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Where to start? This will be difficult to put into meaningful words. Our stint at Mangochi Hospital really was an experience of a lifetime, on reflection a priviledge that I didn't fully appreciate at the time. For me the words to describe the experience include mind-blowing, interesting, sad (80%), happy (20%), frustrating, humbling, desperate, poor, unbelievable, smelly, chaotic, beuracratic, mechanical, unfair, ancient and welcoming. Hopefully my choice of words will be explanatory throughout this blog.
Mangochi is the sixth largest town in Malawi, with a population currently estimated at 55,000. The hospital serves Mangochi town and the surrounding rural areas of thousands more people who a huge variety of health needs. The population is essentially very poor by Western standards, with people not thinking twice about walking miles to access healthcare which would be categorised as second or even third class in the UK. Facilities there are basic, equipment is lacking or in poor working order and common resources are limited. Alarmingly some staff in the hospital demonstrated an outward complacency about their roles and responsibilities and emphasis was placed on families to care for and support their sick relatives on the wards.
However we met possibly the most
motivated, capable and knowledgeable student nurses I have ever come across, who were proud to be in training and obviously dedicated to their chosen profession. Five 2nd students were working on their obstetric placement during our time at the hospital. Their general level of communication was excellent and no one would have guessed they were yet to successfully qualify as nurses or midwives. The training programme in Malawi allowed students to opt for a combined nurse/midwifery qualification at diploma level. This is what the students we met were working towards and I am confident that all 5 will be successful. Another thing to note was how proud they all were of their training and this was not only reflected in their professionalism and obvious committment but also in the way they presented themselves - their uniforms were pristine and spotless, a real achievement to say the clothes were most probably washed by hand in Lake Malawi!
During our stint at the hospital the students single-handedly ran the incredibly busy daily antenatal and postnatal clinics each morning in which they were unsupervised and left to their own devices.They competently carried out antenatal assessments, listening in with old pinnard stethoscopes and
palpating women confidently, using a sewing tape to measure fundal height and assist in the calculation of the woman's expected date of delivery.
Alarmingly for us the students also diagnosed intra-uterine death based solely on them not hearing a fetal heart via the pinnard stethoscope, and they were responsible for communicating with the woman before she was directed to the scanning department to confirm the potential diagnosis. The students informed us that they had only diagnosed one fetal death in the previous fortnight but that they were aware it was a relatively common occurrance in Malawi.
The neonatal mortality rate (probability of dying between birth and 28 days of age) in Malawi is approximately 30 babies per 1,000 live births. This compares to about 3 babies per 1000 in the UK. The infant mortality rate (probability of dying between birth and one year of age) is approximately 80 infants per 1000 live births compared to about 5 in the UK. Baby and infant death rates in Malawi are among the world’s highest with the deadliest threats being malaria, diarrhoea, acute respiratory infections and nutritional deficiencies.
On our first day at the hospital we were shown around by
the Chief Nurse, an incredibly young, attractivce and very slender lady who again looked immaculate in her uniform. She took us around most of the wards and showed us various departments including one for infectious diseases which we later found out consisted mainly of patients with TB. The hospital had the usual departments, including paediatrics, obstetrics, male and female wards, x-ray, pharmacy and an exceptionally busy out-patient department.
All admissions to the hospital came via the OPD in the same way an A&E department works in the UK. During the day this room was constantly bulging with all age-groups of sick and injured patients. If it was considered necessary to admit the patient they would then to sent to another queue to be quickly assessed by a doctor (who worked alone) and who may be expected to see more than 100 patients himself. He was also responsible for prescribing medication for those who didn't need admitting and when we sat in on one of his morning sessions he was using his mobile phone to calculate drug dosages because he didn't have his own calculator. Fortunately we had been provided with one from home and were able to give this
to the doctor to make things slightly easier for him.
We were made to feel welcome in all of the wards and on our first day we worked on the postnatal ward. The midwives were very friendly and were again dressed very smartly in white dresses with little frilly caps. However, their work ethic was not the same as what we are used to, and their actual patient contact was minimal. The daily schedule was almost mechanical, with routines taking place like clockwork in an orderly fashion. We were allowed to undertake basic procedures without being assessed and soon became familiar with the ward BP machine and shared thermometer.
All newborns had a very basic first-day/discharge check which consisted of them being weighed, having their axilla temperature taken, observation of the state of the umbilcal cord, the number of digits the baby had and whether he had wee'd and poo'd. There was no stethoscope to listen to the heart, no hip examination, no oral check and no ophthalmoscope to visualise the eyes. No surprise that the examiner was one of the 2nd year studets and very quickly became me and Clare.
