Orientation Begins

The Nurses and Midwives Council received enough paperwork from the States to convince them that I do indeed have a CNM license there and now I can begin the clinical part of getting my license here. I have one month of "orientation" at Bottom Hospital in different areas, an interview before a few members of the Council, and a fee to pay, and then I'll be licensed in Malawi as well. So, this week I began my orientation with antepartum (prenatal) clinic.

The particular building which houses the antepartum clinic also houses the family planning clinic, and the clinic for healthy children under 5. Before the doors open, all the women with appointments for the day (no time slots are given) gather in a covered patio area on rows of cement benches. Several hundred women sit attentively with their babies tied on their backs or nursing at their breasts, as the nurses take turns standing on the steps and giving health talks on various subjects (e.g. signs and symptoms of labor, HIV testing, family planning methods etc.). Then the session ends and the clinic day begins with a type of call and response song. Even though this is just a group of several hundred women from the community and the song is probably just a health message, their clapping and harmonizing sounds as beautiful the music of Ladysmith Black Mombaza (think Paul Simon's African infused music). I would love to record it somehow so you could hear what I mean.

Once the doors open, women are directed inside to sit on benches against certain walls depending on which clinic they will be attending. This morning the four nurses in antenatal clinic saw 150 women. Apparently they can see up to 300 in a morning. (So much for 15 minutes per visit being too short.) Women only come for prenatal care 4 times during their pregnancy. Each time they are weighed, their blood pressure taken, their belly palpated, and fetal heart tones auscultated and that's pretty much it. Depending on where they are in their pregnancy, they are given anti-malarial meds. Oh, nurses also check their tongues and inner eye lids each visit and give iron supplements depending on the shade of pink or red. There are two exam rooms - each with two tables - through which there is a constant flow of women walking-in, handing their small health history books to the nurse, climbing on the tables, uncovering their bellies, climbing down, covering bellies, scooping up children, books and pills, and exiting.

The difference between my training and this environment is stunning, to say the least, and I feel as though this is my very first week all over again, but even so, I am happy to be here. I get to lay my hands on quite a few bellies, ask women "Muli bwanji?" how are you?, "Miyezi ngathi?" how many months?, and try to hear fetal heart tones (FHTs) with the device they use. (It's called a pinard and looks like a miniature trumpet, except envision a flat piece mounted on the mouthpiece. You put the cone side to her belly and put your ear against the flat part.) I found the auscultation incredibly difficult, especially with all the ambient noise, but hopefully I'll get used to it.

I'm sure many of you wonder how the nurse can actually catch and treat problems in such short visits and, well, I'm wondering that too. Yesterday a woman with a fever (probably malaria) was sent to the lab for a blood smear but when she returned to say the lab was closed, she was prescribed medicine for malaria and pneumonia. Another woman at 24 weeks (a complete pregnancy is 40 weeks) who reported contractions, was sent to another hospital in town via public transport escorted by her husband. Both these women came with complaints and although I know the nurses must catch some problems, I'm also sure that many slip through. Especially since they don't use a measuring tape to record the growth of the belly, and since they base the date of delivery on a woman's report of how many months she is, as opposed to a recorded and well scrutinized date for her last menstrual period. Patient education also seems to be minimal, of course there are the health talks and there are posters in the halls on exclusive breastfeeding, anemia, eating iodized salt, and reporting mean nurses (I was excited to discover that I can now read these on my own - pictures help of course), but it seems like there are many gaps. At this point, inspite of my judgments, I am trying to be an observer, I am trying to learn to see as they do first, change will come later.

Yesterday and today clinic wrapped up promptly at 11 and then the nurses set out to cook their lunch. The keep a store of ofa (maize flour) in the cabinet and take turns making nsima for the group on a hot plate in one of the exam rooms (nsima, the staple food, is somewhere between the consistency of mashed potatoes and uncooked dough). Once the nsima is prepared, everyone passes around whatever they have bought from vendors outside out or brought from home (beans, chicken, french fries) and eat. Nomsa, one of the nurses, invited me to share her portion and so the two of us ate off her small plate using fingerfulls of steaming nsima to scoop up beans and chicken.

As I was typing this, a Malawian midwife came and sat at the computer next to me. She is currently getting her PhD at a university in the US but worked here many years in the hospital. She asked me about my days in the clinic and I told her about my observations and she agreed wholeheartedly with everything. Funny enough and totally unprompted, she said, "You can't imagine how I hate those songs they sing. The women sing and dance and they are happy but if you asked them what they learned they keep quiet." She said health education is lacking and even when the message is given, because of cultural dynamics, it makes no difference; the men must also hear. She also said that the midwives are used to working the way they do and are unwilling to change. They want to work half days (afternoons are used to wrap up iron tablets to be distributed the following day), they refuse to see women in the afternoon for various reasons, they say using a measuring tape to check bellies slows them down, and on and on. She said at one point the Ministry of Health even had a program for retraining midwives but none of it worked. The midwives will not lose their jobs because there is such a shortage, there is no change in pay, and so there is no motivation to change. She said, "Wait until you see the delivery ward, you will see all the problems those midwives miss . . . Sometimes you want to tell the women, 'Please have your baby at home, it is not safe here' . . . You will see, the worst is yet to come." And so I will see.