the highs and lows

On the labour ward, there is no distinction between high and low risk women, and in any case, the 1000-bed hospital had only two doctors so their assistance was a rarity even when there were obstetric or medical complications.  Given there is a maximum of four free antenatal appointments per pregnancy (for those who can afford to travel the vast distances required from the furthermost reaches of the central districts to reach the clinics that offer them), those with complications – pre-existing or pregnancy-induced – are unlikely to be identified in any meaningful way, and even if they are, there is very little to be done, with diagnostic investigations, equipment, and treatments even scarcer than doctors. What this left the labour ward with was a handful of highly-skilled, vastly knowledgeable, and completely dedicated nurse midwives, who had learnt, borne of necessity, to deal with everything from eclamptic fits to massive obstetric haemorrhage without the input of doctors. Regularly working 36-hour shifts, simply because if they went home there was no one else to see their women through the births, and delivering over 300 babies a month, the five principal staff members were boundlessly impressive, dealing with both normal and complicated labours and births calmly and effectively.

Nkhotakota District Hospital

The shortcomings in staff numbers and the huge numbers treated was a stark surprise; the antenatal ward had 28 beds, 2 midwives, and 127 patients, with numbers in postnatal comparative.  When the beds were all doubled up, women were required to find a spot on the floor, in the corridor, or on particularly busy days, outside.  At least, we’d been told by one young girl, outside meant you could be with your guardian (the next of kin chosen to be with each woman in the post-natal period so that basic nursing care – washing, feeding, changing the sheets – were seen to) through the last month of pregnancy which women were required to spend in hospital as a result of the high maternal and perinatal mortality rates with birth in the hands of the traditional birth attendants, and through the early stages of labour. And it meant you were closer to the well to draw water for drinking, cooking, and washing. This policy had done good, with the maternal mortality rate dropping steadily, and the deaths experienced in Nkhotakota for the most part as a result of women bought to the hospital too late for any help to make a difference, and looking through the ledger of deaths to be audited, with ruptured uterus the leading cause.

Rates of literacy and education are low, and malnutrition, poverty, and infectious diseases high (with a 12% prevalence of HIV, one of the highest in Africa), which means that, despite the month required to spend in hospital before delivery, antenatal care is limited.  For those who had had children previously, particularly the grand multiparas, perhaps one or two appointments were attended, predominantly to secure the free mosquito net they are entitled to. The distances, and the cost of transport, are crippling, so even to attend one appointment puts strain on an already precarious financial situation that many rural Malawians find themselves in.  Even with government funding the ambulances’ supplies of fuel regularly run dangerously low. Women, then, often arrive in established labour present with previously undiagnosed breech, twins, anaemia, severe pre-eclampsia, cephalo-pelvic disproportion, the list goes on.  But, stalwart and resolute, the midwives are there at the doors of the labour ward to treat and care for each woman who passes through, and hopefully, to see them on their way home with their babies in their arms.

The shortcomings are not limited to staff and fuel alone. Supplies of suture materials, sterile gauze, delivery packs, surgical blades (for when the scissors are blunt or simply missing), aprons, all at one time or another dwindle to just a few meagre offerings. So the midwives adapt, and carry on with their job, using blunt dissection and forceps to cut the umbilical cord, and cajoling absorbable sutures from the main theatre (if they have them, that is).

Beds

In the face of such challenges it is hardly surprising, then, to see a marked different in the attitudes towards childbirth in Malawi.  Aside from the lack of birth partner, aside even from the complete absence of any form of pain relief save ambulation and sheer will power, the women it seemed to me, to accept rationally and silently their role in the labour and delivery, crying out only on occasion, and only when their baby’s head is crowning. There seems not to be the same emotional involvement, bearing a child is simply a normal step in life.  With the baby checked over, weighed, and wrapped in chitenje (the ever-present, traditional, multi-colour strips of fabric with uses as multiple as their patterns), they are placed to the breast with no compunction and no concern – the posters outlining UNICEF’s BFI recommendations wholly unnecessary in a country where it goes without saying that babies are breastfed, regularly until two-years, and with no shyness in public places where there is not so much as a second glance in the direction of a feeding baby. The only time formula crossed the threshold of the postnatal ward was in my hands, recently purchased as a result of desperate, difficult roamings through the markets to feed a new-born whose mother had succumbed to hypovolaemia as a result of uterine trauma following the midline caesarean delivery of her baby necessitated by undiagnosed CPD, and, devastatingly for myself and the staff alike who had been by her side for the hours of her labour, and had attended the caesarean section to receive the baby, had passed away. Her death was difficult to comprehend, difficult to move past, not only for the tragedy that engulfed her family and the eight children who survived her, but also because it was wholly avoidable. Whilst hypovolaemia was the registered cause of death, that it was precipitated by the long gaps between post-natal maternal checks as a result of staff and facilities hugely stretched over capacity is undeniable.  But even as we mourned her loss, the baby had to feed. And so, with deep breaths and a swallowed grief, I explained with the help of the midwife as translator (she’d not seen powder used so had little idea what to say) sterilisation and bottle-feeding to a heart-broken sister whose family lived without electricity, boiled water on the open fires that dotted the rural villages, and had barely enough to afford the kilos of maize, cassava, and rice needed to sustain the family, let alone the price of the formula.

