THE BIRTH OF SCARLETT

I remember clearly the first time that Katy experienced the reality of childbirth. She was 15 years old at the time. I had been working as a midwife for several years at Acuario, which at that time was the only and pioneer natural childbirth clinic in Spain. Acuario gave childbirth back to women at a time when medicalized/hospital birth was not only the ‘norm’ but highly recommended as the only safe way to deliver a baby. I had already birthed my first three children in my own home when I met with the Acuario team so was not in need of any convincing that child birth belonged to women, belonged to parents, childbirth was a normal physiological process and in most cases was much better carried out with the attendance of a well qualified midwife in a conducive environment, a homely environment, whether that be the mothers actual home or somewhere like Acuario. I spent many years working ‘on-call’. My services would be required at any time day or night to attend births at Acuario or in women’s’ own homes. I was almost always ‘on-call!’ Christina (not her real name) was just 15 years old; she was the teenage daughter of a work colleague. She had hidden her pregnancy for as long as she could but when finally it became impossible to hide any longer she told her mum and came to see us at Acuario. I first met her in the scanning room. I remember touching her abdomen and commenting that I felt she was at least four weeks more than diagnosed by the Ultra Sound Scan. I still rely strongly on my abdominal palpation skills over USS when the first scan is carried out in an advanced gestational age. In those few minutes I connected to Christina in a special way, she was the same age as my own daughter; she could have been my daughter. During the short time that remained of her pregnancy we met many times and I promised I would be with her when she delivered her baby. The call came early one Saturday morning. I was at home with my children. I don’t even remember why she came with me ..…but Katy came with me. On arriving at Acuario and entering the delivery room I found Christina laboring in the warm water of our birthing pool. She was accompanied by her mother and a colleague of mine was also present. Katy came too. She sat discreetly on the rocking chair in the corner of the room and witnessed the whole experience. Christina was laboring well. Her contractions were coming fast and strong and I could see that she was close to pushing her baby out. The whole atmosphere in the room was of love and caring. Supported by her mother, other friendly familiar faces and a well experienced midwife (myself) she confidently rode the waves of pain and turbulence to receive her new baby into the world amidst the smiles and tears of those around her. Katy was there. I don’t actually remember talking with Katy after the experience, although I’m sure we did, but I do remember years later overhearing a conversation she was having with a friend about childbirth and in relating the birth of Christina’s baby was heard to say: “….afraid of childbirth? Oh no!....If she can do it like that at 15 years old…I certainly can!” In our household my children were well used to hearing all the details of the births I had attended, especially the home births and the many very special and beautiful experiences that women were having as they received their sons and daughters into the world with my professional help, guidance, care and love. I don’t think I ever discussed childbirth at home in any other way than as a wonderful, incredibly powerful experience that was totally within the innate instinctive capacity of the female mind and body. A ‘good birth experience’ was totally achievable by the majority of women. It was women’s numerous fears and anxieties that are directly interfering in the birthing process. Healthy,confident, secure, instinctive women who believe in themselves and their bodies, in the whole process of reproduction were more likely to have a successful, positive, uncomplicated experience. I spoke as a midwife who had accompanied so many women and parents through childbirth but also as a mother who had birthed her own four children in the comfort and ‘normality’ of her own home. I spoke always with confidence and security so I suppose this was what my children received during their childhood and formative years. So the way was firmly set for my eldest daughter, as she approached her own decision as to where and how she would birth her own child. Katy had always referred to me being present in the birth of her children, but I certainly never took it for granted, so when the day came and she announced the news of her first pregnancy I waited patiently and silently for her decision. I think she just took it for granted that I knew I would be there, not only as her Mum but as her midwife. I was anxious to ensure that the decision was also supported by my son-in-law Nick. I needn’t have worried as he expressed very clearly that he would only feel secure in having the baby at home if I was present. I guess that if it wasn’t enough to have accompanied so many women in labour and received so many babies into the world during my 15 years working with Acuario not only in the birthing center but also numerous home births I now had 4 years experience in Malawi delivering babies under extremely challenging circumstances with very little back up in the way of medical staff or equipment. These years of being part of the wonder of natural birth and the power and strength of women without option of pain relief or epidurals with only the most basic materials and equipment and lack of true vigilance and accompaniment during labour and birth has all led to reinforce my convictions and beliefs that we women have amazing bodies and souls that are designed beautifully for caring for our children both in and out of the uterus. That babies are strong and determined, hardy souls fighting for survival even before they are born The female body works…. babies are born safe and well and mothers are washing their own soiled cloths just one hour after birth and walking long distances to their homes 24 hours later. It never ceases to amaze me. Of course it doesn’t always work; childbirth has always carried its risks. Vigilance, awareness and the appropriate skills and actions in the case of sudden emergency situations, are vital for safe outcomes, for saving the lives of mothers and babies in any environment but especially in my work in Malawi. During Katy’s pregnancy I was often asked by amazed colleagues