Sunday Morning~ Blantyre
Mnyanga sulemera mwini ~ The tusk is not heavy to the one who wears it.
November 19, 2017
When I was in nursing school, the maternity care in the states was so horrifying to me I couldn’t imagine going into it as a specialty. The whole thing was so medical model that I saw no role for me there. The nurses played nursemaid to the doctors, rooms of screaming women were ignored until they had to push, then they had to transfer to a stretcher, be wheeled through the hallways to the delivery room, and transfer to a table with metal stirrups. Everyone yelled at her not to push until she could be given her spinal anesthesia and be draped with sterile gowns. Then the gowned and masked doctor would walk in, cut an episiotomy, and deliver the baby with forceps. The baby was handed off to the nurse while the doctor delivered the placenta and repaired the episiotomy. It was a big deal when the father was let into the room to stand at his wife’s head (they had to be married) gowned and masked like a surgeon and warned not to touch anything as if it were all radioactive. If it was a boy, the doctor turned from the woman to the baby and circumcised him on a little side table before the mother even got to hold (or see) her baby. The babies all went to the nursery and only went out to the mothers at feeding times. I hated every minute of it and swore I’d never work in there. I planned to have all my children at home. I never even wanted to work in a hospital with the way people were treated there. Dying patients were left alone; no one even talked to them. Nurses had to wear pantyhose and a cap. It was a big deal when we were allowed to wear white pants and a tunic. I hated the hierarchy and how nurses were demeaned. I wanted to be a visiting nurse and go to people’s homes. I had discovered Elizabeth Kübler-Ross and wanted to work with the dying. A blood pressure cuff was the most technology I wanted to use. After graduating and getting married we went off to the Peace Corps and I worked as a public health nurse here in Malawi. It was here that I saw how real natural childbirth could be managed more humanely with skilled midwives. I admired the midwives tremendously and working with them, decided that’s what I wanted to do. I wanted to help change the way we cared for women at home.
So now, here I am, rounding a huge circle to teach midwifery back in Malawi. Lectures started on Monday for the first year students. I’m teaching the same course I taught last year, so am more relaxed about it. I won’t have stressful hours waiting for information to download from the internet; I already have the power point presentations and a clearer idea of what’s expected of me. I can find my way around. This has put me at considerable ease and I was looking forward to getting started. My only anxiety is learning everyone’s names. Just when I think I’m getting them all down, the girls change their hairstyles and throw me all off. I put the hair with a name, like Rhoda=Red Dreadlocks. Then one day Rhoda comes in with a shaved head and I’m like, “Don’t do this to me!”
Monday was the introduction to the module and midwifery. I was there with my colleague, Gaily, with whom I’ll be co-teaching. It’s a long course, fifteen weeks, with loads of content, so two of us share it. Gaily started with the overview of the module, a bit dry, but necessary. She went over how the grades will be calculated and issued and what the learning contract was. Then I started on the introduction to midwifery practice. Last year when I did this I was a nervous wreck and to break some of the ice I asked each of the students to tell us why they chose to go into midwifery. I shared my story about coming here in the Peace Corps and learning how powerful the midwifery role could be and deciding that’s what I wanted to be. Then we went around the room to hear from everyone. Last year the students told stories of being present when their mother or auntie gave birth and admiring the midwife so much they wanted to emulate them, or they spoke in broader terms of wanting to help women or their country have healthier mothers and babies. It was a good launch into the content of the history of the profession and the scope of our practice. It was so successful that this year I thought I’d do the same thing. I told the new class the story of wanting to be a public health nurse when I was in nursing school and wanting to work in global health. I told them I realized that in much of the world, public health IS maternal child health and after my Peace Corps experience I felt I could be more useful if I were a midwife. I thought that was a good lead in. Then I said, “Ok, we’ll start here and go around the room and tell us why you want to be a midwife.” I pointed to the woman in the first row. She said, “I didn’t want to be a midwife. I applied to medical school and didn’t get in.” Ok, bad start. I said, “Ok, well, welcome. Next.” and pointed to the boy behind her. He said, “I didn’t want to be a midwife either. I also applied to medical school. I am disappointed to be here.” This was not going well. I didn’t even respond to that one, I just said, “Next?” That girl said she wanted to be an accountant but her family pushed her to go to midwifery school. The next one wanted to be a teacher but her family thought she would get better pay if she were a midwife. Several said they’d applied to medical school but their grades weren’t good enough. Out of the twenty students, two said that midwifery was their choice. I was scrambling to recover from this little ice-breaker fiasco. Even when you really want to be a midwife it’s hard. No one goes into this for the hours or the pay. I felt like saying, “Okay, well then. You are all screwed.” Instead, I said, “Well, hopefully by the end of this year you will all be grateful that you ended up here.You are the hope for the future and are capable of really making a difference.” That was the last I saw them. The Thursday class with them was cancelled because of a class meeting to discuss student loans. Anyone who hadn’t paid by Friday was kicked out. Hopefully I haven’t lost class members. I’ll find out tomorrow.