That was one of many steep learning curves faced when working with challenges unimaginable to many. Having only recently undertaken a training course on neonatal stabilisation in the UK, I soon became a normal sight in the corner of the main theatre, waiting with linen still damp from the autoclave to receive the babies.  Whilst gestation was widely unknown, calculated on admission in labour using measurements by fingers from the xephisternum rather than “dating scans”, many babies came in to this difficult world bawling and wriggling for all their might, ready to take their chances with an under-5 mortality rate of almost 10%.  For those that didn’t, I became accustomed to using the “penguin” (a small plastic manual suction stored in chlorine to keep it as sterile as possible) to help dislodge mucus and, more often than not, fresh meconium, from lungs struggling for breath, and a bag valve mask for the rescue breathes, made all the more difficult by the lack of masks to fit a baby other than fully term.  The ancient resuscitaires had ceased to work reliably, but the nursery had one with a heater, so it became a normal routine to find a midwife walking swiftly down the corridor with a beautifully, colourfully wrapped baby, hoping the heating was on and the space wasn’t already all taken under it, given at any one time there are likely to be three or more new-borns curled up in a line. There was one oxygen line in maternity, and one oxygen converter in the hospital, donated along with an ancient, cumbersome ultrasound machine by a western hospital.  Still, it was all the hospital had, so they made do. With anywhere between four and six neonatal deaths a month, and about the same again for intra-uterine deaths and stillbirths, it should not have come as a shock that I was to experience both.  And whilst these were difficult and terribly sad, they did not quite have the scale of tragedy with the maternal deaths.  Where the doctors were largely absent from the moment-to-moment clinical running of the wards, the clinical officers took their places, offering what they could in terms of expertise and guidance. The compassion of the staff often broke through the trials of practicing under such circumstances, exemplified for me in one particular case.

A tiny new-born lay struggling for breath on the resuscitaire as I entered with my own colourful bundle needing the help of oxygen and warmth to establish his foothold on life.  I looked to the clinical officer at her head, trying to use an outsized mask to coax the air into her and knocking again and again up against the impossibility of the situation. For every squeeze of the bag, most just slipped around the insufficient seal.  When at last “bala”, “it is finished” was called, the woman next to me let out the long breathe of her own she had been holding, and no doubt willing into her child, and let her head fall dejectedly down, the pose mirrored by the exhausted clinical officer who had been battling for her life. The baby had been born prematurely at 24-weeks, an age where even in the best-equipped hospital it would be a challenge to pull her through, with the clinic she had reported to unable to stop the labour with tocolytics or mature her baby’s lungs with steroids.  She sat and explained that she had known her baby wasn’t ready for life, and had requested to go home hours beforehand so that at least she could die surrounded by her family, but that the midwives and clinical officers had kept her in hospital against her will.  It was a heart-breaking scene, the mother without her child alone in a place she didn’t know, but it was with great tenderness that the clinical officer quietly explained that they had to keep the baby in hospital to give her whatever slim chance she had a life, despite the impossible circumstances.  He also offered her the ambulance to take her home, which, given the scarcity of fuel and that it was one of only two operating in the area, was the most that he could have done to reach across the crevasse of grief.  And now I had the resuscitaire.

Resuscitaire

For every one of these moments of sadness there were many of unbridled joy; the two beautiful, healthy twins, delivery after delivery of perfect little babies, the mother’s mothers smiling and laughing at my attempts at speaking Chichewa, the midwives’ incredulity over the strangeness of the English, and the bonds made in the throes of labour, despite culture and language throwing up barriers.  Lastly, being asked to name a baby after a long labour ending in an emergency caesarean and further surgery to repair the severed uterine artery and damaged bladder, through which I was able to remain alongside was the defining moment of my time in Malawi, and of being a student midwife, demonstrating all the best of the country and all I want to be as a professional.  For anyone offered the chance to work overseas, embrace it.  It will be frustrating, it will be challenging, and it will be difficult, but you will learn more than you could ever imagine and will meet extraordinary people along the way.

Harriet + baby

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