August 28, 2016
Sunday morning in Blantyre
Whew, what a week. I spent my first week in labor and delivery and came home Monday evening in a state of distress unlike any I’d experienced so far. I thought maybe I should write about it right away, but wasn’t even able to do that. I left the hospital that afternoon, staggering past the market, looking at the ground, muttering “Oh my God.” I’m going to have to dig deep here to get through the weeks of orientation. I thought a few days would give me some perspective so wanted to wait until today to write. I slept great last night despite the blaring music from the bottle store down the path, and will try to do a good job of describing my week with a little more perspective than I had that day.
The mornings start at 7:30 with a morning report. The hospital is so big, that the reports are done by departments, so our’s is just maternity. This includes: antepartum, gynecology, postpartum, labor and delivery, obstetrical surgery, and neonatal intensive care nursery. The night midwife gives a report of all that transpired on the ward for the past twenty-four hours. It’s done in English, but when there is a heated discussion, they almost always revert to Chichewa. A few times the matron has reminded them that I’m in the room and please speak in English. I have to concentrate to understand the English; I don’t know how I ever did this in French. The reports consist of the numbers of admissions, discharges, births, deaths, and those that “absconded”. Then there is a description of the problem cases. The incidence of deaths are always described in detail, or what detail they have. Often the case is a bit lacking in detail, like cause of death. The matron is a conscientious, brilliant woman, with a gentle demeanor. I’m so impressed with her investigative questions that are non-threatening, but shows what a deep level of critical thinking she possesses. She doesn’t miss a trick. The nurse-midwives have so much to deal with. The sheer volume of what they do in an ordinary shift is mind boggling to me. I watch them, completely non-plussed, glide through their days, dealing with one problem after another, in a manner that must have evolved from deep survival mechanisms.
After report on Monday I went with the midwife in charge to get oriented. She had no time for this, but she was very polite and showed me around the ward (which I’d seen on my original tour and almost fainted) and gave me a brief description of what happens where. I saw the “Recovery Room” had six broken beds with torn mattresses and a few women were sitting there with their babies. I asked the midwife how long they are kept in this room? She told me they have to wait until there are six women to take them over to postpartum. The volume is so high, they can’t take them one at a time, so they are held in this room until it is full, then they are brought over in a group. So it can vary from ten minutes to eight hours in there.
I was told there were eight midwives on the day shift, which is 7:30 to 4:30, and six on the night shift, 4:30 p.m. to 7:30 a.m. Whew. That’s a long shift. But often they have only five or six during the day and as few as three at night, for 50 to 60 deliveries. The place however, was swarming with people, all looking like care-givers. I learned these were all nursing students, twenty-four of them from three different nursing schools, all working in roles that would be a high-level labor nurse position at home. They looked to me like they were doing all the care. So even though there are twenty-eight bays with a bed and laboring woman at one time, and five or six midwives, there is usually a one-on-one student with the woman. This was heartening. But the students are completely unsupervised. In fact, at the nursing school where I’ll be teaching, there is only one clinical instructor for 250 students in midwifery. I’ll be number two. But many of the students were already nurses and were coming back to school to get certified in midwifery, and they were really good. They were doing all the assessments and the deliveries completely independently. One of them told me it’s the way the government gets free labor.
Ok, I know that the first day is the hardest in an unfamiliar environment. I know that I will adjust, and by Thursday, I wouldn’t call it adjusted, but was more resigned to the conditions. Only a few of the sinks have water. Some of them have clogged drains with standing, bloody water in them. I saw one maintenance person scooping it out with a cup, and gagged. The beds have no sheets. The women put down one of their chithejes, the cloth they use for skirts, luggage, child carrying, sanitary pads, dish cloths, towels, blankets, shawls, EVERYTHING. This cloth is used for everything. There are thousands of colorful patterns and the newborns are often identified by which chithenje they’re wrapped in. The women are asked to bring at least six chithenjes, a plastic basin, and a guardian. The guardian is paramount; they do a lot. It’s always another woman: mother, mother-in-law, aunt, sister, someone. God bless those guardians.
