, so many people needing help, needing care, needing love..........

LUCAS LEAVES

2008-06-17T17:25:00.003+02:00

I didn't write about Grace's baby last time. There are always so many things to tell. During her stay in the pediatric ward at the central hospital here in Lilongwe her condition seemed to deteriorate daily. It was impossible to make a diagnosis as neither the technology nor the experienced operators can be found here in Malawi. As her breathing became more and more difficult and laboured they could only treat with antibiotics, just in case she had a chest infection diuretics for her pulmonary and cardiac congestion and oxygen to help her breath, to try and keep her more comfortable. It didn't work and although I visited daily and she received more medical care and attention than any other baby on the ward Grace's baby Angela died last week. She was just 4 months old. Maybe her little lungs were too immature? or maybe she did have that congenital heart defect? Whatever.... the necessary neonatal care and attention were not available and another Malawian baby dies. Born too soon and in the wrong place.
I was invited to attend the funeral and visit her house the following day. It was a sad day, I could only give Grace a hug and tell her how well she had loved and cared well for her beautiful baby. That she had been a good mummy. Baby Angela would remain forever in her heart...and in mine.

I am challenged daily and that is exciting and stimulating. Labour ward continues to be busy and many bad things happen that are avoidable but I think that now after nearly 6 months I am finding my way to work, to care and to live with the reality of the situation that faces me daily.
I dont like it, I will never like it. Its not acceptable, it will never be acceptable but I am happy in my work and enjoy great pleasure when it goes right. I do everything I can to make it go right and with the support of my friends and a few colleagues, I cope when it goes wrong.
There are always many students to teach and many inexperienced young clinical officers. They now come looking for me as they know I will always be kean and eager to share as much of my knowledge as I can. Today I arrived just in time to find one midwife attending a breech birth very obviously without even the most basic knowledge of how to assist. I was able to instruct her as to the different manouvers necessary and them take over when it became difficult. It was satisfying to achieve a healthy baby and a better informed midwife.

Last Sunday I said goodbye to my little Lucas for a month. He left on his own to go to spend some time in England with my family and then on to Spain to be with his Dad, with Alasdair and with Fiona. Just 7 years old but with so much confidence as he bade me goodbye and went off to board the plane for the long flight to London. I had given him a small wooden crocodile necklace. Everytime he touched it he was to think of me. We spoke on the phone whilst he was waiting in Nairobi for his connection. " I've touched the necklace twice he told me!" He will have a wonderful time but I will miss him.

On the way back from the airport I went to visit Pilirani and her twins, Edward and Alex. I am always a little nervous as I never know if I will find them healthy and well. They were doing incredibly well but are still very vunerable. As usual the children from the village came running to greet me and carry my bags. 20mk ( 200mk/1 euro) for looking after my car...thats normally at least 4 of them and 20mk for carring the bag! The boys were fit and well. Both weighing well over 4kgs. now with chubby cheeks and more chins than me! Pilirani is still supplementing her breast feeding with 2 formula feeds a day so she needs me to continue taking the milk. At nearly 1.000mk a tin she could definitely not afford it. As I got up to say goodbye the Aunt came out of the house carring the twins elder sister,age 4 years. She was obviously sick. I examined her as best I could and asked many questions. It seems she had been sick for 3 weeks. She was covered in a rash that she had been scratching and was bleeding. Her skin was dry, she refused food and took little water. I'm a midwife and a nurse but not a doctor. I could not diagnose her condition but I knew she needed help. I gave them money for transport and made them promise to take her to the hospital the following day. I am anxious to know how she is. Talking to medical friends it may well be a vitamin deficiency ...this would not suprise me. The diet for the majority of the village people is maize flour made into dumplings and little else. Not dying of hunger but of malnutrition.

I have been invited to accompany a good friend and her family to Zimbabwe for 5 days this weekend. My family are very concerned for my safety due to the political situation at this time in that country. My Zimbabwian friends are in constant contact with their families living in Harare and feel it will be OK for the trip to go ahead. I will tell you all about it when I return. We will drive through Mozambique and onto Zimbabwe. I am looking forward to seeing more of Africa. It is a beautiful and fascinating continent its places and its people. I feel very lucky to be here.

BEING ACCOUNTABLE

2008-06-02T17:22:00.004+02:00

I'm begining to think Thursday is my unlucky day, or more correctly unlucky for those little babies and mums on labour ward.
That's why I didn't write last week. You see I felt just too responsable and responsabilty weighs heavy at times.
It was a busy morning, starting at 7.15am. yet another 2nd twin born over 2 hours after the first. I found him on the resussitaire barely alive just a small heart beat and nothing else. Oh no not again! Each and every time it happens I try to find the person responsable but no one feels responsable. I try to explain how we should have cared for that mother and her babies, what was the correct procedure for a better outcome but I am obviously not being heard or I'm not speaking loud enough.
I did report the case loudly and clearly on the ward round. The clinical officer who attended told me he didn't want to do a c/section because the baby was well presented. Well presented and almost dead! He died at 4pm. that afternoon...thankfully....as the level of brain damage would have been huge.
Two rather complicated referred cases both with prolonged labour needed my attention. They had been fully dilated and pushing for how long? Together with the students I started sorting out how to deal with these women. Their was no immediate urgency as both babies were fine, but neither could they be left without constant care and observation. Unfortunately I have to leave the ward on Tuesday and Thursday to lead our workshops. At 10.30am. I handed over to a senior midwife and to the clinician on duty. I explained everything to the young student who had been working with me and reluctantly left their side. My instructions were clear. One woman could be encouraged with the help of a drip for just 30 minutes more, before assisting with a vacuum extraction, and the other should birth within the hour or be seriously considered for a c/section.
It was not untill I returned two and a half hours later that I realized my mistake.
Both babies had been born vaginally. Both had been born 1-2 hours after I left. Both in poor condition needing intensive resusitation. Both had been admitted to nursery. Both these outcomes could have been avoided.
So what had been my big mistake?
I suddenly realized that 3 midwives from labour ward had been present in the workshop, plus myself. This had left just one midwife on the ward with all the students and a very inexperienced clinical officer.
What was the point of teaching them in the workshop when there were distressed babies and birthing women unattended just 20 metres away?
It still lays heavily on my shoulders, I still don't understand how this can have happened. Of course its not really my responsability, I was not in charge of labour ward. There was a clinician on duty. But that's what I am hearing just too often. Of course I take responsability, we must all be responsable, we must be accountable. Accountable to such a degree that we realize that what we do, that how we act, does and will always make a difference.

This morning I arrived in labour ward and was greeted with the usual " bed 6 is pushing'
I hurriedly ( I think I'm the only person in Malawi who hurrys) collected what I needed and came to her bedside. How long had she been pushing? A referred case with prolonged 2nd stage. She had arrived on labour ward at least 20 minutes ago. Why hadn't anyone done anything? Listening to the fetal heart I knew that this baby needed to be born quickly. I encouraged her to push, performed a good size episiotomy ( incision to facilitate a greater vaginal opening and therefore a quicker birth) and with 3 pushes the baby was out. Floopy baby..not breathing, slow heart rate....not again! I quickly resuscitated the little one and slowly but surely he came round. When I took him to nursery later for a 24 hour observation period he had already had a good breast feed with his happy mum.
Ok so where do I go next? " There's a twin in bed 10...fully dilated...we know you like twins" the night staff called out to me, glad to be able to hand over after a long and busy night.
Twin one came out head first with no problem. Twin two was a breech and needed more care and attention but with active help on my part was born just 10 minutes later.
Before the night staff left they had all become aware that twins can and should be managed actively and safely. I said nothing, but hope that this would be an example to them.
" Good work, thankyou " commented the midwife in charge at night.
I felt positive and pleased. It was enough to keep me going for what turned out to be a long and difficult morning.

