The first Lady visits the new Bwaila Maternity Hospital in Lilongwe the capital of Malawi.
This hospital was funded by The Rose Project and opened in October 2009. In its first year 14,000 babies were born - an increase of 2,000 on 2009 figures. This is attributed to the good care at the hospital which has been a big hit with local people!
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.
Annie Lennox, singer, mother and passionate campaigner on HIV and Aids awareness last week visited Bwaila Maternity Hospital.
Lennox, who was awarded an OBE for her work in raising awareness of the HIV/ Aids pandemic across Africa, made her way to Malawi last week with the Scottish Parliament’s Presiding Officer, Alex Fergusson, at her own expense and is involved in a packed itinerary which also saw her visit Phuti School in Lilongwe, where Scots charity Mary’s Meals operate.
But as she comforts a child in Bwaila Hospital in Lilongwe, Malawi, Annie Lennox shows she is also a mother who understands the need for tender loving care.
A day in the life of our hospital…
I started at 7.15am ,and began by ensuring that the midwife allocation was carried out and that the blackboard with patient data was updated constantly during the day encouraging the charge nurses and students in their responsibilities. Every task or procedure I undertake is carried out whilst constantly teaching.
Yesterday I delivered 2 sets of twins; one complicated and the other not. 2 breech births, one that I was called to assist in emergency with an obstructed head. 3 vacuum extractions. Various prolonged labours. Supervised at least 6 other deliveries with students. Sutured 3 perineum’s whilst teaching clinical officer students. I resuscitated 4 babies, managed 1 PPH (post partum haemorrhage, diagnosed and sent to women to theatre . Managed I severe APH (anti partum haemorrhage) for placenta abruptia with a good outcome for mother and baby. I taught on the morning round consisting of clinical officers and clinical officer students, midwives, midwifery students, interns and doctors. I admitted 4 referral patients with acute pathology.
I finished after 5.30pm, there was no time for breaks. We delivered more than 52 babies in 24 hours! This was a busy day. But then most days are busy.
Rachel
Bwaila Maternity Hospital
The new Bwaila maternity hospital, opened by Mary Robinson in October ’09 is buzzing with activity! The women are enjoying their surroundings and improved clinical care.
The hospital has created energy of its own and other national and international funding organisations are becoming involved to ensure that maternal and infant health becomes a priority in Malawi. The Rose Project, with assistance from UNICEF, is funding a senior midwife- Rachel MacLeod to oversee clinical practice in the labour ward.
Rachel MacLeod, TRP representative at Bwaila with charge nurse Magrete.
We are also funding 20 midwives in partnership with Haukeland University Hospital Norway. These midwives will commence work in January 2011.
Progress at the hospital is being monitored and the data shows that post partum haemorrhage has decreased over the past few months. There is now a concerted effort to address the high level of birth asphyxia at the hospital, with new protocols being implemented and in-service training in the area of resuscitation.
This was my first visit to the new hospital since it opened and it was wonderful to see patients enjoying the facilities. In the old hospital- due to overcrowding- many women experienced dehumanising conditions- frequently being submitted to giving birth onto the stone floor and in some cases unassisted .To all of you who gave so generously a very big thank you from the women attending the hospital!!
The state of old hospital, built in 1939, meant that many women gave birth onto the stone floor.
Lighthouse Clinic
Lighthouse clinic a HIV and AIDS Clinic (opened by The Rose Project in 2006) is next door to the new maternity hospital. The healthcare teams in both the hospital and clinic are working towards co-ordination of services. This is particularly relevant in the area of Prevention of Mother to Child HIV Transmission in pregnancy. 30% of the women attending the new maternity hospital are HIV positive. If a HIV positive expectant mother is placed on treatment at 26 weeks of pregnancy, the risk of HIV transmission to her child is almost eliminated. Mother to Child transmission is the second most common form of HIV transmission in Malawi. It accounts for 30,000 infant being born with the virus each year. Very few of these children celebrate their second birthday.
