clinical supervision

My day starts at 5 a.m. when my alarm rings to through me out of bed. By this time its just starting to dawn and the birds are already busy talking to each other, especially the crows which is not the nicest music. So I get up and turn the water heater on. It takes about 20-30min to heat up the water for my morning bath. While this is happening I prepare myself some breakfast, usually toast with peanut butter and jam and a cup of tea (all Malawi-made of course), fills you up and is quite tasty! I iron my uniform and clean my shoes. Then I start to fill the bath with water. Its not exactly that it comes out in a stream, its more like a little trickle so I start just doing bucket washes which is not so time consuming. A real long bath then in the weekend.. Besides the usual washing procedure I often need to wipe up the water in my bathroom coming from the window and other holes in the wall. During rainy season this never really gets dry so every morning and every evening I find a bigger or smaller pond in my bath. Hello fungus!

Usually by 6:30 I leave the house and walk the 30min along the streets of Mandala (which I found out means “money” in one of the tribes languages, so I basically live in money, fine for me) while the sun has already risen up and making me sweat.
At around 7 a.m. I reach the campus just to find.. usually no one. There is arrangement made with one of the college drivers to pick the students up from their hostel just around the corner at 7 a.m. but reality looks different. First of all the driver has to collect the off campus students, usually clinical officer students or nurse students, but they don’t need to be at the college before 7:30 a.m. so they don’t need to hurry. Even though there is one middle size bus and one minibus available it seems not to be possible to pick up two lots of students in the same time, they say because of the fuel or because usually one of the vehicles is broken or needs to be cleaned or something like that.

So I walk to the hostels to wait for the bus together with the students. On the way there I ask myself why I still come here for 7 a.m. every morning but I convince myself that it’s a good example maybe someone notices. At the hostel is a lot going on. Students leaving or coming back from night shift, having breakfast, playing music, getting ready for work. I stand outside with some of them and chat about last days shift. I think they´re still not quite used to having one of the lectures in their part of campus but they seem to enjoy and ask me a lot of questions about Europe and my work there.

Every single one tells me that he wants to go to work in Europe once. Some are surprised when I tell them that in Germany we don’t speak English, that the official language is German. Hard to believe for someone brought up in Malawi it seems where English is more like an official sign showing you are educated and well off then just a language. Although everyone is proud of their Chichewa and I think they can be!

The bus arrives around 15min past or 20min past 7 a.m. but yet we can not leave (by the way duty starts at 7:30a.m.): the kitchen is not ready preparing the lunch boxes yet. It wasn’t communicated to them that they have to be ready by 7 so we have to wait. I don’t know who is responsible for that but they promised to be ready by 7 tomorrow. So slowly the bus fills up with about 20students, some going to Zingwangwa, some to Limbe, some to Ndirande and some to Mlambe Mission. We also collect the students who are on nights this week (and already waiting for our arrival) so there s not enough space for all. So arrangements have to be made who´s going first and who´s going later, discussions start and all gets a little bit out of control until somehow the students have organized themselves and we can leave. I think to myself we should make a list of everyone who goes first, who gets collected first and who´s second and so on. There should be a list for everything, for the food arrangements, the transport, tick who´s present, tick who´s late and how late, tick, tick, tick. How can you ever get this in order. We stop at the college again, its 7:45 by now. The students need to collect Sobo (an orange squash, they´re entitled to one bottle for 10 students per day) which is kept in one of the lecturer´s office who hasn’t arrived yet. Also gloves need to be collected but its only one box a week and no one kept record who has already collected and how much. Again I wish there was a list, but the person who keeps the gloves in the office doesn’t have a list so I just hand them out, trusting the students and thinking as long as there´re still boxes we should use them. Someone tells me that Mlambe is a special case because it’s a private hospital and they have to get a box per day, as the patients have to pay for that otherwise. Sounds fair to me. We´re waiting for the key of the “sobo-office” after another 10-15min we can finally leave. Note: now its past 8. We start our trip to Zingwangwa where we drop the antenatal students. Yes I was in Zingwangwa for the first placement but it got complaints that there are not enough deliveries for the amount of students who are located there so they have taken the labour ward students from Zingwangwa and split them up into one half going to Limbe now and the other going to Ndirande as these are the more busy hospitals. All 24 students who were on the antenatal ward in Queens now got sent to Zingwangwa, yes 24!