and friends how I could feel comfortable attending my own daughter during childbirth? My answer was clear. How could I possibly NOT attend her? I have accumulated so much knowledge and experience over the years that I knew had helped so many women, as well as all that I had felt and learned during the births of my own four children, how could I not share this with my own daughter, to help her? I am her Mum…I am a midwife. I wasn’t able to be physically present with Katy during her pregnancy as I was still in Malawi but I followed it closely with frequent photos and phone calls. I would like to have been around more but I needed to keep all my holidays to ensure I would be present for the birth. It was sometimes difficult to be so far away especially when she was feeling low or sick or just needed some advice. With telephone calls and e mails I would talk to her of the pregnancy, of the birth, answer her questions and reassure her of her ability and capability as a woman and as a mother. I was happy to hear of her visits to the midwives who supported her decision to home birth. I was happy to hear of her NCT meetings where both she and Nick were able to freely discuss their feelings and decisions and continue to feel supported. I was happy to hear that Nick was supporting her, caring for and loving her as together they approached the moment when they would receive their little one into their family. The baby was due around 16th December. I confidently booked my flight to arrive in London on 10th. Somehow I knew this would be fine. Once she knew I was in the UK Katy was anxious for me to be close so on 14th December I saw my first born, MY baby, with her beautiful swollen belly, carrying her own baby. What an amazing moment that was! The following days past quickly and comfortably as we filled them with preparation not only for the baby but for Christmas. My younger daughter was with us much of the time excitedly, lovingly, supporting her big sister. As her due date came and went Katy began to experience those impatient feelings known to each and every heavily pregnant mother. We made bets on when the baby would arrive whilst Katy waited for those first signs of labour. She was waiting to feel pain, that’s such a good thing! I vaguely remember hearing movement during the night as Katy began to feel the first discomfort of labour and started to move around her bedroom. By 5.30am I was awake and knew that labour had started but I stayed in my bed reading my book and awaiting her call. At 7am. she and Nick went downstairs. I could hear Katy retching and vomiting so decided it was a good time to see if I was needed. “We were just going to call you!” Katy exclaimed. She had been having mild contractions since around 2am. They had been gradually increasing in strength so she decided to get up from her bed and find more comfortable positions. All was well…. Nick was with her holding the bucket, holding her hand and giving her the love and comfort that she needed. She had the Tens machine attached to her lumbar area which seemed to be helping but now she needed to have an idea of the progress of labour. After a quick hug and words of encouragement I put on my midwife hat and performing her first vaginal examination found that she was 2cms dilated. All was well… the baby’s head was well down in the pelvis and the cervix was thin and soft, just ripe for a smooth transition into the active phase of labour. I had brought my small ‘doppler’ along so we were all able to listen to the strong healthy heart beat of the little one inside as she too rode the turbulence of the uterine contractions that were slowly but surely facilitating her descent and passage into the outside world. Most of this time Katy was sitting or lying over her birthing ball, rolling her pelvis to aid the descent of her baby which gave her relief from the increasing discomfort as labour progressed. Nick was always close by whilst I preoccupied myself with my own things, remaining close, but lovingly distant. Katy was coping extremely well. Her positive attitude, full understanding of the process of labour, her self-assurance and confidence in the strength and ability of her body to birth her baby were highly evident. As a mother I loved and cared for her with words of praise and encouragement, as a mother who knows her daughter Katy is a strong, capable and decided woman and that her body is naturally able to birth her child safely. As a midwife it was evident to me that the labour was progressing well, the baby was in good condition and the mother was in her chosen environment with the support of the persons of her choice. All was well…. Katy understood that she was still in the early phase of labour and needed to save her energies for the later stages. She took comfort from the use of the TENS machine or the back massages, the small distractions and nutritive snacks provided by Nick and the security of her own home, her chosen midwife, her beloved husband and her mum.(That’s just two people!) Around 11am Katy needed to find a new way to cope as the contractions increased. It seemed a good time for her to take a hot shower or bath to relax her mind and her body and help her to focus. She now needed to isolate herself from outside distractions allowing her body to take over without resistance, allowing her body to increase the production of endorphins and take her into its own world of acceptation and instinctive response. She was now 4cms dilated. The baby’s heartbeat remained healthy and strong. All was well… Once the bath was filled to the top with warm water and lavender drops to aid relaxation Katy entered the water. She gained immediate relief as the heat penetrated her tense muscles and allowed her body to relax and her mind to give up all resistance and accompany the contractions as they pushed her baby’s head down onto the cervix, stretching and dilating with ease. As all resistance left her it became obvious that her body increased its production of Oxytocin and the contractions became more frequent, longer and more powerful progressively. All was well… As her midwife I explained clearly at each stage what was happening in her body, I reassured her that all was well and that what she was feeling was good, it was ‘OK.’ As her Mum I truly knew her strength and conveyed my love and pride in how well she was managing each and every stage. I was close, but not too close, Nick was there…Katy had all she needed. During my time at Acuario I had learned the best use of water in labour and birth. At this stage it would not be beneficial for Katy to remain too long in the bath. There are many other ways of easing the discomfort and the warm water could be kept as an option for a later stage. So after one hour I encouraged her to leave the water and rest awhile in the familiarity, comfort and security of her own bed. It was now 12.15pm. Lying on her side with Nick snuggled up behind her, a hot water bottle on her lower abdomen I sat on the floor by her bedside with my hand on her belly and talked her calmly and quietly through each and every contraction for the next one and a half hours. As the contractions became longer and stronger I could see that Katy would need to find a new way to relieve the pain. She expressed the urge to pee and began to feel pressure low down in the birth canal. It was now 1.45pm. All was well… Now Katy was finding it hard to ride the storm of the contractions. The strength and intensity was at its maximum. All the signs showed that she was close to delivering her baby…but…could that really be true? It had been far too quick for a first time mum! I must admit to thinking that if she was just 5or 6cms, which would have been the average expectation for a first labour, then how would I help her through the next several hours? I suggested she go to the bathroom to pee whilst I prepared a nice warm bath for her. This she did. It was the first contraction that came fierce and strong as she sat on the loo that gave her that unmistakable urge to bear down. Now I knew for sure…the baby was close, she was ready to push. We once more listened to a healthy heat beat from inside her uterus. All was well… We helped Katy into the bath and as she settled into the comforting warm water the next powerful contraction came and she spontaneously and instinctively pushed down deep into the birthing canal and we had our first sight of the little ones’ head covered in dark hair. At this point I suddenly remembered we should inform the local midwife who was prepared to attend the birth. I quickly called the local birthing centre, “I am calling for Katy who is booked with you for a home birth. I’m sorry to leave it so late but things have progressed very fast and she is now in second stage and we can see the baby’s head! All is well…” I’m not sure she believed me as she knew I was a midwife so probably thought I had planned it that way (which I hadn’t) but she spoke very kindly and said she would be along straight away .At this point both Katy and Nick experienced a small moment of panic, of realization that this was the moment they had been waiting for and suddenly it was a bit too much, a bit scary. I spoke to them calmly but firmly to allay their fears and keep them focused. I immediately realized that this was now Rachel the midwife talking, Rachel the midwife with all her skills and knowledge who had taken over my whole being. Rachel the midwife who automatically and instinctively knew how to take this precious woman and her baby safely through childbirth as she had done so many times for so many women and babies. Like most other first timers Katy held back her true power with the first few pushes. Why on earth would a woman cause herself so much pain as she is stretched wide open? Much better to hold back, to resist, trying to lessen the pain. But this is short lasting and with the right encouragement and support Katy quickly realized that she must use all her power, all her strength and determination to safely birth her baby. It took Katy just 30 minutes to push her little one out into this world. The local midwife arrived just two pushes before Scarlett was born. I respectfully asked her permission to continue assisting the birth which she kindly agreed to. So it was at 2.15pm on 21st Decemebr2011 that this midwife, this Mum, received her own granddaughter into the world, this midwife/mum who encouraged her daughter to take her baby into her own hands as she was being born and gently lift her out of the warm water and onto her breast. What an amazing moment! But I was still the midwife as I encouraged Nick to cut the umbilical cord, to physically separate his daughter from the sole care of her mum, symbolically accepting his role as her father in the responsibility of the lifetime care of his daughter. I was still the midwife as I delivered the placenta and assured myself that there was no excessive bleeding, as I checked for tears or injuries. Nothing…. All is well…. Katy stayed in the bath for a while whilst we all stared at Scarlett in amazement as if she was the first baby ever to have been born and that her tiny fingers and toes were like no others and of course she was more beautiful than any other baby ever to have been born! We played with Scarlett as she floated and relaxed in the familiarity of the warm water. I helped Katy to shower and accompanied her to her bed to rest and organized for her a warm cup of tea and something to eat. I kept in my midwife role until Katy was safely and securely tucked up in her bed with little Scarlett nuzzling at her breast. It was then that I so appreciated the presence of the local midwife who took over the rest. She just took over the tidying up, the documentation, administrative stuff and the advice and formalities. It was just what I needed! I could now be Mum! We laughed, we talked and we shared memories of the day. We made lots of telephone calls to all those waiting to hear the good news. We drank cups of tea and we opened the door to the ‘other‘ grandparents. It was a particularly emotional moment for me to see Katy’s little sister (my Fiona) sitting on the bed with Scarlett in her arms and looking and feeling so happy for herself and for Katy. Nick was the calming influence. His relief that all was well that his woman and his daughter were safe was tangible. He was a proud man. I still remember clearly the sight of Katy snuggled up in her own bed with her little daughter Scarlett suckling at her breast. It took me back to how I felt when she was born. The best moment was when it was all over. I was in my own home, in my own bed with the people I most loved in the whole world. My baby, my man and my mum. I want to finish by sharing how Katy and Nick felt about having a Mum/midwife; Thank you for being the best midwife we could ever have had… for giving me the birth I’d always dreamed of, Scarlett the peaceful arrival she deserved and for keeping calm when Nick was struggling too. It was a wonderful experience we will never forget. We have no doubt that you being there made it as easy and as special as it was.