The Lighthouse clinic is now placing approx. 26 expectant mothers each month on HIV treatment, the majority have been referred from the new maternity hospital’s antenatal clinic. Additional family members of these expectant mothers are included in the service and are checked for HIV - where positive they are treated and followed up . All patients are routinely tested at the maternity hospital’s antenatal clinic - unless they request otherwise.
Rural HIV Counselling and Testing Programme:
The Rose Project, in partnership with Irish Aid, is funding a three-year HIV counselling and Testing programme in the 35 rural district healthcare centres surrounding the capital city, Lilongwe. The programme is being run by Lighthouse Clinic. Training has taken place of 90 healthcare assistants and these assistants have been placed in the district health centres, for the most part this is near their homeplace. They carry out counselling and testing and where individuals are positive refer them to Lighthouse clinic or another Anti Retroviral Centre, nearby. A central part of the programme is Prevention of Mother to Child HIV Transmission. A healthcare assistant carryies out counselling and testing as part of the antenatal services at the health centres. The Ministry of Health is working towards having an anti-retrovial service available at each district health centre, however the acute shortage of doctors and nurses is seriouosly impeding the implementation of this service, and is the greatest challenge to healthcare delivery in Malawi.
Part of the funding includes motorbikes for supervisors to visit the centres as transport to the rural areas is scant and particularly expensive. Also some health centres are up to 100K from the city centre, where Lighthouse clinic is located. Despite the obvious challenges, the training of healthcare assistants has been hugely effective in many areas of healthcare delivery, and is going a long way to bringing vital treatment to many people.
The figures for the first year and a half of this programme are encouraging and Lighthouse Clinic have been quite surprised at how well the programme is progressing, given the obvious challenges. Out of the 35 district Health Centres there is only one centre with a doctor! In some cases there are only 2 qualified nurses . The numbers attending the health centres are huge and the level of sickness - alarming.
Thus far, 147,531 people have been tested through this programme. These people receive extensive counselling on the importance of remaining positive. For most, this is the first ever health visit they have had! 11,261 people have now been treated, which is a great achievement in the 18 months of this outreach. Furthermore, 1628 expectant women were tested and referred onto treatment.
Community Based HIV Programme- with CAFOD
Community Based HIV programme located in Kapiri on the Malawian Zambian border, focuses on Prevention of Mother to Child HIV Transmission in pregnancy. Despite the acute shortage of healthcare workers, the programme is progressing remarkably well principally due to an extraordinary committment from volunteers in the community.
The programme co-ordinator stipulates that all women presenting for their first ante-natal visit must be accompanied by their partner- in a patriarchal society such as Malawi, this is progress!! During this first visit, the couple are tested for HIV (unless they request otherwise.) Should a woman attend the first visit without her partner, she is supported to bring him along for the next visit or a health volunteer will visit him at home.
If positive, the treatment is commenced. In an area where 16% of the population is HIV positive, this programme is vital. I met many couples who had cycled into the healthcare centre- the women on the cross bars- all in great spirits!! A great sense of camaraderie and community prevails at this centre.
If a women tests positive, a community volunteer supports the couple through the pregnancy, ensuring treatment is adhered to and counselling is sought where necessary. When it comes to caring for neighbours- the Malawians are the experts!
John and Charity heading home having attended the antenatal clinic, they were both caunselled about HIV and later agreed to be tested. THis programme is on the Malawian/Zambian Border where HIV is at 16%, one of the highest in the country
If the man tests positive, he is counselled about living safely, ensuring that he does not transmit the virus to his partner.
In addition to the PMTCT programme, The Rose Project provides funding for terminally ill patients to have home-based care. There is a shortage of morphine at the moment and this is creating unnecessary suffering for patients. The Rose Project is looking for ways of resolving this recurring problem.
Before we left Kapiri, a community volunteer brought us to visit a young woman who had given birth at the healthcare centre on 17th February. This woman called Mary had been distressed to discover that she was pregnant. She is HIV positive. Her husband, (now deceased) had been working in the Tobacco fields on the Zambian border and had become infected through prostitution. She has three children already. Mary has been on treatment and the baby will now be tested at 6 weeks. When a HIV positive expectant mother receives treatment during pregnancy, the risk of HIV transmission to the baby is reduced from 56% to 2%. Both mother and family will continue to be helped by Kapiri Community Health centre.