Here ae some pictures from my week with the students in Limbe:

Limbe Health Centre before the madness starts

Maria, Jack and Davie

labour beds

the equipment

the madness aka antenatal clinic

postnatal/antenatal ward

the whole Limbe crew (from left to right: Eunice, Justina, Charles, Maria, Jack, Davie, Patrick. front: me, Simock and Grace)

Anyway. After dropping these 24 in Zingwangwa the bus is nearly empty so we go to Ndirande where I hop off with the 5 students I am supervising in labour ward this day. The poor students on nights are already waiting for now nearly 1 hour to be collected. The bus goes back to the college to pick up the Limbe and Mlambe crew, until the last group reaches their placements it will be almost 9, meaning the night students have been waiting for almost 2 hours and the day shift is almost 2 hours late on duty. Only because there´s not enough transport and if there were there would be not enough money for fuel. So it is just the way it is.

Starting my shift with the students is a bit easier in Ndirande then it was before in Limbe or Zingwangwa. First of all the group is not so big anymore as half of the group is doing nights, second of all they actually have a table and some chairs in the labour ward so it is possible to sit down and have a proper hand over. The official handover has already been given so we have to do a little one for ourselves as the midwives have already vanished. Helpful here is the report book where usually every patient in the ward is written in. So the students get allocated to different clients, the clients who are initially just behind the curtain and could listen to the whole handover if they speak English. So the babies get born and I am busy trying to make the students document everything, not to forget about the vital signs and the importance of 4th stage of labour blablabla. The Malawian women are amazing! Not a peep, not a complaint, absolutely natural they go through this long path of giving birth and often without a scratch on the perineum. I try to teach the students to encourage them in speaking out their concerns or ask if they have any questions but the women are just quiet, they have too much respect it seems. It is easy to take advantage of this power you have as a care giver so this is one of my goals to teach the students that it is possible to work hand in hand with the women. It is so motivating to see one of them just taking the woman´s hand or showing her another position where it´s maybe not so uncomfortable.
Midday we have an hour break, but often we´re too busy to take the full time. I try to introduce the system of relieving each other because someone should stay with the woman but that only works when I am actually around and say who relieves whom it seems.

The Ndirande crew with newly delivered mom (from left to right: Emanuel, Doreen, Thandizani and Nelson) William is taking the picture

By 5p.m. the shift is over but it usually takes up till 6:30 p.m., after dark, until I am home because again we have to wait for the bus and then collect other students. So it’s a long day but when I am home, had my dinner and am off to bed I feel that bit by bit it actually works and little by little we can make it a little bit better. I also learn a lot for myself. Patience first of all but also how strong a woman in labour is, how tough a baby. How to trust your intuitions when you don’t have anything by hand, like a CTG or Doptone, not even a sterile delivery pack sometimes. It doesn’t mean its better but it makes me understand what it actually means to be a midwife. It means to be mid (=with) the wife (=woman). I now can feel almost every position of the baby just by abdominal palpation, can tell the size much better, if its maybe twins and in which position they are, can hear the heart beat with the Pinard and can tell almost by the minute when the baby will be born. I love my job and Africa inspires me!