THEN WHAT?

Dec 18th 2011.
It’s cold, it’s icy, but it’s England! Here I am, once again, surrounded by the love of my children and my family. It’s also a very special day for Lucas. Today is his 11th birthday which he is spending in Spain with his papa. I am with Katy and Nick in the north of England and we are all full of excitement as we await not only Christmas but more importantly the birth of their first child! She very cleverly decided to be born around this time so as to assure that her ‘yaya’ from Malawi would be present to help both her and mummy welcome her onto the world. Katy decided very early on in the pregnancy that she would like their daughter to be born in the coziness and comfort of their home. I am excited, calm and confident that it will be a truly beautiful and memorable experience for us all.
It’s been a long time since I last wrote to you all. The past few months have been by far the most difficult that I have experienced since I arrived in Malawi 4 years ago. I will need to explain to you why it’s been so challenging for me.
The shortage of FOREX due to many political reasons, of which I am not going to pass comment, has been the root cause of the problems we are facing in Malawi during this past year which have over time become more and more acute with little hope of improvement. This of course affects all walks of life but I will just focus on how we have been affected at Bwaila and how this has personally reflected in my life.
We started to feel the effects of the fuel crisis early this year. Fuel is the basis of so many areas of our daily life without which it is difficult to function correctly and efficiently. Little wonder so much of the war and power struggles in the world are somehow connected to fuel. Fuel is transport. Fuel is electricity. Fuel is water. Fuel is supplies. Fuel is work. Fuel is leisure. Fuel is food. Fuel is production. Fuel is health. Fuel is not resourced in Malawi. Fuel needs to be imported. Foreign purchases need foreign exchange. Malawi has a Forex crisis.
During the first half of the year we began to notice the shortages of materials and drugs at Bwaila. It became impossible to restock the cupboards in each and every delivery room as our main stock room was half empty as was the central medical stores. It became normal to hear staff shouting out around the ward “ has anyone got any sutures in their room?” or IV fluids, or catheters, or gloves or medication. But we carried on improvising as best we could. The situation became steadily worse and by September was clearly reflecting on the standard of care that we were able to give our mothers and babies. So when situations began to arise whereby the absence of essential medication resulted in loss of lives of our mothers or babies it often became too difficult to handle.
When the mothers blood pressure is dangerously high with the risk of convulsion and subsequent brain damage or death it is essential to administer the appropriate drugs. So if they are just not available…then what? When the mothers are recovering from major surgery and crying out in pain and the most you can offer is a Paracetamol…then what? When the mother is hemorrhaging after the birth of her baby and the life saving injection to contact the uterus and stop the bleeding is not to be found…then what? When a difficult labour needs essential interventions and the materials are scarce…then what? When a woman needs to be brought in from an outlying village or health center due to complications or needs emergency care or when she needs to be transferred to the main hospital unit for intensive care and the ambulance has no fuel…then what? When the patients condition or progress of labour needs to be documented and there is no paper for photocopying …. Then what? When the photocopying machine runs out of ink and there is no money to replace it…then what? When the power is cut and the generator has no fuel so the oxygen concentrators cannot function, the theatre is in darkness…then what?
During the latter part of last year we faced these and other challenges on a daily basis. It wasn’t about lack of obstetric skills, it wasn’t about tired overworked or demotivated staff, it wasn’t about negligent care, it was about an ever increasing lack of support by the government to ensure essential health care.
I remember Alinafe. She was 23 years old and pregnant with her 3rd child. At some stage during her labour in one of our more distant Community Hospitals it all started to go wrong. They decided quickly that she needed a C/section. There was no power and the generator had no diesel so they could not perform the life saving operation so she was referred to Bwaila. The ambulance was called. There was no fuel. By this time the ambulances they has ceased to be given priority in the fuel queues so Alinafe had to wait until morning when fuel could be found to bring her to us. By the time she arrived she had been pushing for hours. The baby had become impacted in her pelvis due to a mal position and try as it might her body could not expel it. We rushed her to theatre but were unable to save either her baby or her uterus. Alinafe lived….but only just.
Continued on 10th Feb 2012.
With each day that passed I found myself becoming less able to cope with the situation and longing for some ‘time out’ some time away from these frustrations and seemingly impossible challenges.
And so I spent 5 weeks in the UK during the Christmas period. Mostly in the north of England being around my 3 elder children but also visiting my mother and my siblings in the South.
My daughter gave birth to her first child, a girl, on 21st December in the comfort of her own home. I ‘Mummed’ and I ‘midwifed’ and was truly astounded and priviledged to be able to share in this wonderful moment that really belonged to Katy and Nick but that I will always form a part of. ( I will publish my reflections on the experience of being a midwife to my own daughter in a later blog.)
Christmas was spent at Katy and Nick’s house with Fiona and Lucas. Alasdair and Laura were in Spain. We then all got together for New Years’ celebrations which were comfortable and cozy. I always appreciate the times when all my 4 children in the one room!
Lucas and I returned to Lilongwe excited and enthusiastic to begin a new year.
Within days we were back into the routine of school and Bwaila, friends and social life.
All is well…………………………….