Mary holding her new baby with Agatha Dodo- CAFOD's representative- Mary received treatment during her pregnancy to prevent HIV transmission to her baby.
On 25th February, Founder of The Rose Project, Mary Donohoe was awarded an honorary Fellowship of the Royal College of Surgeons.
Mary also opened the RCSI 29th annual international conference entitled, Integrating Care More Effectively: Unlocking the Potential of Nurses and Midwives, which examined the challenges currently facing the nursing and midwifery professions. The conference was attended by more than 250 nurses and midwives.
The Rose Project in partnership with Irish Aid is funding a three year HIV Counselling and Testing programme in the rural healthcare centres of Lilongwe, the capital of Malawi.
The programme is being implemented by Lighthouse, an AIDS centre built by The Rose Project in 2006 and funded since then.
For many of these people, this is the first ever healthcare visit.
The individuals who are HIV negative, receive counselling and education about remaining negative.
Those who test HIV positive, receive counselling and are treated on site, or referred to a centre for treatment.
5887 tested positive and are receiving treatment
1628 expectant women have tested positive and are now receiving treatment to prevent HIV transmission to their babies.
575 were referred for TB treatment.
Our Winter Lunch, being held on Friday 5th February in The Royal Irish Yacht Club, Dun Laoghaire, is fast approaching! Due to great demand, only 20 seats remain available! So, in order to book your place for one or more of the remaining seats, please contact Deirdre Naughton on 01 4969131 as soon as you can. This lunch kick starts the fundraising activities of The Rose Project in 2010 and promises to be a very entertaining and enjoyable afternoon.
(Seats are €100 including mulled wine reception and wine with lunch. Reception at 12.30 for Lunch at 1 p.m.)
We would be delighted to see both new and familiar faces there. So if you would like to support the work of The Rose Project by attending, please contact Deirdre in The Rose Project Offices on 01-4969131 or email deirdre.naughton@roseproject.org
On the eve of World AIDS Day, the World Health Organization (WHO) is releasing new recommendations on treatment, prevention and infant feeding in the context of HIV, based on the latest scientific evidence.
WHO now recommends earlier initiation of antiretroviral therapy (ART) for adults and adolescents, the delivery of more patient-friendly antiretroviral drugs (ARVs), and prolonged use of ARVs to reduce the risk of mother-to-child transmission of HIV. For the first time, WHO recommends that HIV-positive mothers or their infants take ARVs while breastfeeding to prevent HIV transmission.
“These new recommendations are based on the most up to date, available data,” said Dr Hiroki Nakatani, Assistant Director General for HIV/AIDS, TB, Malaria and Neglected Tropical Diseases at the World Health Organization. “Their widespread adoption will enable many more people in high-burden areas to live longer and healthier lives.”
An estimated 33.4 million people are living with HIV, and there are some 2.7 million new infections each year. Globally, AIDS is the leading cause of mortality among women of reproductive age.
New treatment recommendations
In 2006, WHO recommended that all patients start ART when their CD4 count (a measure of immune system strength) falls to 200 cells/mm3 or lower, at which point they typically show symptoms of HIV disease. Since then, studies and trials have clearly demonstrated that starting ART earlier reduces rates of death and disease. WHO is now recommending that ART be initiated at a higher CD4 threshold of 350 cells/mm3 for all HIV-positive patients, including pregnant women, regardless of symptoms.
WHO also recommends that countries phase out the use of Stavudine, or d4T, because of its long-term, irreversible side-effects. Stavudine is still widely used in first-line therapy in developing countries due to its low cost and widespread availability. Zidovudine (AZT) or Tenofovir (TDF) are recommended as less toxic and equally effective alternatives.
The 2009 recommendations outline an expanded role for laboratory monitoring to improve the quality of HIV treatment and care. They recommend greater access to CD4 testing and the use of viral load monitoring when necessary. However, access to ART must not be denied if these monitoring tests are not available.