Lucas ' ran for his life ' on Saturday! Well actually he ' Ran for Wildlife' but he got the name wrong !! It was a sponsored run in aid of preserving the Malawian wildlife and endangered species. He had to run round the athletics track for one hour and would be sponsored according to the number of laps completed. I was very proud to see how he never stopped however tired and managed to complete 10 laps. This was an excellent run and more than most who were much older than him. He too was proud of himself, especially when he went round collecting money. I might find it more worthwhile to collect for health related projects but Lucas definitely finds it a worthy cause and as we are hoping to enjoy a safari with Alasdair and then Katy and Fiona when they come to see us I guess we should pay attention to other issues too.

TIME OUT

2008-05-23T15:07:00.004+02:00

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

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

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

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

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

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

MAKING A DIFFERENCE

2008-05-16T15:52:00.004+02:00

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

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

Some of you have asked how you can help my mums and babies how you can get involved. I refer you to my friend Carol who is supervising my sponsorship and continues to raise money for Bwaila hospital. SOS Malawi carolarad2000@yahoo.com I'm sure she will be pleased to hear from you.

HOT GUYS AND GIFTS

2008-05-09T10:04:00.002+02:00

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

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

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

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

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

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

MALARIA AND MIRACLES

2008-04-25T16:00:00.003+02:00

Lucas has had Malaria!!

I knew this could happen. Actually what worried me most was not recognizing the symptoms sufficiently quickly for early treatment. I had been told by all that rapid diagnosis and treatment was the key to success. As it happened I need not have worried. Lucas had a text book case, it was unmistakeable even for my untrained eye. Saturday morning we went off to football as usual. Lucas played well though I felt he was more distracted and came to the side line more often for a 'water break' After, we passed by a small shopping centre to pick up some groceries and met Tarek. It was his birthday so we stayed to have a milkshake with him. Without finishing his drink Lucas proceeded to fall asleep at the table. We made some comment about men and there sleeping habits but I knew something was wrong. Lucas NEVER slept during the day. By the time we reached home he had a slight fever 37.5C I wondered what he was sickening for? Over the next 2 hours his temperature rose to 40 C . He was sleepy and complained of headache. He was too tired to eat or drink and was too weak to even walk to the bathroom. I didn't hesitate. I carried him to the car and drove less than 10 minutes to a small clinic that had been recommended by a friend. We were seen immediately. Excluding any other signs or symptoms of infection a small finger prick sample of blood was taken which they examined straightaway under the microscope. It was confirmed in minutes. Affected red cells were seen but we had caught it in its early stages. Treatment in the form of tablets was prescribed and we went home. I was advised to use paracetamol to lower his fever and cold flannels or baths if necessary. Well everything prooved necessary! His temperature osscilated between 38.4 C and 40C for 36 hours. All weekend activities, including a birthday party and " sleep-over were cancelled. I stayed at his side constantly during that time either in bed or on the sofa. I was amazingly support by friends both by phone, messages and visits. Most had experience of the same with their young children, I found this most comforting. I think the worst moment was the first night at midnight when he was supposed to take his second dose of treatment. He immediatly vomited the lot! I phoned the clinic who helpfully told me to give an anti sickness tablet, wait 30 minutes and repeat the dose. This I did and much to my relief it stayed down. Then it was a waiting game. Sunday didn't see much change and I had my doubting moments but he was also not getting worse, which served to console me. Monday saw some improvement and he started to eat and drink a little. Its amazing how we feel so much better when children eat! Right from baby and infant time if they would only eat, breast feed, take the bottle, then they must be alright! By the evening I could see the difference and on Tuesday he wanted to go back to school! He stayed at home with his nanny and I felt confident enough to leave him. Wednesday he went back to school and is now active and happy once more and very proud to be the only one in his family who has had Malaria!
In conclusion I would say it has been a great learning experience for us both. That Africa is definitely the best place to be sick with Malaria! They really know what they are doing. The attention and treatment was fast and effective. The medical staff were knowledgeable, understanding and efficient...in short ,with all their short comings in other ares I could not fault them.
So now I'm not so scared of Malaria! It might still sound desperate and frightening to you all but this is Africa and we are learning to live with and in it.
Malaria is a killer disease here in Malawi. The people live too far away from health facilities. They have no money for transport. Although medicines should be available free many times charges are made and the 500 MKW is more than most can afford. ( I paid 3.500 MKW in total for Lukis treatment as we attended a private clinic, this is totally out of the reach of most Malawians who maybe only earn that much in a whole month)
There is so much malnutrition, HIV, Hepatitis, chronic anaemia and other ailments that Malaria kills. We are the lucky ones. Lucas is a fit healthy active child. He was diagnosed and treated fast and his body responded. Yes, the medication is available....but only for some. Yes, the medication works.... but only for some.

And what about the miracles then?

I arrived on Labour ward, as usual, at 7.30ish on Tuesday morning. What would I find today? A second twin waiting to be born! Quickly I looked in the notes to see the time of birth of the first....5.30am! more than 2 hours ago! I tried to find the fetal heart but without success..or maybe yes, maybe I could hear a faint heartbeat or not? I decided to actively get that baby born. It was her 4th child she should be able to push it out quickly, it would be quicker than a c/section if it was alive and I could not send her for a c/section if it was dead. So where was that baby and why hadn't it been born yet? I examined her, she was fully dilated, was it a head I felt? I broke her waters and found a hand and an arm! Oh no this was not a good sign. But wait, I was right, I could also feel a little head. I called for assistance and encouraged her to push. Chimani...Chimani...push..push, kwambiri....kwambiri...more..more. That mother was amazing. I dont know if she realized she was pushing to save the life of her baby or if she could hear the urgency in my voice, could sense the need to respond, but she just pushed with all her strength and out came that 2nd little girl with one hand up alongside her head. I thought she was dead. Quickly cutting the cord I felt for a heart beat. I couldn't believe it! It was slow, but it was there. At my side was Anne the Norwegian midwife, she took the baby from me straight to the resussitaire and started work...suctioning out the mucus that obstructed her airway and forcing oxygen into her little lungs. I heard a small infant cry! "She 's coming round" shouted Anne. And she was! An hour later her mother got up, showered and proudly took her 2 little babies to postnatal ward after breast feeding them both. It took a while for the adrenelin to subside but I'd never felt so alive!
Today I had a meeting with Lucas' teachers at 11.45 so I decided to go to labour ward for a few hours untill 11.30. Lucky I did, as we were just 3 midwives, 5 students and a full ward. Anne and I started to sort out who needed what and when and before 11am most of the babies had been born. I was walking past a bed where a doctor was examining a newly admitted referred patient. I could see the umbilical cord pretruding from her vagina. Oh no! cord prolapse! Is the baby dead? Is the cord pulsating? " Yes" When, at what time, how long had the referral and journey taken? There was no time for those questions they were not important now.. First baby or multigravida? "3rd" is she fully dilated? " yes" what is the presenting part? " a foot " Then we can get the feet down and pull, we can deliver this baby, it will be its best bet, its only hope.
The Norwegian obstetrician was at my side, Anne came quickly to help, we worked as a team and the little one was born. Just a faint heart beat was felt. We worked together to help that baby to survive. It took a while but slowly he started gasping, taking little breaths, getting pink ( yes African babies get PINK too!) I took him to nursery. Will he make it? I don't know yet but at least we have given him a chance.

I could tell of the ones that didn't make it but I think that this week I'd rather end on a positive note. The two Norwegians that I have talked of will be leaving next week. Two more have come in their place. Their government has promised to supply these medical staff for a period of 5 years. They each do a 6 month stint. I shall be sad to see them go. They have become well trained and experienced collegues during their time here, they will be greatly missed on labour ward. It takes time to learn and accustom oneself to Bwaila and now they are leaving. I wish them well. Who knows, maybe one day they will come back? Africa needs such as them, Bwaila needs such as them, the mums and babies need such as them, I need such as them.

