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!
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