Preventing mother-to-child transmission and improving child survival
In 2006, WHO recommended that ARVs be provided to HIV-positive pregnant women in the third trimester (beginning at 28 weeks) to prevent mother-to-child transmission of HIV. At the time, there was insufficient evidence on the protective effect of ARVs during breastfeeding. Since then, several clinical trials have shown the efficacy of ARVs in preventing transmission to the infant while breastfeeding. The 2009 recommendations promote the use of ARVs earlier in pregnancy, starting at 14 weeks and continuing through the end of the breastfeeding period.
WHO now recommends that breastfeeding continue until the infant is 12 months of age, provided the HIV-positive mother or baby is taking ARVs during that period. This will reduce the risk of HIV transmission and improve the infant’s chance of survival.
“In the new recommendations, we are sending a clear message that breastfeeding is a good option for every baby, even those with HIV-positive mothers, when they have access to ARVs,” said Daisy Mafubelu, WHO’s Assistant Director General for Family and Community Health.
National health authorities are encouraged by WHO to identify the most appropriate infant feeding practice (either breastfeeding with ARVs or the use of infant formula) for their communities. The selected practice should then be promoted as the single standard of care.
Benefits and challenges
An earlier start to antiretroviral treatment boosts the immune system and reduces the risks of HIV-related death and disease. It also lowers the risk of HIV and TB transmission.
The new prevention of mother to child transmission (PMTCT) recommendations have the potential to reduce mother-to-child HIV transmission risk to 5% or lower. Combined with improved infant feeding practices, the recommendations can help to improve child survival.
The main challenge lies in increasing the availability of treatment in resource-limited countries. The expansion of ART and PMTCT services is currently hindered by weak infrastructure, limited human and financial resources, and poor integration of HIV-specific interventions within broader maternal and child health services.
The recommendations, if adopted, will result in a greater number of people needing treatment. The associated costs of earlier treatment may be offset by decreased hospital costs, increased productivity due to fewer sick days, fewer children orphaned by AIDS and a drop in HIV infections.
Another challenge lies in encouraging more people to receive voluntary HIV testing and counselling before they have symptoms. Currently, many HIV-positive people are waiting too long to seek treatment, usually when their CD4 count falls below 200 cells/mm3. However, the benefits of earlier treatment may also encourage more people to undergo HIV testing and counselling and learn their HIV status.
WHO, in collaboration with key partners, will provide technical support to countries to adapt, adopt and implement the revised guidelines. Implemented at a wide scale, WHO’s new recommendations will improve the health of people living with HIV, reduce the number of new HIV infections and save lives.
Malawi mums need support
Mary Donohoe warns that when we recruit healthcare providers to Ireland from developing countries where shortages exist, we cause deaths
The Rose Project is an Irish non-governmental organisation, founded in 2003 by former nurse Mary Donohoe. The organisation has raised significant sums of money and supports locally led healthcare programmes in Malawi.
Malawi is a landlocked country in southern Africa and ranks among the most densely populated and least developed countries in the world. With the majority of people living on less than $2 a day, life is a challenge.
Travelling around the capital city of Lilongwe and its rural surroundings, one is struck by the sinister poverty, with lack of healthcare being a major contributing factor.
HIV positive
According to official figures, 15 per cent of the population is HIV positive; however speaking with hospital staff and healthcare professionals generally, it is estimated to be considerably higher in urban areas.
Prior to the advent of HIV, the healthcare system in Malawi was severely challenged; with its arrival, it has been brought to its knees. Efforts to increase access to healthcare and to maintain and improve the quality of care are being severely hampered, due to the acute shortage of health workers and appalling conditions in the hospitals and health centres.
In relation to healthcare workers, the situation is at crisis level, with only one doctor per 100,000 people and 56 nurses. Nowhere is this more evident than in the area of maternal and infant mortality.
Malawi has the highest rate of maternal mortality for a non-conflict country, with one in 14 women losing their life in childbirth. The country also has one of the highest levels of vertical HIV transmission in Africa, resulting in 30,000 babies being born HIV positive each year. Few of these infants reach their second birthday.