TEACHING OR FACILITATING

2008-04-18T16:21:00.003+02:00

As time flies by and each week passes I find it increasingly difficult to find the right moment to sit down and write to you all. Everyday there are stories to tell as I become more and more involved in the different aspects of African life and health care.

It has been a week full of teaching. I find myself particularly involved with the clinical teaching on labour ward passing from bed to bed observing and questioning, trying to make the students think about their practise in a new way. To see the woman as an individual with a story to tell quite unique and special and therefore to be treated as such. Sometimes its difficult to stand back and let them attend, even whilst I am supervising. Inexpert and clumsy, results in torn perineums or less sensitive handling of mother and baby as they perform their tasks but I guess thats just part of teaching. and learning. Its a priveledge to be with them to be part of their training, to maybe have some influence. I hope that my words will be remembered and my example sufficient to aid them to be better more caring and knowledgeable midwives in the future.
But not all the students are receptive and many have a dangerous overconfidence after just a short time on labour ward. Then there are the students that are more concerned about filling in their papers for x number of vacuum extractions, twins or breech deliveries and can be found attending these births totally or inadequately supervised. I returned from workshop on Tuesday to the cries of a woman in bed 2. Behind the curtains I found a very newly trained CO supervising a student midwife with a vacuum extraction. I had been aware earlier that she was "on the look out" for vacuum extractions. Things didnt seem to be going well. The whole scene was chaos and the woman out of control. On enquiring as to the whereabouts of the fetal stethescope to check the baby's condition I found that they didnt have one. They hadn't seen it as and important part of thier equipment! I could not let this continue and pushed past to examine the lady. I found that the conditions were not favourable for this sort of intervention and told them to stop untill I called a senior clinician. I ran to operating theatre where I found him having lunch. Fortunately he was finishing and came straight away. ( Luch hour in Malawi is sacred and even an emergency will not be attended to untill after lunch!) He attempted to extract the baby but soon decided it was not possible. I hurried her to theatre where the baby was born by a difficult c/section. I stayed to recussitate a very floppy baby then transferred him to nursery. Today the baby has been discharged from nursery and is with his mother. He is one of the lucky ones. I dont understand this behaviour. I cannot condone this behaviour. But it exists and it continues. The workshops are going well. I am called the ' facilitator' Its the new word instead of teacher. I rather like it! I have now finished the first session which consisted of 4 groups. 35 midwives attended in total. Feedback has been good so far and I am encouraged. Next week I will introduce a new topic as we start to analize our individual practices and attitudes.

Pilirani and the twins Edward and Alex are still doing well. They now weigh in at 3.700 and 3.050 kgs. respectively. The harvest has begun. The maize is picked and being ground into flour. This week she did not complain of hunger. The boys are hungry babies and growing fast. They are still taking 2 formula feeds a day and I continue to supply them with milk powder. I have however advised her to try stop these supplements now that both mother and babies are stronger.
Grace spent 5 days in hospital with little Angela whilst they treated a chest infection with antibiotics. I was disappointed to find that when I visited on Monday she had already been discharged without doing the cardiac scan. This happens often. If she has a cardiac complaint it will not be investigated untill next time she is admitted with the next infection or failure to thrive.
It is frustrating but it is Malawi. I hope that she will start to grow and gain weight and that it wont be necessary.

It is not uncommon for me to attend 5 to 7 births in one 9 hour shift. Some are quick and straight forward but many long and complicated requiring the maximum of my skills.
Just 2 examples this week...1. A referred case with prolonged dilatation phase. Aparently she would be unable to deliver due to an abnormal cervix. I was told to try a vaginal birth but it was unlikely. After much care she pushed out a healthy boy and avoided a c/section.
.... 2. It was her 5th pregnancy and she still didnt have a living child. She had been admitted during the night and was well in labour. I started caring for her at 7.30am. At 8.30am. the doctors do there "round" The orders were clear.. " This lady will be c/sectioned immediately " It was not for me to question this decision which was made in the interest of mother and child but I do question as to whether a c/section is really the safest option, not only here in Bwaila but in any part of the world? I started to prepare her for theatre. IV infusion, urinary catheter, consent form etc. She started pushing, what could I do? Ten minutes later she birthed a healthy bouncing baby boy! She was so happy and so was I! I'm not sure if the boss knows yet but I'm sure not going to tell her!!

TOO MUCH TO TELL

2008-04-09T13:36:00.003+02:00

Some days I sit down here in front of the screen and dont know where to start. Today is one of those days.

I am back on labour ward. This week we had an influx of students. Clinical Officer students and nurse/midwife students. Its their first time on labour ward, they need so much clinical teaching and training which is not readily available. They stand around confused or try to do the little that they know how, often making mistakes, not realizing the importance of listening correctly to a fetal heart or checking the uterine contraction after birth. The CO's have so little knowledge I am amazed, the midwives somewhat more. They need constant supervision but find trained staff with little enthusiasm for the task. I regularly find myself with 5 or 6 students round the bed, not ideal for the labouring mother, but I am aware that their need for training is so great there is no option. I enjoy this part of my work and find the students generally open and enthusiastic to learn. We are using the birthing chair more often and now I am not seen as crazy when attending a mother who chooses crouching position or ' all fours' to give birth. Yesterday one of the very newly trained midwives came to me to ask for the stool. She thought that 2nd stage (pushing) would be more effective in that position. She and another young midwife assisted the mother to birth on the stool and I was around to help. It was most encouraging.

My first official group session with the midwives took off yesterday. There were 8 midwives from both Bwaila hospital and Kamuzu Central. It turned out to be a relaxed fun time, which was my intention, but I was able to challenge them with some pertinent questions. If you,or your daughter were pregnant now and looking for the best possible care for you and your baby would you come to Bwaila hospital ante natal clinic ? Bwaila labour ward or postnatal ward? Would you have your baby looked after in Bwaila nursery? We looked at our own expectations of care and the care that we are giving. We looked at the uniqueness and individuality of birth and talked of choice. I showed some images of birth in Europe, natural birth in various positions with caring midwives and partners. They were able to see the joy and happiness that can and should be part of giving birth and which is far from present in our hospital. It was good to see their faces as I presented a totally different concept from that which they are used to. They all noted and commented favourably on the presence of the fathers in the birth. I realized that deep down, despite their culture and customs these Malawian women felt just like us, the need to be loved, cared for, and supported, especially at this time. To share the birth, this life changing event, with the person they love most, the father of their child.

Somebody said to me today that the Malawians are cold, emotionally dead, that they dont care. That they dont know how to love their children that none of that really matters. I dont believe it. Maybe their circumstances and experiences have made them keep their distance, not love too
much for fear of being hurt, for fear of too much pain, for fear of loosing. Maybe they have just shut down, maybe its the only way to survive.

I arrived on labour ward at 7.15am. The clinical officer had been called to attend a possible ruptured uterus. The baby was dead. Had died in the time the mother was on labour ward. There was not time to ask questions to find out why. I was asked to assist a vacuum extraction. The baby came easily. I think he forgot that it was dead and started to place it on the mothers abdomen. I took the baby, dried it and carefully wrapped it in the special 'chitenge' cloth she had brought. I looked into the mothers staring emotionless eyes and said I was so sorry and asked if she wanted to hold her baby. Her face told me nothing not grief, not suprise, nothing, it was blank. I was troubled. I asked the CO if anyone had told the women that her baby had died. He asked her.. in Chichewa. NO ! No one had thought to tell this mother. She was expecting a live child! I could not believe it, this is not acceptable, this is not professional, this is inhumane.
It made me question once again, had they been right ? did they really not care!