After a woman is assessed in the little room by the door to the ward, she’s given a status according to priority. Those in very active labor go straight into the labor and delivery room with the twenty-seven other women, and others, not so active, sit on a bench and wait. For hours. Sometimes they get sent to one of the clinics if appropriate. The screening process is pretty good from what I observed. There were three students doing the assessments and one midwife supervising. I spent most of the first morning putting my eyeballs back in their sockets.
At one point a maintenance person opened the door and said there’d been a delivery in an ambulance. A woman being transported from an outlying clinic had delivered on the way by another patient in the ambulance. A student ran down to the parking lot and delivered the placenta, which she hand-carried, wrapped in a chithenje (of course) to the red bucket in the ward, designated for “placentas only”. (I saw a ton of other shit in there, though.) It’s a long walk to carry a dripping placenta. This woman got priority seating in the labor room, just in time for her postpartum hemmorhage. Blood everywhere. But it was handled quickly and efficiently and I was impressed. The students and midwife got the bleeding controlled, an IV in, pitocin given, and the blood sopped up, within a matter of minutes. (I know this because I spent so much of my week watching the clock. I can’t count how many times I said to myself, “it’s only been a half hour?!”) I will say, though, the charting is extremely simple. I can see why they have time to take care of so many women. The charting is done on scraps of paper tied together with a piece of gauze. Someone in the admission room punches two holes in the paper and threads a string of gauze which has been cut into a strip, through the holes, a little like our fourth grade book reports. Only our reports had nice construction paper on top. These do not. Anyone walking by can write what they want on the scraps of paper, such as a medical student creating a plan of care for a woman he saw for ten seconds. Then the latest plan gets more or less followed. The plans, as far as I could tell, were not consistent with the current status of the women, but based on some diagnosis previously recorded. (Eyeballs back in.) The part I liked about it though, was, no one was looking at a computer. Or a monitor. There are a few dopplers for fetal heart tones, and they are used appropriately, and shared well among the staff, but no fetal monitor.
At noon that day I came home for lunch, not that I had a big appetite, but I felt like I needed to eat something in order to be able to go back for the afternoon. When I got back over there at 1:30, a few of the midwives were sitting in their break room eating their lunch. There is a table to eat at and a side table with a microwave on it. Next to the microwave is a large hole burned in the table. Under the hole, on the floor, is a blackened electric burner, which, I assumed, caused the hole in the table. Since the midwives can’t leave the hospital at lunchtime, their food is brought to them, either by the hospital kitchen, or a friend. As I was sitting and chatting with the ones that were still eating, a large rat ran out of the adjoining room, through the eating area, out into the hallway, and headed down toward the labor room. I gasped (I did not scream) and came off the chair about two feet into the air. Not one of the other midwives budged. Not one bite of their lunch was disturbed by this sight. The midwife across from me popped a bite of nsima into her mouth and said, “That was a big one.” When I got back into my seat, I said with a hint of alarm, “You have rats in here?” Again, not missing a bite, the midwife in charge said, “Yes. They go for the placentas.” They giggled a bit at my reaction, and kept eating.