The postnatal ward was probably the
mot chaotic place I have ever worked in. It was exceptionally busy and full to capacity with newly-delivered women and their babies. Women sat on the floor with their babies laid next to them as there were no cots and no seats. There was a distinctive stench in the ward which we agreed was a bad mixture of stale blood, sweat, urine and faeces. It was probably the worst smell I have ever experienced and made both Clare and I feel physically sick after a very short period of time.
I had a small camera with me on the postnatal ward and I got permission from a midwife to take photos of the surroundings. I also asked some of the mums if I could photograph their babies and they were delighted to see their baby's picture on the camera.
I approached a young mum who had twins laid on a bed at the end of the ward. They were well-wrapped and I asked her through basic sign language if I could take a photo of her new babies. She nodded and I slightly loosened the blanket that they were wrapped in. To my surprise one of the babies
was very pale and appeared to be gasping for breath. I looked at the mum and she did a cross sign with her two index fingers to indicate to me that she thought the twin had passed away. I looked at Clare and quickly picked the baby up and carried him to the midwives' office informing the staff there that I thought the baby was very ill. They were almost as surprised as I was and one of them told me and Clare to follow her with the baby.
We went into the room where we had done the first day checks earlier and put the twin in the cot. There was an incubator in the room and Clare went to switch it on, however it wouldn't switch on simply because there was no power supply lead. We suggested the baby had oxygen and whilst there was piped oxygen in the room there was no tubing to attach to the baby. The baby was gasping and was very pale so the midwife decided to take him to the paediatric ward for oxygen. I carried him there and Clare fetched mum so she could accompany her baby to the ward.
The baby was put in a cot in the paediatric high dependency bay which already had two paediatric patients in beds. Both of them seemed to be very ill but neither of them were monitored and no staff were in the bay. Oxygen was commenced on the baby via a pre-used nasal cannula which was dirty and which wouldn't securely attach around the baby's face/head. However oxygen could be delivered through it and immediately the baby's colour improved albeit he was still incredibly pale. The baby was also floppy and unresponsive and we expected that he was most likely suffering from hypothermia and hypoglycaemia as well as severe respiratory compromise but there was no way to tell exactly what was going on. We wrapped the baby up in his blanket and made sure the nasal cannula was securely in his nostrils.
Mum didn't speak English and so we asked the midwife to explain what was happening. It wasn't clear to us exactly what was said to mum and when the midwife had finished talking she left us all with the baby in the high dependency unit. We managed to get the mum to hand express about 5mls of
breastmilk which Clare cup fed to the twin. This wouldn't have happened at home because the baby would have received intravenous fluids, however we had no such luxuries and decided to try to feed the baby the only way we could. He didn't swallow any of the milk and it dribbled out of his mouth. At least he had tried his mummy's milk and hopefully his mouth would have felt better for a short while. The sad thing was mum had an incredible milk supply - something that isn't very common in a newly-delivered lady at home.
This whole situation (on our first day at the hospital) was incredibly stressful for several reasons:
• we were unable to communicate effectively with mum and couldn't tell her the most basic information or do anything to verbally reassure her;
• we knew that the baby needed monitoring, respiratory support and medication which was not available;
• the midwife had left us and the paediatric ward staff did not get involved even though the baby was very ill;
• one of the children already in the bay had severe respiratory distress. He was coughing and vomiting and was being cared for solely by a
lady we assumed to be his mum. He had bulging eyes and was obviously very poorly. That sight in itself was very distressing as there was no sign of any intervention from staff and the child was obviously terrified.
I felt totally helpless and wanted to turn round and walk away. However at this time the twin's mum decided she needed to go to sleep and proceeded to lay down on the bare floor in the middle of the room - no mattress or blanket, just on the floor.
Piled up in the corner of the bay was a stack of mattresses which we assumed were for such purposes and we started to get one off the pile for the mum to lay on. We also saw a screen and went to put the mattress behind the screen so the mum had some privacy. However, no sooner had we got a mattress off the pile that a nurse came into the room and told us that the mum wasn't allowed to lay on the mattrress because they were for the staff to use at night. It was unbelievably incredible and something that I found
hard to cope with. We decided to take the mum back to the postnatal ward and see if there was anywhere where she could rest and then we went outside for some fresh air.