JUST ANOTHER STORY TO TELL

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

LOW RISK

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

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

SOME RISK

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

MEDIUM RISK

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

HIGH RISK

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

MORE MALAWI MIRACLES

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

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

MALARIA AND MORE

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

BACK TO BWAILA

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


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


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

TIME OUT

Today I start my annual vacation. We will return to Europe for the month of December. I need rest; I need to recover, to find the renewed strength and enthusiasm vitally needed to face the ongoing challenges that will present at Bwaila next year. To put back, to replenish, to be in the company of my precious children, my family and old friends, to feel their love fill me and their support encourage me to continue to be able to give and to serve the very poor, very neglected, very under privileged women and babies of Malawi.
It’s been a very hard two weeks. Since the new referral unit opened at Kamuzu Central Hospital and we at Bwaila became a District Maternity Unit the number of births we are attending has hardly changed. We are daily attending more than 40 births many of which need very special care and attention.The new central unit took some of the more difficult cases but they also took ALL our medical staff. We are now led by the District Health Management Team who for many reasons, not least the huge area/population that falls into their responsibility, are noticeable by their absence. Staffed mainly by midwives, with their continued reluctance to take on more responsibility, a few clinical officers with very varying abilities plus interns and students it has become evident that the care we are giving is less than adequate and the women and babies are suffering.
Having diagnosed severe fetal distress in a young first time mother who was still not in active labour I found the clinician in charge to request an immediate c/section. It was 12.30pm. Theatre was informed, the admission nurse was ordered to prepare the mother for theatre and I had to leave the unit for one hour. On my return I asked after her and it was presumed that she was in theatre. I thought no more of her and continued with other work. A 2pm I overheard a conversation which sounded as if it concerned this woman. I was called to scan a woman as the midwife couldn't hear the fetal heart. Entering Room 8 I found my emergency c/section woman still waiting to be prepared for theatre. She had been put in a room and been forgotten. I quickly scanned her and to my relief found that the baby's heart beat was still present but extremely fast. This baby was in severe distress. We prepared her for theatre and the baby was extracted at 2.50pm nearly and two a half hours after I had first recognized the problem. The baby was born dead.
This is unacceptable.
Our protocol on the unit is to perform c/section on all first time mothers whose babies are presenting breech (bottom first)
Wednesday morning on arrival at labour ward I was told there was a breech delivery on a primigravida, fully dilated and pushing, in Room 4. On entering the room I could see that both the baby's feet and legs were visible, blue and puffy. This baby needed delivering fast. Realizing that it was too late for a c/section I quickly put up an IV and emptied her bladder. I delivered the baby with the appropriate maneuvers and some help from a young Norwegian midwife colleague. After resuscitating the baby it was able to stay with its mother without need for nursery care. This mother had been on our labour ward for most of the night but the breech presentation had not been diagnosed.
This is unacceptable
Thursday morning I arrived as usual at 7.15am. I enquired if there were any problems and was told there was a breech to be delivered in Room 2. On entering I found both feet and legs already delivered, blue and puffy. Glancing at her case file I realized she was a primigravida... NOT AGAIN! I commenced the IV line and emptied her bladder and couldn’t believe that I was facing the same again, two consecutive days. Slightly encouraged by the experience of the previous day though a little alarmed by the size of the baby's feet (I imagined a big baby) I started to deliver the breech. The shoulders came well, with the correct maneuvers, but the head got stuck. I attempted all the correct maneuvers, instructed a colleague to assist and at last the baby's head was born. I rushed the baby to the resuscitaire but my attempts were in vain. The baby died.3.3kg...Too big for a 17 year old woman. Looking back over her file I found that she had been admitted before midnight, the midwife had not been sure of the presenting part so requested USS confirmation. The young intern performed the scan and was also not sure but documented that the scan should be repeated in the morning by seniors. Both recorded a head presentation. She spent the night on the Ante Natal Ward calling for help around 7am as she felt her 'waters' break and 'something' in her vagina. She was attended 30 minutes later when she was found with the baby's feet protruding. They rushed her to labour ward which is where I found her. Three mistakes from inexperienced staff with no senior back up resulted in a young mother with no live baby.
This is unacceptable.