Reality

The weeks go by like seconds and since the students have arrived I find myself being really busy organizing lectures, marking tests, helping in preparation for their clinical placements. It is really rewarding, I enjoy this new experience of being a teacher.
The students seem to be very eager to learn all about what it means to be a midwife, I am happy to have the opportunity to take a little influence on their view of things, what it means to give focused, patient orientated one to one care, how busy it will make them in the hospital but how rewarding it is in the end when you are in full control of the situation, the patient is trusting you and the delivery can be a special, harmonic and unique experience for all people involved.
I have my focus set on the interpersonal relationship, how important respect and privacy is in any situation in our job even there are a lot of challenges here like lack of staff, equipment, motivation, poor infrastructure, low wages plus working extra hours. It is so hard to work against all that and still have a smile, be friendly, caring, patient, organized. In the books is written how to provide proper care, the hospital is this paradise like place where everyone is happy, no one has pain and everyone is smiling. The theory of things is simple. Documentation and humanity as the key, taking responsibility, following the guidelines and liking your job comes next. And build on this is then the patient focused motivated one to one care everyone is dreaming about. I try not to lose reality when I am talking about all these things. I give examples from how work is like in Europe. The one to one care in Ireland where it is busy but possible is a good example. The more natural, alternative patient orientated midwifery care in Germany with water deliveries, aroma therapy and acupuncture is another. Community midwifery, self employed midwifes, home births, birthing houses all this is possible, safe and a luxury available for everyone. But are we not all complaining in every country, in every hospital? What about individualism, woman friendly, natural deliveries in the active management of Dublin´s hospitals? The high epidural, instrumental delivery and episiotomy rate is alarming. One to one care is provided but only when you are already in labour meaning in reality at least 5 cm and well engaged head, then the waters get broken and delivery is pushing harder and harder and harder! The hard time, the beginning of labour where the cervix starts dilating, the painful, scary, longest period in labour is the time you are on your own with your husband and a gymnastic ball maybe. Is that proper care providing? In Germany it is not so much better; everyone is scared doing something wrong. In the hospital labour is more a medical problem because so many things can go wrong and are unpredictable, unpreventable. It is more individual and alternative but everyone is kind of standing with the back against the wall, fearing if problems arise they´re with one leg already in prison. That makes the section rate rise to one of the highest in Europe and causing a lot of tension between doctors and midwives as the doctors are the ones responsible for anything pathological, a line which is not easy to be drawn in labour where situations can change from being absolutely fine to not good at all within seconds. The midwives should be trained in higher standards so legally the doctors can rely on them better and the midwives on each other. How it is in other countries in Europe I don’t know, I heard Holland is pretty good, Spain pretty bad. However, everywhere are problems, in Africa it is definitely the money, in Germany the legal issues, in Ireland the infrastructure.
So does it make sense to teach these 50 students about all this, all the preventive, high attendance antenatal care with 50 ultrasounds in 40 weeks? The patient focused care, the epidurals, water deliveries, one to one care when the reality looks so totally different and they simply don’t have a choice but caring for 3-4 patients in the same time, not having any proper equipment and doctors and other midwives who just don’t really care. That is so frustrating. But I decided to still let them know how it could be, the good and the bad sides. What is the goal we´re trying to achieve, what are the problems and what can each and every single one of them do to get a little step further bit by bit. Malawi has to find its own way, and this is the new generation! I am happy to be able to have a little influence to help them to look out of the box.

This week then they started their practical placements in different health clinics around Blantyre. I followed 6 of them to Zingwangwa, a poorer part of town with a little health centre. The maternity unit is very small with only 1500 deliveries a year, 3 labour beds in labour ward only separated by curtains and standing so tight together that in between is barely enough room to turn around. Postnatal and antenatal ward is the other room, all in one with 10 beds. So you can imagine what happens in busy days. It is out of control, dangerous, unorganized, and unhygienic. A lot of women get transferred to Queens because in Zingwangwa is no theatre or ultrasound and the only ventouse machine they have is anno 1900 and the resuscitaire is not working. The basic equipment is also a challenge. When we started there was no cotton wool, the delivery packs are incomplete, suturing is done with cord clamps and without local anesthetic because there is none left. Even oxytocin is missing sometimes or gloves. It’s scary! In the whole ward is only one blood pressure machine, 2 fetoscopes of which one is broken and one measurement band to estimate the gestational age by measuring the size of the belly. Women are not sure about when they got pregnant, a lot of them don’t go to their antenatal visits, more than 60% are HIV positive. There is no own ambulance car for the clinic, if there is a post partum hemorrhage or a bradycardia they have to call the ambulance from Queens which takes usually about at least 30 min to arrive if it’s an emergency. If it’s just a prophylactic transfer or for the baby it can take up to 2 hours until it comes. It´s crazy! The women come often in a very late stage usually by foot, they get thrown on the bed, deliver hopefully a healthy, term, and alive baby while they get yelled at and get discharged 2-6 hours later because there is no space. So how to motivate, organize and teach students in a proper way in this situation? This week was tough! The deliveries have to be done by me, because as soon as a lecturer is in the room the staff midwives seem to disappear and skeptically look through the window from the office to labour room and talk in Chichewa probably about what I am doing wrong. The same time every step needs to be explained to the students, meaning every single step while the multip on the bed is delivering her 6th baby with one contraction. Then trying to find all necessary equipment without knowing the ward at all just to find out that it is nonexistent. But by the end of the week at least we found our way around much easier, managed to have a little bit of a structure in the work we were doing and the students got a better idea of how to organize yourself as a midwife in labour ward.

The weekend at Cape McClear was a perfect preparation for this busy week. I took a lot of energy from that even though I had a cold but still enjoyed the beach, the fish and the sunshine.

A few pictures to give you an idea of this little heaven.

Next week I still will be in the clinical placement with the students, I will try to take some pictures sorry I didn’t manage to take some last week. But we will be in placement for 12 weeks now so a lot of stories, pictures and good and bad experiences will be coming.

Enjoy!