Update on Pilirani and the twins... Last week both babies looked good. Both looked lively and active. They were needing to supplement breast feeding twice a day with milk formula but they were growing and gaining weight. I could see that Pilirani had lost weight. I was not suprised as I know they will be hungry untill they start harvesting next month. This time I found maize flour to take plus sugar and other fresh fruit and veg. Not enough, but it will never be enough. I gave her a tin of milk powder for the babies. It is relatively expensive and out of reach economically for most families. It can be supplied freely at some centres but most do not have the means or money for transport to collect it. Also breast feeding is 100% encouraged for all its other benefits. Before I left the older children were sent out to the field to cut some maize cobs for us to take home. I look forward to my visits to this village these people are just amazing!

Our visit to Grace was somewhat frustrating. We arrived at the famous wobbly plank bridge to find that a minibus had broken down right in front of it, blocking our passage. It took us more than an hour to find our way over and around the small stream that separated us from her house. We could see her house in the distance but it was not safe to leave the car and walk. When we eventually arrived I was pleased to find that baby Angela had gained 400g in 2 weeks. She looked peaceful and content. Grace looked well. I could see her Aunt had been feeding her well and that she had gained weight. Grace wanted to know when she could come to my house? Maybe next time I assured her. Or am I creating a dependancy that could become difficult? How difficult? Why difficult? What am I afraid of?
Grace phoned me yesterday to tell me that her baby was sick that she was not feeding and crying a lot. I told her to take her to the hospital but I doubted that she would. This morning when I spoke to her she had no transport nor money. I picked them up at 11am. and we went to Central hospital ' under five clinic' Baby Angela has been admitted to the nursery with an infection. I mentioned that she may have an underlying heart problem so they have ordered a scan. Her condition did not look too bad though once again she had not gained weight in a week. I am pleased that this will be an opportunity to investigate a possible heart problem and that we took her in plenty of time to be treated sucessfully. One of the problems in health care, in general, is that by the time the children(or adults) are taken to be seen at the hospital they have already passed through the local health clinic, the traditional medicine (witch doctor) and often arrive much too late for our medicine to be effective. Tomorrow I will return to see how Angela is doing and take some food for Grace.

My last assignment to finish my "orientation" was a few days on the postnatal ward. There are 2 midwives on each shift. They are caring for High risk postnatal, postnatal and ante natal mothers. Around 70 to 80 women. This is what I wrote as I came off duty last Friday...
Today I felt that however much I do there will always be more to do. However much I give it will never be enough. However much I care still more will be needed. The queues are endless the corridors are full and overflowing. As we emptied out the beds so they filled. High risk went to low risk. Low risk went home and high risk was filled again from theatre. No bed available ? just put her on a matress, from that pile, on the floor. I laughed to find myself kneeling down on the floor putting up an IV infusion, taking blood samples and cleaning dressings. There was very little chance to get to know the women just get the basics done. The drugs, the dressings, IV lines urinary catheters, but its fun to do it with a smile and a word of encouragement even if more than half didn't understand a word I was saying! Being on postnatal ward also means attending the outpatients who come back for removal of sutures or any other postnatal complaint. If labour ward was busy, if Antenatal clinic was busy, if in nursery I never stopped, well postnatal was no different! Is it any wonder things get missed or mistakes are made ? Is it any wonder?

Two of the midwives were talking together I didnt understand but I knew it was serious. I asked what was it that was bothering them? They told me it was the extra shifts. They were expected, though not obliged, to work 2 or more extra shifts a week. For each shift they are paid 600MK. (3 euros) or 800MK for nights (4 euros) By the time they pay their transport and a meal there is almost nothing left. I asked them " so why do you do it?"
" because if we dont there is no one to care for the women they will be left unattended"
I felt humbled..
" so now if you see us sitting down, you know why"
I felt ashamed..

Life in Malawi is full of conflicts, life at Bwaila hospital is continually confusing..

But I love it!

BEAUTY AND FRUSTRATIONS

2008-03-26T12:06:00.008+01:00

This morning I decided I should finish my obligatory "orientation program" for my official registration with the Malawi nurses council. This means spending 3 days in the Ante natal clinic. Up to 100 mothers are seen between 8am. and 12am. As you can imagine they are passed through at great speed. It seems that the basic checks are done but there isn't much time for midwife/mum chit-chat! In the same building is the underfive vaccination clinic, family planning and a special HIV follow up clinic.This means lots of mums and babies milling around. I am amazed to see how well everyone knows where to go and in which line to queue. On asking for an explanation for this very organized chaos I was told that there is excellent communication and support between the mothers. It was evident, the next mother in the line would look after the young baby or child while she was being seen. I think we could all take example from these women in this way and also find some of their endless patience as they wait their turn happily chatting away to each other without that feeling of anxiety, impatience and stress that is so palpable in European waiting rooms.

Before I tell you all about our weekend on the Lake, I should first let you know how Pilirani and her twins are getting on.

OnWednesday morning we (Doreen and I) set out early to do our visits. Lucas was at school and would be picked up at lunch time by a friend.

First I called in to the nursery to fetch the portable scales for weighing the babies. We then passed by the market and bought fruit, vegetables and bread. I had already prepared a tray of hard boiled eggs as I worry about the lack of protein in the average diet which mainly consists of a maize flour porridge. This serves to fill their stomachs but instead of being used as part of a balanced diet it is often the only thing they eat.

I had been in contact almost daily with Grace and her tiny, prem baby. She had left nursery weighing only 1.500kg. and with a possible heart problem. We would first go to see her.

I wrote the above last Wednesday and have tried unsucessfully to complete and post 5 times since then! It has been so frustrating! I am daily learning the lesson of how little control I really have over so many things. I am told that all the internet conections in Malawi were either down or slow and could only access some sites.. obviously my blog wasn't one of them! So, for those of you who began to worry that you hadn't heard, I thank you for your concern and for those who are eagerly awaiting my next installment...here goes!!

Grace met us on the "main" road, a muddy potholed track leading to who knows where! She was thrilled to see me and gave me a big hug. She climbed in the car and off we went onto the minor tracks. I still havn't managed to acquire a more suitable vehicle so was particularly challenged by a narrow wooden plank bridge and a steep muddy grooved incline. I even stopped to take pictures as I thought no one would believe it possible to pass! I have now realized why both Doreen and Grace are so confident that we will get through...Neither of them has ever driven a car!! Still their encouragement definitely helped! Grace is living temporarily with an aunt and uncle whilst the baby is so tiny. It was obvious that they have a little more money as the house is built of bricks and there is a small amount of furniture. I was shown into the main room and we sat on the sofa and talked for a while. Grace speaks some english but it was good to have Doreen there to make sure that we fully understood each other . The baby had not gained weight in the 2 weeks since discharge from the nursery. This is typical of babys with heart problems. I also felt that she was not giving enough feeds so advised her on 2-3 hourly feeds day and night. The little one, weighing just 1.5kg looked strong and active so I hope that when I next visit I will see some weight gain. I left her with the milk, sugar and fruit I had brought promising to return in 2 weeks time. Before leaving I was desperate for a bathroom so I was shown to the toilet facilities. I have still to improve my aim when peeing down a small hole in the ground but am working on it! I was touched when they brought me a bowl of HOT water to wash my hands. Its these little things that bring me such pleasure.

Precariously we took the road back, I was glad to reach the main road and drove the 30 minutes to reach Piliranis village. The welcome was tremendous we were greeted this time by the great grand parents. On enquiring their age nobody could remember ! The twins looked great and had regained the weight they had lost. I do hope this continues. I am concerned about Piliranis diet untill the new harvest begins. It is a great strain on an already hungry body to be feeding 2 hungry babies. I shall take what I can but I can't feed the whole village, I never feel I have taken enough.

