Birthing a dream

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?