When we returned to the postnatal ward the twin had been brought from the paediatric high dependency bay and was being cuddled by his mum in the baby check room. Grandma had arrived and was sat with mum and the other twin on the floor. The baby was still gasping and was a poor colour. The midwife said he would stay there that afternoon.
As we were talking to the midwife a 34 week baby was brought into the room in another cot. He too was gasping and moaning and we were told that he would also stay in the room that afternoon. Again he was not being monitored and he had no family members with him.
When we spoke with the student nurses the following day they informed us that both babies had died. It's hard to be 100% sure but we are quite confident that both of them would have stood a good chance of survival in the UK. There was
a wierd kind of acceptance that babies will die in Malawi - professional counselling/support is not an option and bereavement care is left totally to families to provide.
We also found out that the poorly little boy in the high dependency bay had also died later that day - he had asthma.
After that incredibly negative experience we didn't return to the postnatal ward during our stay at the hospital.
The following day we attended a baby clinic in another part of the hospital which was very busy. Maternal postnatals and baby checks were performed by the students with up to four women and their babies in the room at any one time. Obviously this meant that confidentiality was impossible to maintain and if a woman or her baby had a problem it was soon shared with whoever else was in the room at the time. This didn't seem to be a problem with anyone even when women had their caesarean wounds checked and basic internal examinations performed whilst others were present.
The baby checks followed the same format as the first day checks did and I think the babies seen by me and Clare actually
got more than a standard Malawi-style examination. We picked up several cord granulomas and sticky eyes which were referred to the doctor for treatment. I was asked by one of the students to teach him and his friend how to thoroughly examine a baby like we would in the UK and that afternoon he had selected a 'normal' newborn and with mum's permission I talked the students through the examination process (without a stethoscope or ophthalmoscope). Hopefully they picked up a couple of new techniques to assist them with future baby checks.
Infection control standards were lacking at the hospital and basic initiatives followed in the UK were almost non-existent. Even though they were excellent in most aspects of their practice we noticed that the students didn't wash their hands at all in between patients, even when they had physically examined a lady or checked in a baby's nappy to see if he was wet or dirty. There was a shortage of disposable gloves and luckily we had plenty of our own. We constantly used alcohol gel and washed our hands (even though there was no soap or no paper towels for us to use) and tried to reinforce
the importance of handwashing in between patients, but it was obviously not something that came easily to the staff and was not standard practice in any of the healthcare settings we worked in. That was especilly hard for us because we knew that if basic infection control was implemented then rates of disease would probably be reduced and ultimately lives saved. I soon realised that we couldn't change the culture but we could try to influence individuls, albeit temporarily whilst we were there.
Postnatal women were provided with iron tablets and 3 doses of anti-malaria prophylaxis. The first anti-malaria tablet was taken in the clinic and all women were offered water to take it with out of the same cup that was not washed in between patients. Also paper sheets on the examination couches weren't routinely changed and thermometers were not always cleaned before being re-used. This was something that we both found hard to accept, but could do little about other than make sure we applied acceptable techniques ourselves when going from baby to baby.
I don't want this to look like I am being ultra-critical because I appreciate we were in Africa and in one of
the poorest countries in the world, but I think it is incredibly sad that something as basic to us in the UK as handwashing was done so infrequently in the hospital where disease was rife. A question I couldn't and still can't answer is 'why are basic standards so low in the 21st century when so much foreign aid has supposedly been poured into Africa?'
I was surprised to see an emergency trolley in the clinic and although basic it was kind of impressive that one was available. It held a few assorted cannulae, a bandage, some drugs and a bag of dextrose that had expired in 2010. However, there was no routine resuscitation equipment for mum or baby and the trolley was dusty and dirty.
We witnessed different levels of poverty amongst the mums and babies we met in the baby clinic. Some babies had nice clothes and proper nappies on, and often we noted cords that had been treated with an anti-bacterial powder. The majority of babies however were naked and smelly, having old and dirty rags wrapped around their bottoms. One baby we saw was wrapped only in a Manchester United flag and was completely
naked underneath!
A couple of checks that stood out for me in particular included one done on a baby called Mavis (unusual name for a baby in my experience but significant to me as it was also my 85 year old Grandma's name!). Mavis was a week old and had been in hospital since birth due to having some kind of respiratory infection and fever. She was coughing and sneezing during her check and was referred to see the doctor again. Monitoring was not available and blood tests were not routinely done to assist diagnosis. All babies presenting with a fever following birth were treated with 3 doses of penicillin and gentamycin and stayed in hospital until the fever had subsided. I don't know what happened to Mavis - I can only hope she had the strength to pull through.