Easter weekend was spent on the southern shore of Lake Malawi. It was an oasis of calm and peace. The incredible richness and beauty of this country made it hard to believe the reality of its poverty.
We were generously entertained by some friends we had met at the airport on arrival.
Time was spent relaxing, eating, swimming, canoeing, snorkeling and daily trips in the speed boat to visit small islands and coves. Luki was able to show off his already acquired fishing skills (endless hours fishing with his father in Spain) catching 3 or4 fish each day. These were later prepared and served for our supper. One of the highlites had to be "feeding the fish eagles" Fish were caught in the evening, then on an early morning trip to a nearby island they were thrown to the eagles who swooped down to retrieve them as they touched the water.It was truely amazing! After 5 days of sheer bliss we returned to Lilongwe.As you can imagine Luki wanted to stay for ever. I wouldn't have minded either!

Back at the hospital and after 3 days in Antenatal clinic I returned to labour ward. They were obviously pleased to see me. It is good now to feel part of the team. I am accepted and welcomed in all departments. Yesterday I was attending a young unmarried girl, first baby.( Its difficult in Malawi to have a baby outside marriage, culturally not acceptable) It was a long tiring labour and equally long 'pushing' stage. We went over the official time limit both for first and second stage. The senior midwives began to ask questions. Although I explain clearly that both mother and baby are fine, that women are all different, that we must be capable of adapting to the individual needs of each woman and each birth, they find this concept almost impossible. I was not following the rules and that made them feel insecure. At last a healthy baby boy was born with minimum intervention and a lot of hard work on my part. Not to mention that young mother. The senior midwife commented that I must be very tired. They do watch! they are noticing! at the moment that is enough for me. I managed to catch 2 other babies during the same shift and although labour ward was not busy, women laboured alone and even one popped out unattended.
Where were the other midwives? Why weren't they alongside caring and encouraging? I still can't answer this.

Next week I start teaching... officially! I prefer to think of it as group leadership of midwives who will regularly get together to talk, share, discuss and learn. It will be a time to explore our own feelings and motivation. We will be realistic within the environment in which we work but we will be willing to change, to improve. From these groups we will go out with a new/renewed vision to experiment new techniques with the sole aim to improve our care to women and babies.
Well at least I hope so!!!

SOMETIMES ITS ALL TOO MUCH

2008-03-17T15:10:00.005+01:00

I didn't write last week, I couldn't write last week.

What could I tell you?

Of the mother that should have been taken to operating theatre at four in the morning, who failed to be assessed and examined by the clinical officer on duty. The c/section was done at 8am. the baby was dead, the mother hemorraged so severely she needed a hysterectomy and later died in the ambulance on the way to intensive care in the central hospital. No blood was available at either hospital .

OK.. so she was HIV positive which was probably the cause of her poor general state, would further complicate her chances of responding to the hemmorage and lead to her death ...BUT ... here in Malawi there are more NGO', charity organizations and do-gooders spending huge sums of money on AIDS projects then any other cause, so I am afraid I can only ask why? why?

Or should I tell you of the morning that on arriving at labour ward I was asked to attend bed two where the 2nd twin was waiting to be born. I listened for the fetal heart and found nothing. I examined her and felt the umbilical cord presenting and not pulsating.The baby was in an impossible position for a vaginal delivery. So when had the 1st twin been born? At 4.20 am. more than 3 hours ago! The clinical officer had visited at 5.10 am. the fetal heart was heard, he told the midwife to wait! She waited. Too long for that baby. ( one midwife's comment was " well she does have one" )
But she had two babies! two healthy babies! untill she came into the hospital!

Or maybe I should tell you of the 2 prem babies. Just 28 weeks gestation, weighing around 1kg. Both breech presentations both difficult to deliver the head. The first was determined to live but lasted just 5 days the second was just too prem. too small.

Or I could tell you of the mother that transferred in after delivering the first twin in a local health centre. It took 3 hours for the ambulance to arrive. The second twin was dead and the mother needed a c/ section for bad presentation.This was confirmed by an ultrasound scan done by one of our clinical officers. Whilst waiting to be taken to theatre she pushed out a live healthy 2nd twin head first!!!

I can talk about it now but I couldn't write it all down last week.

I went to see Tarek, I just needed to talk, to get it all out of me. As usual, he listened and he talked and I felt better. He also gave me something to read, things he had written about human rights.. what are they..what do they really mean to us, to you, to the developed world, the politicians and how relevant are they to the mothers and babies in our care. It started with a quote which I would like to share (actually I'd like to share it all, but its not mine to share.
"It is possible to adapt to a given situation precisely because you have got to live it and you have got to live it everyday. But adapting does not mean that you forget.You go to the mill everyday-it is always unaceptable to you, it has always been unaceptable to you and it remains so for life-but you adapt in the sense that you cannot continue to live in a state 0f conflict with yourself"

My second visit to Pilirani was less eventful as we managed to take all the right turns.

She looks well and the c/section scar is totally healed. When I asked if she felt strong her mother replied that she can now carry a full bucket of water on her head. I guess that means she is very strong! I certainly couldn't!

Unfortunately the twins Edward and Alex weren't doing as well as I expected.They both looked lively and active but underfed and not gaining weight. In fact Edward who had been doing so well had lost weight. We talked about breast feeding, she said "they are very hungry babies" I could see that! She seemed to have plenty of milk but I did suggest that maybe she should supplement. I asked about her diet. She was eating just beans and potatoes.

Last year Malawi produced a bumper crop of maize..the staple diet. More than enough to see them through till the next harvest. Unfortunately someone sold off a large amount to neighbouring Zimbabwe and S.Africa leaving insufficient for the people of Malawi! No one seems to know how or why it happened but poor Malawians are now dying of hunger and severly under nourished due to some high-up political "mistake"

I took bread and bananas, it was not enough. This week I shall take eggs (hard boiled) and rice.

As I got up to leave, Pilirani went to her mud hut and came out with a plate of dried beans for me. She had so little but still gave me of the little she had. It was so difficult to take but I knew I should. I got in the car and cried. This is just one family that I have the priviledge to be part of, but how many more are there like that? It was all too much for me last week.

I must just tell you a last detail..... As we walked through the fields of maize that leads to her house we met a very small child walking towards us. I recognized her as one of Piliranis elder children.She is just 4 years old. On her back she carried what I thought was a doll (silly of me.. little girls in Malawi don't have dolls) I could not believe it when I realized she was carrying Alex the smallest of the twins, now weighing 1.550kg.!

Friday was my day off. I dyed my hair and painted my toenails with my friend Filly. The choice was dark or light brown. I now have a very youthful dark head of hair and bright pink nails. It felt good to do that!

On Saturday evening I had my first real "night out" since arriving. It was a charity dinner dance in one of Lilongwe's nicest hotels. It was a great night. The food only reasonable but the music and company fabulous. It was totally therapeutic. I danced nearly all night to the golden oldies.. of my era, lots of Rolling Stones, Meat loaf, Rod Stewart and Michael Jackson. I was exhausted but happy and felt this was a good way to recharge and prepare myself for what I might find this week.

Easter is close and school holidays.We will be going to spend a few days by the Lake with some kind friends. We are very much looking forward to the break. I am looking forward to the rest and Luki to the snakes!

On Tuesday I shall go to visit Pilirani again and also Grace, who has been phoning me everyday just to make sure that I havn't forgotten her. Well actually she gives me a missed call and I phone her back, but its always to say the same " dont worry I will come to visit and I havn't forgotten you"

.