Friday morning I arrived at the same time. I looked into Room 2 and saw one of our new midwives attending a birth. I opened the door to greet her and ensure she was OK when I became aware that a breech was hanging out delivered to the level of the umbilicus. The shoulders and head had still not been born. I noted that the baby's colour was blue nearly white and the umbilical cord was not pulsating, this is not a good sign. I had no idea of what had happened prior to my entry nor how long the baby had been waiting to be born but I could see that it needed delivering quickly. I encouraged the midwife to actively assist with the birth of the shoulders when it became obvious that she was unsure as to how to manage the situation. I tried to explain but quickly had to 'take over.' The shoulders came easily. 'Is it her first?' I asked. 'No it's her second child' I was told. That made me feel better. I soon realized that no contractions were coming to facilitate the birth of the head. 'Put some Oxytocin in her IV line' I ordered. I looked up...There was no IV line! I had been quick but by now I was extremely concerned for the well being of the baby. Still there were hardly any contractions meaning that the mother’s pushes had little effect. I had already called for help from another midwife who I instructed to assist with the flexion of the after coming head. Should I take time to put up an IV line or continue to try and extract the head? Time was running out and I knew it....whatever I did would be wrong, whatever I did would probably not be in time....I couldn't believe it, I didn't have time to save this baby. Time had run out. Too much time had passed. The baby was already dead, maybe it had died before I entered the room? I don't know, but I felt useless, I felt impotent, I was angry, I was frustrated, I was devastated. I told the mother I could do no more. I calmly put up the IV line with Oxytocin, I emptied her bladder of over 1000mls. of urine and with no more than 3 good contractions and pushes I easily extracted her 2.9kg baby. The baby had died due to a full bladder that had prevented the head from descending, poor uterine contractions with no IV line to allow me to give the correct medication and a huge lack of skilled staff.
This is unacceptable.
Of course it is not only due to lack of staff, to lack of experienced staff, to lack of the drive to improve skills, to implement knowledge and skills that cause these tragedies. No, it is so much deeper and more complicated than that. The wages are unacceptably low, the work load is heavy, constantly heavy, the moral is low and the staff are little appreciated by the higher management. They are easily and quickly critiscised when things go wrong but rarely praised for their efforts.
This is unacceptable.
A few weeks ago our only ambulance was taken to be used on ‘stand by’ for the African Union Conference in Lilongwe. It was parked for a whole week outside the hotel just in case one of those eminent people should need emergency transport. An open ‘pick up’ truck was provided some days or else an old hard top truck. It was in these vehicles I made two emergency transfers to the central hospital. The mother had been transferred to us through a local health centre after a home birth. She had had a massive hemorrhage and was critically ill. We stabilized her condition at Bwaila and managed to find one bag of blood to transfuse but she needed more blood and to be cared for in the ICU. Just getting a patient in this condition into the back of a truck is a challenge but then we also had to transport her numerous relatives with bags and bowls and even a bundle of fire wood. I took up my seat in the front facing backwards to check her condition and carrying an ambu bag just in case she stopped breathing. I prayed that her condition would not deteriorate as I could not imagine performing effective resuscitation in this truck. I ordered the driver to get there quick, that this was an emergency. We started off out of the hospital and onto the busy shopping area surrounding Bwaila. “Put on the siren” I ordered. There was no siren. “OK , then sound the horn” The horn was not working. “Lights” No, not working either.
This is unacceptable
What an amazing driver! Totally oblivious to any danger, or so it seemed, he pulled out into the centre of all the traffic and just kept going. Not to be deterred by either on- coming trucks or pedestrians he just kept going. Luckily I was facing backwards for most of the journey, except when we came to junctions or traffic lights when I stuck my head out of the window, waved my ambu bag and shouted very impolitely for people to get out of the way. It worked .We arrived in record time and delivered our patient into the care of the ICU staff still alive. Our return journey was somewhat more sober. “ Madam,” exclaimed the driver. “ We were all very impressed with how you cared enough to make sure we got there quickly, this is not normal behavior, the relatives have asked me to thank you”
( No I guess this is not usual Malawi behavior but I had done it before. I was reminded of an incident when I was seen almost flying down the mountain road in Spain, waving my white flag out of the window, as I personally and successfully transported one of my ‘home birth’ mothers to the nearest hospital.)
Each and every one of these women stays with me today. My heart is sad and my spirits are low as I leave Malawi. It is such a difficult place to leave. So much to do, so much suffering, so much poverty, such a hard life for so many. I love these people, I want to always do my best for them and it is so hard to accept that even my best is often not enough.