Other memorable baby checks carried out by Clare and I were on twin boys called Elvin and Elvis! They were 11 days old when we met them and weighted 2.9kg and 2.5kg, not bad for twins. Mum was well-dressed and had good English and was accompanied by her mother for support. The boys were appropriately well-dressed and were
both active and alert. We examined a twin each and both of them were fine. They are memorable to me not only for their amusing names but also because they could have passed for 'ordinary' babies in the UK and were a stark contrast to the majority of the more vulnerable-looking babies and mums we met at the clinic.
The youngest pregnant girl we saw at the clinic was 16 years old, and it is not uncommon for girls as young as 13 to attend. Women receive 4 appointments for antenatal care during pregnancy but can attend more frequently if there is a problem. Ultrasound scans are only available if fetal death is suspected or if the woman can afford to pay for a dating/fetal anomoly scan. The antenatal and postnatal hand-held document was good and was filled in appropriately by the students. Pregnant women were expected to buy their record at a cost of approximately 10p. Interestingly some women didn't know their own date of birth and their age was estimated.
We also attended a busy immunisation clinic at the hospital where babies were routinely immunised against pneumonia, polio, TB and measles assuming the vaccines were available.
The clinic was led by two Health Care Assistants and was very well organised. Good documentation was kept in the baby's hand-held record and the HCAs logged attendance and uptake in their own register. Thick cardboard sharps bins were used to dispose of used needles and unused vaccines were kept in a freezer provided by UNICEF.
Babies and toddlers up to 5 years of age were weighed outside the hospital on special scales which were suspended from a large tree. The children were wrapped in a thin shawl or blanket and attatched to a hook at the base of the scales. Most of the babies objected strongly to being suspended in mid air and it was difficult to get an accurate weight because they were wriggling about so much. One small baby actually fell out of the sling whilst hanging off the hook and was saved from a nasty head injury by the speedy reaction of his mum who grabbed his leg just in time.
Health Surveylance Assistants manned these daily weighing sessions and were responsible for recording attendance figures in a government-generated register. They referred any baby or child who fell below his age-related centile to the
doctor for assessment. A lot of the babies and children we saw at the weighing tree were underweight and obviously malnourished and again we saw a mixture of both very poor and more affluent children.
I had a good chat with a Health Surveylance Assistant called Emmanuel under the tree one morning. He soon delegated his job to Clare and I and between us we weighed a good few babies, logging their details in the hand-held record and the register. Emmanuel was very interested in life in the UK and asked me questions about politics, the Royal Family, money, jobs and football. He asked in particular a lot of questions about Margaret Thatcher possibly because Malawi had recently seen it's first woman president, something Emmanuel was not impressed with as he openly admitted that he felt women should be seen but not heard! Needless to say he soon realised that was not an option when he was with me and Clare!
Next to the weighing tree was a patch of grass where women waited for results when they had undergone HIV testing. A finger-prick blood test was freely available at the hospital to all postnatal women who didn't
know their HIV status, and once they had provided blood they waited on the grass with their babies before they went back into the hospital to receive their result. If they were positive they were provided with medication and told how to access the required treatment. The system operated well and women were seen in a timely manner, but there was no evidence that they received any form of counselling if they were positive. Again, this whole set-up was bizarre to me, but there didn't seem to be any fuss from anyone when they were given a positive result and I actually wonder if the full implications of life with HIV/AIDS are fully understood in Malawi.
We had a reasonably good day on the general paediatric ward and although we saw some very sad sights, we also had a relatively positive experience. The children's ward at Mangochi Hospital has about 35 beds and admitted children with a huge variety of medical problems. In true Malawian style the ward was the definition of chaotic, being noisy, under-resourced, short-staffed and jam-packed to the rafters.
On the day we were there the 35 beds actually accommodated 79 patients with 3 children
laid sideways on some beds. The children weren't necessarily related and each child had at lest 2 relatives with them. The ward was absolutely heaving with people and again privacy and confidentiality were totally compromised. The ward was long and narrow and the 35 beds were spaced out down the whole length of the ward. A small nurses station was positioned in between the ward and the high dependancy bay. This area was also where medication was administered and food was served.
Just inside the ward was a small treatment room where children went on initial arrival to the ward. Cannulas and drips were sited in this room by a doctor with a nurse supporting. There were no toys in the room and no child-friendly pictures on the bare walls, just an examination couch and an array of medication. This is where I met one child who I will never forget and whose story brought some happiness to my time at the hospital.