The nine fourth year students I have on labor and delivery are terrific. I’m getting more comfortable over on the unit and a few times this week the residents even asked me advice. I’m seeing being assigned there has been a blessing in disguise. It’s hellish, but it’s good for me to get to know people and show I know what I’m doing since that’s where we’re hoping to establish the model ward. On Tuesday I was in the utility room doing a newborn assessment with a student and looked around for something to use to trim the cord. I saw bundles wrapped in chithenjes on a counter and thought they were packs of instruments. When I went over there I saw they were dead babies, labeled with tape, beneath a sign on the wall saying “Please leave still births in the mortuary”. I’m not sure if these babies were waiting to go where they belonged or what, because we weren’t in the mortuary. Seeing them all lined up on this counter was rather shocking though. I have to periodically go back to my office to collect my wits.
Wednesday was my hardest day over there yet. The students are being thrown, head first, into this experience and they are overwhelmed and a little scared. They need to have experience doing vaginal deliveries and the residents need experience doing c-sections. Hundreds of those surgeries aren’t needed and my students feel powerless to advocate for the women or speak up about their assessment of the situation. I’m trying to help with that, but with so many women delivering and bleeding, screaming and seizing, the whole place just looks like chaos. I was with a student as she finished doing a delivery and was trying to control the bleeding postpartum, when I heard a woman scream in the next bed and looked to see the head crowning. I grabbed some gloves and told another student to get ready to do the delivery. She said, “But madam, this baby will be macerated.” I said, “What? This baby is dead? You know this?” She said, “Yes. There is no fetal heart.” I said, “Ok, I’ll do it. You stay with me and watch, though.” So I delivered this little lifeless boy and asked the student to ask the mother if she wanted to hold him. He looked perfect. She said she did, so we placed him on her chest as she began to wail. I told the student that baby has not been dead very long. It looks like the placenta abrupted as a huge clot came out with the baby. The student told me this woman had two seizures when she arrived and was here waiting to go for a c-section. The operating room was full so she had to wait. They’d given her some magnesium sulfate and her seizures stopped, but it probably caused her placenta to separate. Young. First baby. Another bundle for the utility room. At least she did it vaginally. Ugh. It’s hard.
On Friday mornings I have decided to do a skills lab with them where we can practice some skills without someone bleeding to death in front of us. I was never very big on simulation before, but there is something to be said for learning in a controlled environment. It’s nothing like the real thing, but at least we can talk a little about process. I also give them a chance to talk about some difficult cases and go over how it was handled. This is a huge advantage of being close by. When I went out to the district hospitals I never had time for this. So, even though it’s not what I thought I wanted, I’m glad I got assigned here. Something good came out of the bloodsucking violence.
Which leads me to…we got permission to break our curfew this week for Thanksgiving. The other volunteers are allowed to come to our house Thursday for dinner. George and I went shopping for it yesterday and couldn’t find a turkey, but bought four chickens and will make do with those. The mangos are ripening and I’m planning a mango drink with mint and hard cider as an aperitif. Maybe I’ll try one today to test it out. We have thousands of mangos on our tree starting to ripen. Chimemwe pointed to a ripe one at the top yesterday and I asked if we had to wait until it falls? It was at least thirty feet in the air. He laughed, “Ah, no! I can pick it.” and I swear in twenty seconds he was up that tree and back down with the ripe mango in his hand without even disturbing one leaf. He handed it to me, “See? There you are!” I held it up and said, “Chimwemwe, this is why my friends are jealous that I have you.” He laughed and put his shoes back on. He is adorable.
It rained last night and the air is cooler this morning. It actually felt good to get under the blanket last night. It’s been hot and humid and feels like I’m wearing a hot wet sweater all the time. The rainy season is just starting and has been sporadic, but such a relief. Some pale lavender lilies exploded in bloom around our house this week. I hadn’t even known they’d existed but there they were, just quietly, patiently waiting for the rain.
Love to all,