BANK HOLIDAY ADVENTURE

2008-03-07T08:10:00.002+01:00

Monday was bank holiday, Lucas had a day off school so we decided it would be a good day to go looking for Pirilana and her twins. At 7am I was in the hospital nursery starting the days work. I knew they would be short staffed that day so I was able to help out with the daily cleaning of cots and weighing of babies. The mothers wait anxiously to see if their baby has gained weight, if today will be the day she can return home? Some of these mothers live a distance from the hospital which means that they may have arrived well before giving birth and been camping out away from home for some time. Their stay is then extended whilst the baby is in nursery making them impatient to get home. Most of them will be accompanied by a "guardian" and often other siblings. The guardian will look after them during this time preparing their food in the basic hospital kitchen and washing their clothes. They will have very little money to buy food so if they then have to stay a week or more after birth it becomes very difficult for them. Basic meals are provided by the hospital courtsey of an NGO. but are not always sufficient. Breast feeding one or two infants whilst recovering from giving birth often with underlying chronic conditions like anaemia, TB. HIV. Hepatitis , malnutrition etc. demands a good diet and care, this is not present. I was able to give my sandwich and fruit juice to one of my mums the other day who had not eaten for 24 hours. It felt good to sit at her side and share in this way reminding me once again how much I have and how little they expect.
But back to my story of Pilrani and her twins!
I collected a portable weighing basket, met up with Evelyn (a Dutch medical student who is here for 2 months) who had asked to acompany me and went home to pick up Lucas. I had decided to take our " nanny " Doreen, with us to translate. Pilirani does not speak English and I doubted if I would find English speakers in her village. I met Doreen last time I was in Malawi so was pleased to employ her to look after Lucas whilist I am working. Though outdated, the word "nanny" is widely used to describe these ladies, as are many of the words used here dating back to the British colonial days. So we set off with our instuctions of how to arrive. Doreen insisted she knew where we were going and I believed her...first mistake! She was eager to please but her experience of travelling everwhere in an overpacked minibus had not made it easy for her to understand exact directions. So we missed the turnoff! By the time we had nearly arrived at the airport I guessed we had gone wrong so we stopped and asked! I was glad to have Doreen with us. We set off again with new directions and decided to take the "short cut" Turning onto a mud road I began to doubt we would arrive. Doreen assured me it was a good road! We are still in rainy season so although a dry sunny day the ridges, bumps and holes caused by the rain were evident! I am still driving a hire car..just a normal saloon..definitely not the best car for this sort of adventure. My farming background and four wheel drive experience came in handy and slowly, very slowly we manouvered our way through and around the difficult bits and arrived at the house with a white flag. I must admit I was expecting a large white banner, we found a small piece of rag, the size of a handkerchief, tied to a stick! Once again.. lucky Doreen was there !
There were a few mud huts alongside the track so we enquired as to the whereabouts of Pilirani.
From out of nowhere men and children appeared and offered to take us to her hut. Leaving the car to be watched over by one young man, we set off behind a " gaggle" of children all laughing and talking and running at our side. Through the plantations of maize ( this is used for everything and upon which their whole diet is based) winding round the outskirts of the village past the small mud huts with thatched roofs...yes just like the postcards or images on the tele..we turned the corner and there she was sitting on the step of her hut, home, breast feeding one of the twins. What a suprise! she didn't think I would come! She cried out and covered her face but we could sense how pleased she was to see us. It was a very special moment. The other ladies ( we later found out were her sister, sister-in-law and other family members) jumped up and fetched a cane mat.This they spread out on the ground for us to sit on. We took off our shoes and sat down. Again it was good to have Doreen who translated for me. She showed me the twin boys..Edward and Alex.. I could see that Edward, the largest, first born was doing well but Alex looked thin and ill. I guess I was glad to see them alive but became worried by Alex' condition. We weighed the babies and sure enough Edward had gained 400g in the 2 weeks since discharge but Alex remained the same. Doreen helped me to ask the questions and understand as Pilirani explain how they were feeding and her own worries about Alex. I took his temperature and was relieved to find that it was normal. His breathing was good. I listened to his lungs and they seemed clear. He showed no signs of infection but was clearly severely underfed. Edward was obviously taking the best, leaving little for his brother. I advised her to express breast milk and give it in a cup, thus supplementing the poor feeds as he was becoming slowly weaker and less able to take directly from the breast. I also left her some packets of milk formula with strict instructions, once again, on how to make and use them should she find that she does not have sufficient milk. I hope I did the right thing?
I had bought gifts of knitted blankets and hats for the boys and left them with one of my home baked chocolate and banana cakes. There would not be sufficient to feed the growing crowd that had by now gathered around to inspect the " msungu" ..white lady, but maybe enough for Pilirani and her family. We met her 2 older children and her husband, were introduced to the great grandmother and head lady of the village who came to meet us and shook hands with everyone. Lucas was rather overwhelmed by so many staring faces. His blonde hair is particularly interesting to the local children who laugh and giggle in a way that can be disconcerting to a 7 year old boy. After promising to return next week we followed the children back to the car where the young man was still on guard. The 100kw note (50 cent.) for his services was received as if it were gold and the car was intact. We waved goodbye. Finding the correct way home was far simpler but not nearly as exciting. I am negotiating the purchase of a small jeep which until bought I think I will return the easy way!
I think of Pilirani and her boys everyday. I hope I will find them alive and healthy when we return though I cannot be sure . They still have along way to go before I can feel they are out of danger. Edward weighs 2.250kg and Alex 1.450kg. In most countries they would still be incubators!
It was hard to leave nursery but I felt I should go back to labour ward. I have made friends there so will return often and have told them to call me if they are particularly short staffed or overworked. I hope they will. I will keep up contact with the mums who are caring for their babies in the "kangaroo" nursery I have some very special mums there. Look out for news of Grace and her little one. She has a heart murmur which seems to be the cause of her slow weight gain and "failure to thrive" Grace is a dedicated mum and we have a special relationship. I shall not loose contact with her.

My return to Labour ward was dramatic with breech twins. Helping to save this mother from an almost inevitable c/section was good. There were a few " adrenalin" moments but all turned out well. 2 boys ...1.900kg first then 2.200kg came quickly behind. Wow! am I learning a lot ! Mother nature is wonderful and so knowing and babies and mothers are stong even under the worst conditions. Thankyou!

HELPLESS BUT NOT HOPELESS

2008-02-28T15:14:00.004+01:00

As I walked out of the nursery today I wondered how many more tiny lifeless babies would pass through my hands ? How many more mothers I would have to call to tell them that their child had died? Despite the limited care we had given, the time they had spent squeezing their empty breasts for the last drop of milk, their little one just hadn't been strong enough, just didn't have what was necessary. Today it was a young 20 year old mother. Her second pregnancy, her second baby, but nothing to show for it. The first had not survived either. Very tiny, very prem, he didn't really have a chance. The impression is that life is cheap, expectations are low or non existent and another little mound of earth in the village cemetry was was all she had left.

I am amazed each day as I learn more of Malawi, of their ways and of their customs but especially of what they don't have and would never expect. Most of the births will not be registered officially. This means that when they die nor will it be necessary to register the death. Procedure is that the baby's body is wrapped, labelled and put in the hospital fridge. (on labour ward and its generally full) The family will arrange their own funeral with very specific rituals that the older women will pass down to the younger ones. I believe it is for women only, that the men are not present. The child will be collected and a procession will make its way to the cementry, the women carry branches of leafy trees to signify the loss and respectfully all will make way to let them pass. The cementries are easy to recognize as there will be a large number of trees growing there. Each village will have its own area. The baby will be laid to rest with no official recognition that it ever existed.

So this past week has been dominated by the loss of little lives. A baby born with kidney problems lasted just 24 hours. One with a congenital heart defect whom we found impossible to wean off oxygen after more than 10 days just needed a pediatric heart specialist .. in Malawi there are none. (and they certainly dont have the money to be treated elsewhere) Premature babies sometimes weighing less than 1kg. or 1- 1.5kg would survive and thrive in UK, in Spain, in many other countries, but here in Bwaila nursery they have little chance.

40 babies in the nursery. One of the nurses I know has worked more than three 24 hours shifts this week, at night on her own, plus a day shift. The nurses are paid (relatively) well for working extra shifts.Who can blame them for wanting to supplement their meagre earnings. I joke with her that Bwaila nursery is her home that she really doesn't have a home to go to ! I tell her that I don't know how she stays awake to care for the babies. I know she doesn't stay awake. I know their care is minimum and I want her to realize that I know that too. But what will that change? The nurses have to rest but if the babies are not cared for they will die. The matron came to see how they could cover for a nurse who is sick. She must know the situation. Is it really only important to cover the shift without taking into consideration the level of care? I have no answer and the problem is throughout the hospital, throughout health care in Malawi. Today is my day off and I cannot get them out of my head. I know I will have to pass by to see them sometime during today. Who will check if they are feeding ? Who will support the mums and ensure they have enough milk? Who will take the c/section babies to their mothers breast then bring them back? Who will make sure they start antibiotics when necessary or feed the tiny ones regularly through the tube?