It was a disturbing afternoon and the rat was only the smallest part of it. I need to adjust and be patient with this hierarchical system. It disturbs me that the midwives, (and students, for that matter) are completely ignored when the medical students and residents are doing rounds. At about 3 p.m., a herd of twelve white-coated people at various stages of training, went from one bed to another discussing the woman’s case as if she were a mannequin. She is not addressed except to be told to lie down, roll over, spread her legs, or be quiet. She is examined, with unnecessary roughness, or just unnecessarily, for learning purposes. One after the other. It was like watching a gang rape. I looked around to see what the midwives would do about this, and the answer was, nothing. Everyone turns away. I was ill. I was shaking. The woman who’d had the hemorrhage was examined one after the other while screaming and trying to get off the bed. I could not figure one reason why she’d need to be examined. I asked one of the midwives why they were doing this and she just shook her head. I left the ward and staggered home, fighting tears. Poor George had had a good day. He’d started the six week psychiatric module at the medical school and was excited about it. He took one look at my face and realized my day wasn’t so great. He listened as I vented, for which I was grateful. I kept saying, “I’ve got to toughen up. I see now the huge difference between the MSF hospital in Shamwana and this. There, we were the boss. We set the standards. We determined the protocols. I’m a stranger in a strange land here. I have no say.” That said, I do see how teaching students can make a difference down the road. It may be a thousand miles down, but I see how we can eventually make a difference. I do believe in this program. It will take time.
Tuesday was better. At least I wasn’t blindsided by the behavior and I didn’t see any rats. (I also realized we didn’t see those in Shamwana because the people had eaten them all.) On that day I stayed with one particular student from the school where I’ll be teaching. She was great, incredibly knowledgable and professional. She gave me great hope for the future. She will be graduating in October and carried herself as though she’d been a midwife for years. She was taking care of a woman who’d transferred in from a health center for failure to progress. She’d been 8 cm for several hours and it was thought she’d need a c-section. I said before that the c-section rate is very high here and the decision making process is incredibly vague. Women aren’t given more than an hour to push before they declare it CPD (cephalo-pelvic disproportion). This is preposterous! They do repeat c-sections on everyone who has a previous scar. I should reserve judgement about this because they don’t have a way of monitoring women in labor for signs of rupture, but it just seems insane. The babies are very small. I have a hard time believing they won’t fit. The woman we were caring for was having her second baby and had no apparent problems and the first birth was normal. She’d been in labor for more than a day and hadn’t eaten anything. She did progress to fully dilated but had no energy to push, so when the medical students and residents came through and examined her (horribly) they declared it wouldn’t fit and she should get in line for a c-section. The student went and bought her a thick drink made from maize flour and the woman devoured it instantly. I thought, hmmm, our anesthetists would go ape shit over that right before surgery, but at that time I hadn’t realized that she had to wait hours before her surgery. There was a line in front of her. In fact, she had to wait so long, she ended up delivering vaginally. I happened to still be there when she was delivered by a male midwifery student who was wonderful. He did a beautiful delivery. I was so relieved.
Next day a woman was admitted in labor but she’d had a previous c-section and was to have a repeat. She was moved to the front of the line. But the attending was busy with a woman who had acute onset of psychosis and was screaming and had gotten violent. They had her tied hands and feet to the bed. She was seven months pregnant and screaming and writhing so much they couldn’t get a lumbar puncture done, though, God knows, they tried. That was not a pleasant scene. While that was going on in one cubicle, the woman waiting for the c-section started delivering. I was ecstatic! But as the head was crowning, someone decided it wasn’t coming fast enough and she should still have the surgery. I said quietly, “But we can see the head!” Didn’t matter. She was left alone to wait for the OR. I looked in her face and said, “You can do this. Push.” She didn’t speak English so had no idea what I said. I took her hand and let her feel the baby’s head. “Mwana mutu”, I said. (Baby head. I remembered that much from language class.) Her eyes opened wide and she pushed and it really crowned. Then the medical student, who was the only one around at the time, reluctantly opened up the delivery pack, saying she shouldn’t be pushing because she is going for surgery. I held the woman’s head, saying, “You can do this!” She got my drift. By this time a few other students were there as well as a midwife. A resident opened the curtain more, looked and said, “Well, ok. I guess she’s going to deliver.” And threw a few more medical students in to watch. At one point, the patient reached down again to feel the baby’s head and everyone screamed at her not to touch! She pulled her had away like she’d done something terrible. Opps. I guess I wasn’t supposed to have her do that. I looked at her and said, “Opps. Pepani.” (Sorry) She delivered vaginally, though, so I considered that day a success. It had nothing to do with me; I’m not taking credit. She would have delivered while waiting, but it made me feel better to have been there. And later on I walked by her bed and she motioned for me to come closer. She took my hands and said, “Zikomo, zikomo kwambili.” (Thank you, thank you very much.) It was a bright point.