Now I am back in England in the arms of my family and soon I will be reunited with my children.
One is loved because one is loved. One loves because one loves
No reason is needed for loving.
‘

COMPUTER TECHNOLOGY

There’s no denying that computer technology is the way forward. There is no denying that in the long term an electronic patient register along with accurate recording of hospital data will assist us in identifying our shortfalls and so technically lead to improved patient care.....but....
As you may well imagine it’s an attractive proposal for any would be donor. It looks good on paper and sounds convincing…but…
Over the past year I have been actively involved with an expert team as they worked on creating the appropriate software. Funding became available for the setting up of a simple registration system to suit the needs of the unit and provide the necessary hardware. For this we are grateful. Latterly more funds became available to expand the project, meaning that I have needed to dedicate more of my time to attend meetings and aid with preparatory work. I trust this time away from the clinical situation, away from labour ward has been well spent…but…
Inevitably there will be some resistance from the staff at first until they become familiar with this new method of record keeping but we hope that it will lead to far greater accuracy and therefore better care. Leaving paper behind and changing over to electronic recording should ease the constant challenge we face daily when paper is not available for photocopying. We are assured that it will prove to be easier and quicker but at present I doubt it!
I arrived on labour ward last Friday at the usual time (7.15am.) I found the ward full of laboring mothers with many women sitting on the floor outside the Admission Room waiting to be assessed. On enquiring as to how the night had been I was informed that for the second time in one week there had been just 3 midwives on duty…. Three midwives to attend 27 births.
My first job is to take a look round the ward and receive the ‘hand over’ from the night staff. I must make a quick assessment of the situation and start to prioritize. I am usually the first to arrive much to the relief of the tired and overworked night staff. The arrival of my daytime colleagues is generally delayed and sporadic, meaning I often find myself alone or with one other midwife for the following hour. It has always been a difficult time as I try to sort out the problems left over from the night performing vacuum extractions on prolonged labours and subsequently resuscitating babies that should have been born hours before.
The morning report in the conference room attended by the clinical staff, in-charge midwives and matrons begins at 8am. It is an important time when we get together as a team to discuss the events of the previous 24 hours and the plans for the day. Very often I am not able to attend as there is no one else to cover the labour ward.
At 9.30am I was called to a meeting with the matrons of the Family Health Unit ( antenatal clinic, immunizations, postnatal clinic, etc. …all out-patients) We were to meet with those involved in the development of the new ICT program. I left instructions with the student midwife as to the plan of care for the mother with prolonged labour in Room1 and asked a more qualified midwife to cover her. ‘ If she has not delivered in the next hour please assist with a vacuum extraction or send her to theatre’ I always feel uneasy leaving the more difficult cases but I was needed in the meeting. One and a half hours later I returned to labour ward. The baby had just been born and needed resuscitation and the mother was bleeding. I quickly performed the necessary resuscitation and as soon as I felt able to leave the baby went to assist the midwife who was attending the mother. After controlling the hemorrhage I left the student to suture and document.
So I was in a meeting with the aim of improving care, whilst a baby nearly died and a mother nearly bled to death!
How difficult it is at these times to appreciate the possible benefits of a computerized system when we are having such huge challenges just performing the basic care.
The day continued to be hugely busy with many complicated and demanding situations. I was due to attend a further ICT meeting at 1.30pm. but this was just impossible. I could not leave labour ward at this time, especially after my experience of the morning. Lunch breaks range from 12.30 until 2pm when we work with just a minimum staff. I have always chosen not to take a lunch break preferring to work during this critical time but aim to leave a little earlier. As you can imagine leaving a little earlier does not often happen! Two women with severe pre-eclampsia ( high blood pressure etc.) were admitted during this time. Finding myself without a clinician but now totally familiar with the protocol and treatment of this very serious condition I go ahead and administer the appropriate drugs and care. The challenge then became apparent…… I needed to inject (IM)large doses of Magnesium Sulphate to prevent convulsions a truly dangerous complication of pre eclampsia carrying a high risk both to the life of the mother and the baby. This medication needs to be mixed with local anesthetic otherwise it is an extremely painful procedure. I knew we had been running down our stocks for the past 4 days but were now completely without it. I was aware that the midwives had been suturing the women’s perineums without it, which is totally unacceptable, but assumed that either it was ‘on its way’ or I could ‘borrow’ from another ward. But NO there was no stock in the hospital nor in the pharmacy. I made calls to the Medical officer in-charge who was in a meeting and would call later. The question was now whether I should give the Mag. Sulph. without anesthetic and risk the possible consequences or cause the mother intense pain? I gave the IV dose and waited. Before I left to go home 10 bottles were supplied and I was able to give the medication. I wonder how long that lasted and whether there will be any tomorrow?
Physically and emotionally exhausted by 3pm on Friday afternoon I was further challenged by the admission of a woman in advanced labour carrying a twin pregnancy complicated by a previous c/section scar. Our protocol advises that in our circumstances these women should not labour as the risk of rupturing her uterus and causing death of the child and possibly of the mother is very high. I had just sent another mother for c/section so knew that the theatre would be occupied for some time. I decided that in view of the fact that she was almost ready to push her babies out I would attempt a vaginal delivery. The first twin I delivered quickly and easily assisting with a vacuum extraction to prevent unnecessary strain on the uterus. The second twin decided to put its hand alongside its head making the whole process much more difficult. The little one was born, also with the help of a vacuum extraction 30min. later needing intensive resuscitation which was successful .Even though I gave the necessary medication to prevent hemorrhage the mother still bled excessively , but these are strong women and the outcome for both mother and twins was good.
I went home exhausted…..I burst into tears ….I had a warm bath and a cup of tea… then danced and partied until 3 o’clock in the morning!
It was just another day at Bwaila……….
Today is Monday so I went to check up on my twins from Friday. The little boy(number 2) is still in nursery but doing really well. I am always amazed and humbled to recognize the great power and strength of our instimct to survive. I also visited mum and first twin(big sister) on postnatal ward. I was greeted by huge smiles and hugs. The mother was so happy to have avoided a second c/section making her so much more able to care for her twins.
The toilets are still blocked since Friday and we are running out of local anesthetic again but life goes on at Bwaila and I am happy to be here.