Imlani was 4 years old and was admitted with suspected malaria. I first saw him on the examination couch with his mum and he was screaming his little head off. The doctor was trying to
put a cannula into his arm and he was objecting strongly. I tried to distract him by talking to him but he was having none of it probably because I was white and he didn't understand a word I was saying! Enter the bendy yellow man again and we were in business - Imlani stopped crying and was transfixed by the bendy man he now had hold of. His mum was very grateful and even though we couldn't communicate meaningfully, I saw from her face that she was thankful Imlani had stopped screaming.
The doctor said that Imlani and any other child admitted with suspected malaria would receive intravenous antibiotics and anti-malaria treatment for 3 days. Hopefully this would be successful and the child would recover, although sometimes this did not happen, especially if the child had presented a little bit too late for treatment. Luckily for Imlani his mum had got him to the hospital in time and he made a speedy recovery over the next couple of days.
When we returned the following day Imlani was obviously improving and was walking around. He soon started following me as I went around the ward to say hello
to the 79 patients present that day. We decided to blow balloons up for the children and between us Clare and I inflated at least 80 for the children. Several of them popped and caused a lot of laughter from the parents. We took some good photos of the children with their balloons and it is a sight that I won't forget in a hurry.
I met Imlani's dad when he visited the ward and he presented me with a papaya. He was very proud and was beaming as he shook my hand. Again verbal communication was impossible but I think he thanked me for simply spending time with his son. Whilst I had only behaved with Imlani as I would with any child at home I think this nurse-patient contact was unusual in Malawi and that is what he was thanking me for. It obviously meant a lot to him and I was humbled (not for the first time) by his generosity.
There was a small room on the ward that was especially for babies. Three poorly babies were in the room with their mums, and although there were enough cots for them all, the babies were
laid on blankets on the floor with their mums next to them. This is probably because the mums will lay on the floor at home as cots aren't common in most cases. Luckily I had taken 3 blankets with me to the hospital that had been donated by people at home and I was able to give each mum one for her baby. They were all delighted and instantly wrapped their baby in the new blanket.
We witnessed a medicine round on the ward whereby a nurse sat at a desk near the station and had a register and a box of different drugs and lotions. Each child queued up with a parent and waited for their turn. This worked well until the lunch trolley arrived and the medicine round was abandoned when all the parents rushed back into the ward to collect their plates and cups! Food was provided but utensils weren't! That day the children got chilli and rice which they ate on the ward, mainly with their fingers.
There was a constant stream of admissions to the ward and patient numbers didn't fall below 70 whilst we were there. A lot of the children were
admitted with suspected or confirmed malaria, diarrhoea, burns and skin conditions. Obviously the ward was full to bursting with patients and their parents and the smell was unpleasant, but was nothing like as bad as the postnatal ward had been!
I hope I have gone some way to successfully describing our experience at Mangochi Hospital. At the time, as dramatic as it sounds, the experience was sometimes traumatic for me with lots of the incidents we witnessed being unpleasant,upsetting and downright unacceptable.
However, I am pleased to have been given the opportunity to spend time at the hospital and consider myself very lucky to have been allowed an insight into normal everyday life as it is for the people of Mangochi. It's not every day you can have almost free access to a hospital and be welcomed as warmly as we were by people we met.
I now appreciate how fortunate we are in the UK, not only to have a functioning top-class health service, but also that no matter how much we complain about our lives, work, and money etc, there is most definately a lot more people significantly worse off than us.
I am
sure I will forget the bad smells, poor practice and complacency over time but I know I will never forget Imlani's smiling face, his parents outward gratitude or the students' enthusiasm. These encounters were worthwhile and for different reasons all of these special individuals taught me valuable lessons about my own life. I only hope that I had a positive influence on them too in some small way.
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Denise Ashton
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What an inspiration both you and Claire are, it has really brought home how fortunate we are living either in the UK or here in Spain for myself and having the health service that we have. These children will remember your kindness and treatment towards them when they were sick, hopefully if they have to have medical treatment again they will be treated with the kindness that they rececieved from yourselves. I´m sure you will both be able to relate your stories and experiences for many years to come. I really enjoyed reading your blog it does make you question why these people are still having to live in this poverty in the 21st century, especially with all the aid that is given to these countries. Well done Amanda and Claire proud to know you bothxx