Good god that place is hard.
Thursday, an HIV positive woman with pneumonia delivered at a health center, prematurely, while waiting for an ambulance that had no fuel. They tied the tiny baby to her and she finally made it to our hospital, very sick. I took the baby, who weighed less than 2 pounds, wrapped him, and brought him to the intensive care nursery. I was told to place him in a warmer that had two other babies in it. The nurse came over and asked me if he was labeled. I said, I didn’t know. I was just asked to carry him here.” She wrote the mother’s name on a bandaid and taped it to his arm. “Don’t worry. I did it.”, she said.
Friday I spent the day in the HDU, the high dependency unit, or what we’d call the ICU. It was a lovely day. There were three patients: the one who’d gotten psychotic was there and she was calm and sleeping most of the time. They treated her for malaria and spinal meningitis because they couldn’t tell what was wrong, and she started getting better. Wow. The one with pneumonia was also there. I heard her baby was still alive and her guardian spent the day pumping her breasts for colostrum. She gently did this for hours. I was overwhelmed. The third woman was sectioned for pre-eclampsia at 31 weeks. I was floored that they’d do surgery for a premature baby. When the resident rounded on her I asked if they ever consider an induction instead of going right to surgery? I know that women have seizures here because their blood pressure gets so out of control and they need to deliver, but it seems they’d try an induction first and not condemn her to life-risking surgery again. She told me, yes, they sometimes do inductions, but that was the end of the conversation. I didn’t ask anything else. They are faced with hard decisions every waking minute. The women are really sick and there are so many of them….
Ok, enough of that.
Last Sunday afternoon we went on a fabulous, really hard hike. There are several mountains surrounding Blantyre, and one of our volunteers, Polly, organized this hike with her partner Karl. They’ve done it several times and they are in great shape and half my age. It was brutal. I was drenched in sweat and at one point, thought I wouldn’t make it to the top. I don’t admit easily I can’t make it, so this was serious. I told them to go ahead and I’d go at my own pace. I finally did make it and it was so worth it, but it was steep and hard. Karl said, “The Malawians have twelve different words for “mud”, but none for “switchback”.” It was straight up. On the way down there were a group of three baboons sitting in the trees. They turned their backs to us, but I was a little nervous there. My legs were not able to carry me if I had to run. Then I couldn’t remember if you were supposed to run or not if they came toward you. I think I remember someone saying not to look them in the eye, but I was nearly delirious by then. My legs are still sore from that hike a week later. The baboons ignored us.
The power is going off more and more frequently. We only have it about half the time now and never know when that will be. George got a propane burner so we can cook without power. That’s been very nice. We’ve had to use it several times this week. We also got two big buckets at the market yesterday for storing water. So far we haven’t lost water, but as the dry season goes on, that might happen. I pray the rains are good this year. At the market yesterday I also found a basil plant, a rosemary plant, and a parsley plant. I have high hopes for an herb garden.
We have a gardener, employed by the college of medicine and I asked him if he could make vegetable beds. He readily agreed and made three nice beds out back. He said he could get some seeds if I gave him money, and Thursday I gave him money and a list of the seeds I wanted. That was a mistake. Thursday afternoon he was shit-faced drunk and he hasn’t been back since. I saw him on the road yesterday (appearing sober) and asked him where my seeds were. He said he’ll have them Monday. We’ll see.
I’ll post this and cook while we have power. Then out for a walk. We spent three fabulous hours at mass this morning. Well, maybe two fabulous and one a little tiresome. The music is so fantastic, though. The singing comes straight from the soul. I love it.
Have a good week, all.