To exacerbate the above, Malawi has one of lowest ratios of healthcare professional per patient in east Africa. The Rose Project is addressing all three problems.
Last month, Dr Mary Robinson and the Vice President of Malawi, Ms Joyce Banda, opened a new maternity hospital in Lilongwe on behalf of the Rose Project. This hospital replaces a shed-like building which was constructed in 1939 to facilitate 4,000 annual deliveries.
There are now 12,000 annual deliveries. Many of the women at the old hospital delivered their infants onto stone floors due to overcrowding and unassisted due to lack of staff. In addition, 25 per cent of the expectant women are HIV positive, many with AIDS. This places enormous pressures on existing services.
State-of-the-art facility
While the new hospital is a state-of-the-art facility and the first of its kind in Africa to afford each couple a private room for the birth of their baby, it still has only has only one resident obstetrician and three qualified midwives for 12,000 annual births. To place this in context, the National Maternity Hospital in Dublin has 9,000 annual deliveries with 18 obstetricians and 138 midwives. The challenge is enormous.
Thirty thousand infants are born HIV positive in Malawi each year. This is preventable, however the greatest challenge is the shortage of healthcare workers to implement the necessary initiatives.
In 2006, the Rose Project funded the Lighthouse AIDS Clinic in the centre of Lilongwe. Prevention of HIV transmission from mother to child has been central to the care provided at this facility.
Co-funded by Irish Aid
In 2008, in an effort to bring PMTCT (preventing-mother-to-child transmission) to the rural areas The Rose Project awarded a three-year grant to Lighthouse Clinic. To date, the clinic has successfully implemented PMTCT at 30 of the 40 healthcare centres. This programme, which is being co-funded by Irish Aid, is working well but has serious challenges due to the shortage of healthcare workers at the centres.
Finally, many healthcare workers are themselves unwell having been infected in the workplace with TB/HIV or succumbed to the virus themselves. These individuals need to be cared for in a confidential and safe environment.
Wellness centres for healthcare workers are an initiative of the International Council of Nurses in Geneva and have been proven most successful in halting the attrition rate of healthcare workers in Lesotho and Swaziland, where they have been in operation for some time.
Critical shortage
Last month the Rose Project funded a new Wellness Centre in Lilongwe, which was opened by the Vice President of Malawi. Undoubtedly, the principal challenge to safe motherhood in Malawi is the critical shortage of healthcare professionals.
Africa has 25 per cent of the global disease burden with only 2 per cent of the global workforce. No one denies that developing countries, including Malawi, need to take the lead in providing solutions to this acute shortage of healthcare workers.
Despite limited resources, the Malawian government is attempting to do this; however given the huge level of illness created by the AIDS pandemic, they are keen for international support.
Ireland has one of the most highly skilled medical and nursing workforces in the world. According to UNICEF’s latest figures, Ireland is the safest place in the world to have a baby. Given this remarkable achievement, surely there is a great opportunity and an urgent need for individuals, medical and nursing institutions to become involved in what is now acknowledged to be one of the greatest tragedies of our time — the level of maternal and infant mortality in the developing world.
As a country we have benefited and continue to benefit from foreign healthcare workers, in some cases to the detriment of local healthcare systems. How much of this recruitment is ethical is questionable.
Everyone has a right to access the global labour market; however it is important to remember that few of these workers wish to leave their families and countries. They do so out of need. This need often fills gaps in healthcare systems in rich countries where investment in training has been insufficient.
We need to understand that the recruitment of healthcare workers from developing countries, where critical shortages already exist, is causing deaths. If recruitment must continue, it should be carried out in a fair and equitable manner in consultation with local governments; after all, for the most part they are funding the undergraduate training.
The Rose Project
Over the past 6 years the Rose Project has funded 28 HIV-related programmes in six east African countries, reaching approximately 200,000 people with treatment and care, including five new healthcare centres, medical/nursing training and salaries, large scale prevention programmes, nutrition, drugs and transport.
Mary Donohoe trained as a nurse in Saint Vincent’s University Hospital Dublin and is a governor of the National Maternity Hospital Dublin
For further information please visit: www.roseproject.org
