Archive for March, 2011

First Impressions

The night before starting in Bwaila Maternity Hospital in Lilongwe, I met with Rachel Macleod. Rachel is The Rose Project’s representative at the hospital and works as a clinical midwife in the labour ward. Rachel briefed me on what to expect and what would be expected of me. She gave me a background of the hospital, herself and the challenges they are faced with on a daily basis.

I felt daunted but excited to get started and experience Bwaila for myself.

The following morning I made my way to the hospital and was very impressed by the how modern the hospital was, particularly the labour ward having single rooms for women to deliver in.

Unfortunately due to the huge number of women coming through the doors of the hospital, most rooms accommodated two women and their guardians, which meant very tight space and no privacy for the women giving birth.

On my first day in Bwaila I observed Rachel deliver two sets of twins, a breech birth, a stillborn baby, perform Kiwi extractions for the many foetal bradycardias, care for severely eclamptic women and manage a post partum haemorrhage, not to mention the many neonatal resuscitations that she carried out.

By day three I was assisting her with neonatal resuscitation, a cord prolapse, shoulder dystocia, caring for eclamptic women and performing postnatal checks on women prior to being transferred to the postnatal ward.

The staff in Bwaila are constantly faced with emergency situations, there was no time to process any of it, for me all that I could do was swallow it and move on to the next emergency and think about it later.
One of the most distressing realisations I found was that women did not expect to survive childbirth, a harsh reminder of the insurmountable difference between my world and theirs.

I can honestly say that I found Rachel Macleod to be a truly inspiring midwife. Everyday she worked with an intensity that was hard to fathom considering the huge amount of women presenting to the unit on a daily basis. Her energy and enthusiasm for Bwaila was contagious. I was lucky enough to participate in the tutorials Rachel carries out twice a week for staff. These sessions were interactive and involved simulating emergency situations for the Midwives to practice their obstetric emergency skills.
 
Main challenges in the labour ward

Staffing seemed to be a major challenge on the labour ward. Although their seemed to be adequate staff in the morning, motivation and staff morale were evidently low. Staff themselves, were under huge pressure and obviously exhausted, however, this meant that sometimes women weren’t being cared for sufficiently.

Despite Rachel managing to be present in every room in the labour ward, constantly teaching and motivating, she is only one person and when she leaves, there is no one else who will carry on that motivation, ensuring that all women are getting the highest possible standard of care. Hopefully with time, additional staff and the effects of Rachel’s training, Bwaila will have additional enthusiastic motivated and less stressed midwives.

There were two obstetricians who I saw regularly, however they have now been transferred to the tertiary care hospital leaving Bwaila Maternity Hospital without a resident obstetrician.

It is important to remember that Bwaila Maternity Hospital has more annual births than the Rotunda Hospital (where I trained).  In such an acute unit a full time obstetrician/obstetricians are necessary.

I intend to return myself when I have gained further experience, as I have just recently graduated with a higher diploma in midwifery. I think if there is a facility for sending midwives from Ireland to Bwaila for six-month rotations there would be a great interest and uptake from Irish Midwives. I certainly know of several people who would be keen to do this.
 
Advice I would give to others who would like to spend time at this hospital

I would recommend Bwaila maternity Hospital to anyone who has an interest in working in an emergency maternity care setting. It was emotionally and physically challenging but every positive outcome in the labour ward was rewarding. There is a level of pathology that would rarely be seen in the first world and every skill that a midwife has studied is put into practice. I would recommend to others visiting or intending to work in the hospital to spend a few months there. My time there was so short that I found it hard to process when I came home. It wasn’t until giving a presentation on my time in Bwaila to my class, lecturers and staff from the Rotunda that I came to terms with the enormity of what I had experienced within that short space of time. It was a huge privilege for me to be there and I am sure my midwifery career will take me there again in the not so distant future.

Rachel has been working at the hospital for the past three years and was central to setting up the new Rose Project funded Bwaila Maternity Hospital.

I must admit having felt rather apprehensive during the last few days in UK after my yearly Christmas break but I was ready to return to Malawi. 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. So I returned to Bwaila. Having played such a substantial 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 receive a great welcome from my midwife colleagues.

It had been a difficult December. The unit had been without regular medical cover leaving the midwives and clinical officers (a cadre of healthcare worker specific to Malawi. Clinical Officers undertake a four year training) to take full responsibility for the everyday running of what is probably the busiest maternity unit in Southern Africa.

Despite predictions that the work load at Bwaila Maternity 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 to the tertiary hospital. In addition the health centres  are sending their difficult cases directly to EMMW. However, we continue to have 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 in Malawi 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 require supervision and teaching.

I 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, given their overstretched work situation.

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 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, very often 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. We refer to each other constantly which gives strength to the medical and midwifery cover. I truly feel that together the possibilities to effectuate change are more than ever present.