As I write I am wondering whether the last remaining triplet born on Monday is still alive. They were born in a health clinic...supposedly a twin pregnancy . Mother and babies were transferred to us several hours later when the placenta had not been expelled. The ambulance took 5 hours to arrive..this is normal, but she arrived in good condition and delivered the placenta without hemorraging. The babies each weighing 1.250g were in good condition, just cold. I warmed them up and gave a litle glucose. The next day...what had happened during the night? It was so sad to see the first one go and then the 2nd one the following day. The mother cried when I placed the 2nd one in her arms. I gave her a hug and told I was sorry, that now she must work hard to express her milk to save her remaining child. I put her on the breast pump twice that day and was pleased to see that by day 3 she had plenty of milk. I hope I made her understand that she must feed her baby every 2-3 hours that she must give it warmth and love. Yesterday as I left she was doing well and the little girl looked strong. The nursery is ripe for cross infection. So many babies in such a small area. The nursery room is like a large incubator with temperatures unbearably high for working in but it is the only way to ensure the babies are kept warm. Sometimes the nurses find it too much and turn off the heaters. Sometimes they forget to turn the heaters back on. I arrive in the morning to find several hypothermic babies. This is definitely not good for these tiny things.

I walked to my car yesterday afternoon to go home, my heart was so heavy, I felt a heaviness throughout my whole body that I did not no how to shift. I felt so helpless, so useless, so hopeless. I could do so much in those 8 hours in nursery, never stopping, never tiring, doing all I could and now what? I saw the grieving mother, I went to her and gave her another hug. There was a cry from the distance and one of my mums came running up to me " see you tomorrow nursey " and gave me a big hug . How could I tell her it is a bank holiday weekend, I need to spend some time with Lucas, with friends, enjoy a trip out ? How can I tell I'm not coming tomorrow?

" Yes nursey see you tomorrow"

Yes I will go by. Yes she will see me today.

My spirits were lifted, I felt some of the heaviness leave me. So that's what Malawi is all about.. those tiny little things that mean so much. It doesn't have to be big, it doesn't have to be clever, it may not move mountains, I can't move mountains but I can feel love, and love will get me by once again. Love of my children, my family, my friends and love of those mothers that come into my care that have so little but give me their love.

YOU'VE GOT TO BE TOUGH WHEN YOU'RE TINY.

2008-02-22T15:00:00.003+01:00

I have spent this week working in the Bwaila nursery. It is the referral neonatal care unit for most of Lilongwe and surrounding areas. That means it receives all the sick, premature and low birth weight babies from the largest part of Malawis capital city. There is no neonatal specialist.There is no permanent medical cover. The care is overseen by a very small team of extremely overworked pediatricians covering more than one hospital and not necessarily specializing in neonates. We may receive a short visit from one of them during the morning ..or they just dont come. It is therefore the nurses/midwives who work in the unit who are largely responsible for all the care given and medical decisions. There are, at present, four of these nurses one of whom is not available as she is studying. That means three nurses are covering round the clock 24 hours a day, 7 days a week! Is it suprising then that the care is far from good and sometimes actually missing?
We have limited resources and with no medical presence limited level of care.(eg. no IV drugs or fluids ) Almost no blood tests or other diagnostic means. As I mentioned before they are either strong or lucky.They either get better, more or less on their own, or they die.
The nurses do as much as they can..some are more capable than others. The mothers are very present but need a huge amount of guidance when caring for their tiny baby. Today we had 15 babies weighing less than 1.5kg. and a total of 34 babies. There were just two of us , there would have been one but I was there! The mums express their milk, more or less satisfactorily, pouring it painstakingly into the little open mouths. Sometimes it reminds me of those little birds fallen out of the nest that we used to try and keep alive as children.
Today was weighing day. This occurs 3 times a week. Unfortunately it is more often than not irrelevant as no one bothers to look at the weights to see if they are gaining or loosing. I have not yet found a way of insuring and recording when or if the babies get fed or how much.But I am working on it. It has to be extremely simple and something the mothers can do.The nurse would definitly start off with enthusiasm but quickly give up for lack of time or motivation. I have been watching over the mothers like a hawk and am slowly getting to know which baby belongs to which mother. I am recording how much and how often they feed and giving help and advice on breast feeding and "topping up" with formula, for the mothers who just dont have enough. This is sometimes caused by lack of stimulation. I was amazed to find that several mothers were not feeding their babies at night ! For a 1.2kg baby to go 8 hours without feed is not a good idea!
There is a brand new electric breast pump available which has hardly been used. Today I had the mothers asking to use it as word has got round that it is much easier, less time consuming, and less painful than manual. It really isnt so hard to convince the mothers you just have to want to!
Each day when I arrive I look to see which little one hasnt made it through the night. I am also amazed by their strength and grim determination to hold on and have witnessed some tiny wee scrap pull through start to gain weight and go home. As soon as they start to gain we have to send them home, some are less than 1.8kg.
I wonder what happens when they get home ?
The kangaroo nursery, where the babies are looked after always on top of mum, is highly successful for these small or prem babies, in that it is obviously clear that the method works.
Babies are warmer, happier and gain weight faster. Unfortunately there are only a few mothers who are prepared to devote themselves totally to this type of care. I find that sad and difficult to understand.

I will stay in nursery next week. I am not ready to go. I need to understand more and find some small workable ways to help improve their chances just a little.
Labour ward calls me back, but I have time and feel I should be with the babies a while longer.
Maybe i'll just take them all home with me!!

GOOD NEWS

2008-02-18T15:42:00.002+01:00

Just a quickie to let you know that Pirilani was discharged home today. She looked good. She has made a really amazing recovery. The Malawian women are so strong and so powerful. I long for the day that they realize this, that they realize their true worth. The day they find the confidence and strength not to allow themselves to be treated so badly. That believing in themselves and how much they are worth this begins to reflect in their behaviour.
I took the twins to nursery to weigh them before leaving. They both looked good. Pirilani now has a good supply of breast milk so on my recommendation will only supplement with formula when absolutely necessary. The twins had been with her since the 3rd day.This is against the rules but as she was doing so well I decided to plea her case and it was allowed. I was thrilled to find this morning that each one had not only regained its birth weight but weighed 50g more !! This was surely due to being with the mother all the time. It is well recognized that babies cared for in this way thrive and gain weight much better than when separated from their mothers. (kangaroo care)
I said goodbye to them all giving 500kw ( less than 3 euros ) for their bus fare home and promised to go to their village in 2 weeks time to follow up the babies progress. (they live too far away to return to the hospital )

This week I am working in the nursery with the ill, premature and low birth weight babies. I am happy to be there although it is heart breaking to see the little ones who once again will survive if they are strong or if they are lucky...or if their mother wants them......
We are so close to nature here, as in the animal kingdom, the rule is generally ... survival of the fittest. The weak ones have little chance but maybe, just a few of them, with my care, will have a slightly better chance ??

CONFLICTS AND ISSUES

2008-02-15T09:48:00.004+01:00

Could a seemingly right decision that turns out wrong, be thus called a wrong decision ?

Or a wrong decision, for turning out right, is therefore right ?

This is where I am this week. Let me explain....