SOMETIMES A STRUGGLE

The back-up generator broke down and the power went off on Sunday morning from eleven am. until nine pm.
The on call anesthetist just didn’t show up for duty
….but life went on at Bwaila.
These sort of situations are unimaginable in the developed countries but not with us here at Bwaila, one of the busiest maternity units in the whole of Southern Africa.
So what happened?
38 babies were born during that time.
6 mothers were transferred to the new referral unit it the central hospital for emergency c/sections and 2 babies died. Fortunately we didn’t lose any of our mothers.
I arrived on labour ward on Monday morning unaware, at that time, of the difficulties that had been faced by our staff the previous day and night. The only evidence was the half burnt candles still present around the ward. Many babies will have been born by the light of those few candles and many will have been born in darkness. I was approached by the clinician who had been on call that night. ‘How’s the night been?’ I enquired. ‘Bad, really bad!‘ he replied and proceeded to explain the situation. He asked me to come and see the woman in room 1. It was her 3rd pregnancy. She was fully dilated and had been pushing since 1am. That was over six and half hours ago! The clinician had tried to extract the baby with the aid of a vacuum extraction somewhere around 2am. but without success. He tried in vain to send her to the referral unit but was told that they were too busy. Unable to make any other arrangements and without the anesthetic necessary to perform the emergency c/section, she was still in her room contracting and pushing when I examined her at 7.30am. The fetal heart beat was still present but inevitably showed signs of severe distress. It was immediately apparent that there was no way this baby could be born vaginally. Time was running out for the baby and possibly for the mother, who after so many hours of obstructed labour was in danger of rupturing her uterus which would result in the need to remove the uterus and could lead to severe haemorrage and possible death. I quickly made sure that she was prepared for theatre and asked the clinician to find out if theatre staff could take her in immediately. Fortunately the anesthetist on duty Monday morning had just arrived. Our voluntary obstetrician from the UK was also present and surgery was commenced. It was a risky and complicated procedure due to the time that she had been obstructed needing the help of our German consultant obstetrician. Having extracted a dead baby they then went on to remove her uterus which had been on the point of rupturing with uncontrollable bleeding.
Today she is recovering in our high risk postnatal ward, she is not in danger of losing her life and that is a good.
Of course this is not acceptable. Of course this brings feeling of anger and frustration but we are in one of the poorest countries in the world. The whole health system is inadequate for its people. We are understaffed, under skilled and poor equipped in every way. As clinicians and midwives at Bwaila we are improving, the care and attention to the patient is rarely consistent and the infrastructure does not always support us but we must keep positive and enthusiastic as we aim for excellence.
The new Ethel Mutharika Maternity Wing has now opened at the central hospital. Bwaila will slowly change its function to becoming the District Maternity Unit. All the high risk patients will be sent to the new wing where they can be cared for by a larger medical team and backed-up with an intensive care unit and improved neonatal services.
We will continue to be extremely busy as we the care for the women and babies of the ever increasing and expanding population of the district of Lilongwe. We will still receive referrals from the health centres and villages as well as caring for the pregnancies, babies and young children of the area. Dealing with emergencies, stabilizing patients for transfer and maintaining our own operating theatres will continue to be a huge task. We will lose our doctors to the central hospital leaving the unit to be staffed by Clinical Officers and midwives. The need for more highly skilled midwives will be greater than ever. Midwives able and ready to use their knowledge, make accurate assessments, good decisions and follow through as skilled practitioners is my aim.
I continue to do classroom teaching twice a week and bedside teaching on a daily basis. It’s tiring and often frustrating but it’s slowly making a difference and I am proud of the way some of our midwives are responding.
At the beginning of the year I was able to find funding to present a ‘midwife of the month award’ as a means of encouraging good practice. At that time it was very clear who would win the award as those few clearly out-shone all others. I am pleased to say that we are now finding it very difficult to select just one person each month. This is a sure sign that there are now many outstanding midwives. I find this extremely encouraging…..and you should too!
Last week was a quiet week. Just 25 to 30 births each day. We continued to keep busy but without the sensation that many of the women were receiving less than adequate care.
Today is Monday. I arrived on labour ward soon after 7am. 18 babies were born before 12midday. Just 5 midwives reported for duty this morning. We then lost 2 of them to meetings which left 3 of us to cover the ward, admission room and theatre. There are always problems to solve from the night and also things left over from the weekend. Inductions, prolonged labours, fetal distress, referrals, all needing our time and skills. This generally means that the easy ones end up birthing alone, calling out for the midwife as they push their babies out onto the bed. We enter the room just to clamp the cord delivery the placenta and move on. The babies get weighed, later…. if we find time, the documentation is scanty and the after-care often non- existent. I must have delivered more than 10 babies myself but did not have time to take even one blood pressure. In an attempt to avoid un-necessary c/sections I assisted two women with vacuum extractions and successfully delivered a breech on a very young primigravida. The baby needed resuscitating and the mother suturing. The outcome was good for both, but extremely time consuming, meaning that other mothers just had to wait. The midwives seem tired and demotivated today which I always find distressing. We very quickly ran out of delivery packs meaning that for each and every birth I had to search the ward for some way to improvise. The cupboards were almost empty as they had not yet been restocked after the weekend. I could not find any suture material or cord clamps. It was a hard day for me both physically and emotionally.
Last Thursday we had a visit from a team representing the Nursing Council. They came to inspect the ward and the care and attention we are giving to the mothers and babies. The meeting this morning, which I would like to have attended but could not due to shortage of labour ward staff and heavy workload, was to receive the feedback from their visit. Later this afternoon I found time to hear from one of my colleagues the contents of the report. It was highly critical. The infection prevention standards are not being met. The documentation was poor. The care was not up to standard. The midwives had a very defensive attitude. I was angry and disappointed but not surprised. No account was taken of either the huge lack of staff or materials. This report in my opinion served only to decrease an already low morale. So much of my time at Bwaila is spent in raising morale, keeping the atmosphere happy and positive, giving praise for simple tasks done correctly and celebrating good outcomes. I truly believe that although some official appraisal and control of standards is vital it must be done in a realistic and positive way. I wonder how long it will take to get back the enthusiasm at Bwaila?
Just to end on a happier note…..
Fiona has just celebrated her 21st Birthday in Leeds. I was sad not to be able to be with her but will have a special something with her in December when I am in UK.
Katy and Nick’s wedding is getting nearer (Dec.30th) Invitations are being sent and the dress fittings will start soon. It’s all so exciting I can’t wait!
Alasdair is on the lookout for a good job now that he is a fully qualified vet. He was recently interviewed but hasn’t heard yet if he has been successful …….
Lucas is fit and well again after having being diagnosed and treated for Bilharzia. (A nasty little bug picked up in the lake.) He took part in his 1st fishing competition last weekend. He was delighted to win 4th prize.
Sometimes we have to struggle…..sometimes not. The issue is not the struggle: the issue is who we are as we engage in it.