The woman was in labour with a twin pregnancy. Not large babies, no over extended uterus. It was her forth pregnancy .First child born by c/section, no details but didnt survive the neonatal period..probably severe birthing problems .Second and third born normally and still living. Her labour was abnormally violent ..probably as a result of herbal potions that can be bought or obtained just outside the gate of the hospital. These very often cause too many contractions and much too strong right from the begining of labour thus leading to fetal distress and unnecessary pain and suffering for the woman.But African ways and tribal powers are stong and the women are easily influenced. I/we made the decision to try for a vaginal birth rather then going for an immediate c/section. Surgery of any kind carries a very high risk here in Malawi and should be avoided as much as possible.It is often difficult to make the decision between the fetal well being and the mothers health. A live baby has limited posibilities with a dead mother. The babies were born quickly, both small but lively, active and healthy. 1.500kg and 1.800kg. All was going well untill she started bleeding.
At Bwaila there is no sense of urgency. Nothing moves quickly so whilst all was set in motion to attend this urgent situation, time passed. When a woman is bleeding after birth there is little time. It was one delay after another. With only one operating theatre the c/section in progress had to be completed, theatre cleaned and prepared. No blood in the blood bank meant sending to the nearest hospital 4kms. away through traffic and unfortunately staff lunch hour. Lack of materials plus nothing is ever where you think it should be, resulted in a difficult situation, becoming a live and death situation. Pirilani is still alive. Her bleeding uterus was removed and apart from a fever post operatively, important anaemia, despite the blood transfusion, she is on her way to recovery. The twins are OK for now. Having spent the first night in the nursery with little care and just a little glucose to drink I went to collect them the 2nd day and was thrilled to see how they excitedly latched on to her breasts. Since then I have tried to advise her on how to suplement her diminished milk supply bringing them myself formula milk powderfrom home. I only hope they will follow my instructions and boil the water first, give the right strength and continue with the so very important breast feeding. I worry that I may be causing more problems than I am solving. But without supplements they will surely die.
So maybe now you understand ? Are these decisions good ones ? Or will it only depend on the outcome ?

Work had been steady all day Wednesday untill 4pm. I suddenly found myself assisting births on the floor practically under the beds.I am still not sure where they all came from but when someone shouts "baby coming" whoever is available grabs a few materials and runs. By that time of day materials have not been replenishing for night staff, meaning that there is normally hardly anything available. So with 2 pieces of thread and a razor blade not forgetting a handful of gloves I do what I know best what comes automatically..I catch babies. With a smile, with a squeeze of the hand with gushing words of praise, for this woman has laboured alone, in pain and often frightened she has done what all women instinctively know how to do but should never do alone. She has successfully brought another small child into this world. Much to the amazement of my Malawian colleagues who all came to stare I then proceeded to suture a small perineal tear kneeling down on the floor. My time at Acuario and my home birth experience had trained me perfectly for this, it certainly wasnt the first time for me!! I went home late and exhausted. Its great to find Luki there when I get back it just somehow puts things right and normal again.

Entering labour ward at 7.15am on Thursday morning I found every bed full.
In that first hour I assisted 5 births. One with birth asphyxia, two post partum hemmorrages,one shoulder distocia..shoulders got stuck.. twin breeches and prepared a woman for a much needed c/section. Where was everyone else.The night nurses were going off duty and the day nurses had not yet arrived or were chatting and exchanging news. The cries and pleas of the delivering women were completely ignored or not heard nd I was left to catch babies again. Just time to change gloves but little else, thank heavens for Janet, a dutch midwife, who called in on her way to nursery and delivered placentas for me and helped out with the emergencies. Most of the problems encountered at this time of the morning...and there are many ..is directly due to lack of care and attention during the night, in short, to negligence. That day I finished at 13.30 and took the afternoon off. I really couldn't do any more, I ached and I was tired and not a little disheartened.

The teaching plans are moving forward.I shall have 4 groups of 7 midwives in each group.I will repeat the same workshop over 2 weeks. Tuesdays and Thursdays for 2 hour sessions.
It wont be easy and I shall have to adapt so much of my material for we are not starting from the same baseline with the same feelings or objectives. They will be informal sessions with lots of group participation and lots of feed back. I have a lot to learn and much to share .I am confident I will find a way forward to reach these midwives and something really positive will come from our time together. This will be an ongoing thing which will hopefully last during my entire stay. Other teachers could also be involved. I am hoping it will become such a regular occurence that the midwives will see it as an important part of their working life. A time when midwives can share experiences, discuss cases and practices and complain all they like. Oh how I wish midwives would complain! How I wish women would complain!

SO MUCH TO LEARN... SO MUCH TO TEACH

2008-02-08T08:34:00.000+01:00

Exciting news this week. Its seems that I will officially be able to start teaching. A project has already been funded to set up an ongoing teaching program for the midwives (and I hope others) at the hospital. I have been asked to take part.
Details are still uncertain but those who attend will probably be given a meal or some sort of incentive. This is always attractive to the highly underpaid health professionals.

This week has had its slightly quieter times on the labour ward. I took advantage of one of these moments taking aside any students who wished and I talked about pain. What was their perception of pain and particularly pain in child birth ? How did they percieve the women's pain in labour and did they think they could or should do anything about it ? I soon found I had 10 people gathered round me, mainly male clinical officer students, willing and eager to listen. It was a good moment, I shall try to do this as often as possible along with the clinical teaching each day as they work alongside me. Their training is really quite inadequate and they find themselves in positions of responsibilty with very little preparation, experience or knowledge.This leads to the strict following of rules, as I mentioned in my last blog, with decisions being made too late with disastrous consequences. Recently a fetal monitor was given to the hospital. The foriegn midwives are using this for cases of suspected fetal distress. It was sad, but understandable, to find that many clinical officers did not know how to use this or how to interpret the findings on the graph.

Other big news is that I finally took my birthing stool into the labour ward last week. I had already approached the idea of vertical birth with posters and photos from Spain and had assisted a few births with the women in crouching position, though rather precariously on the bed. One of these had been particularly sucessful as it had been to aid the birth of a 2nd twin. The Malawian midwife was getting concerned. The first baby had been born easily but the second didn't seem to want to come down. I confidently suggested she be told to get up on her feet and crouch.With 3 pushes the baby was born. It did wonders for my credibility !
A few women have now used it for pushing in 2nd stage and 3 women have given birth sitting on the stool. The midwife on the rather dirty floor to the amazement of our malawian colleagues and me sitting behind to support the woman. At the moment it is just interesting and maybe a bit crazy but its early days. I hope time and experience will show the huge advantages of vertical birth. It is not only the midwives we have to convince, the women too are highly reluctant to get off the bed. We have to be careful not to create insecurity and distrust.

I have so much to learn about the people, the women of Malawi.
I was told by a fellow midwife " you have to treat them with aggression, that is what they are used to. If you are too soft and kind they will not co operate." I find this difficult to believe and more difficult to do. I can be firm but kind, but to be aggressive to a woman giving birth ? I think not. Sometimes communication is difficult.
Many babies are unwanted. A result of rape, incest or agression. It is easy to distinguish these women who often have their babies pulled out of them with the same agression as which they entered. These cases are particularly difficult. She may be just 13 years old , very often young girls under 18. There will be no counselling or emocional support for her just rejection and scorn. Many babies will be " just another mouth to feed " All this is reflected in the way she births and the way she receives her newborn. Of course this happens all over the world but here in Malawi it happens a lot ...too much.

I have been fortunate to be able to visit 2 mission hospitals in the Lilongwe area. Both primarily supported by the catholic church. What a difference! Much cleaner, more materiales, more space, sheets and blankets, but more importantly a feeling of caring, of love and concern.This is generally missing at Bwaila. Lucas has been with me on these visits and loves to visit the pediatric wards to see if he can make the children laugh.This is often difficult but when we achieve a smile and a giggle then he is happy. Two cases in particular have stayed in his mind. The small child with severe malnutrition, literally "dying of hunger" and the children with burns. "
" But mummy, when their skin is taken off they are pink just like me !"

EXACTLY !