Zanzibar

Who would ever have thought I would go to Zanzibar on a work trip?I am just back from 3 days there visiting the Midwifery School and the main maternity Hospital.

Students in their classroom

It was wonderful to be near the sea again and have time to swim in the ocean. My day at the College was certainly interesting. One realised how in Tanzania and Zanzibar that there is just so much a better infrastructure and basic foundation than what I saw in Sierra Leone.
The principal of the school was a wonderful older midwife who had a passion for teaching ethics. I spent time with the 3rd year students getting them to fill in a skills questionnaire. There are 68 students in this class. Almost impossible to teach a clinical profession like midwifery with so many.
It was very interesting that of all of them only 1 wanted to work as a midwife when she was qualified. This set alarm bells going for me. We have to find a way to train students in a way that they will want to practice the profession once they are qualified.Also the question really is should we not begin to focus more on quality than quantity? I know not an easy question to ask in an African context.

I was hosted by UNFPA as I was going some consulting work for their mainland office.

The maternity hospital was the main referral hospital on the island. Here too the midwives did the Gap Analysis Assessment. Despite being overworked as they kept telling me, they still seemed to have time to sit and chill.

Midwives doing the Gap Analysis Tool

It is a very busy hospital. The midwife in charge was brilliant. Motivated and enthusiastic. She is committed to doing a great job. In the time I was there I saw her teaching, training, reprimanding, doing clinical work and organising - she is someone to treasure and work with.

A Zanzabari's midwife hands

In the evening as I sat by the beach sipping my G and T , I felt so blessed that here I have the chance to travel around Africa looking at Maternity Hospital, meeting midwives. Just what I love!

Refresher week

I am not doing very well at keeping up to date with the blog.
Really sorry, things been a bit crazy.
A few weeks ago we had a refresher week for the midwives. Now that we have hired new midwives we decided to have some intense teaching time to make sure we were all on the same page.
We had a lot of fun, all learnt or were reminded of many things and launched our new protocols for the Maternity Unit.

 Dr Stephen, fresh from Sheffield teaching Jacob suturing

Paul and Lucas being our technical support team

Dr Elena doing Neonatal resus

Dr Andrew , teaching about Suturing, not preaching even though it may look like it.

Reviving our baby

Some of our wonderful midwives

Twins

I know we are not meant to have favourite but when patients stay in the ward a long time they do just creep into your heart and become so special. We had 2 ladies who were both pregnant with twins who have been with us for 6 weeks and 1 month respectively. They both lived far away and so the safest was for them to stay with us. Also not to mention that if they stay they get a well deserved break at the Hospital hotel . No cleaning, cooking, fetching wood and water. They loved being with us.

Evaline who was with us for 6 weeks was very entrepreneurial and started a little shop by her bed. Selling sanitary pads, baby hats and even socks. She had done her market research well and knew what her captured client base would need.One day I was needing more running socks and as we were doing the round there in the bedside shop I saw a pack of 4. I made my purchase immediately. Saving me a trip to town,

After all these weeks of waiting arriving everyday wondering if these 2 mummies with twins had had their babies, on Tuesday I arrived to find that they were both in labour.

Evaline ended with a C/S and had 2 beautiful little boys 2,9 and 2,5 kg. Sintyati had a vaginal birth with her twins. A little girl and then a boy both weighing 3,1 kg!

Proud Mummy Evaline!

Sinyati with her twins

 Oh it really was a case of a double blessing all around. It was lovely when the next day they ventured to greet each other and offer congratulations and share their  birth stories,

The mummies greeting each other warmly!
Then it was home time and it was one very proud Masaai Daddy that came to take his wife and new babies home.

Surgery

One of the skills I am hoping to learn from Andrew while I am here is how to repair 3rd and 4th degree tears. These are a childbirth injury where woman have a tear into the anal sphincter and if it is not repaired properly it can have devastating consequences.
So monday morning there was a gap in the labour ward so I went to theatre. The first lady Andrew was operating on had had a 4th degree tear for 28 years. She received the injury with the birth of her first child 28 years earlier. It was only when her daughter had a baby that she realised that her anatomy was not as it should be and then on hearing one of our adverts on the radio she came for repair at Selian.

Te patients are under spinal during the operation so she was chatting away to us through Mruma - our Gynae registrar. She was fantastic. So enquiring and courageous, She had very little education but I said to Andrew This is the type of woman I would vote for president! She was fantastic. So she left the theatre not half an hour or so later, with the quality of her life totally changed. What a blessing for her.
The next case for the day was a patient we have called the Rhino lady. She arrived at the hospital about the same time as I did. She was brought to Selain having been charged by a Rhino we heard. She shattered her pelvis in the process and from the shattered bone she developed a fistula. Andrew said in all the 1000's of fistula he has repaired there has never been one before caused by a Rhino. Well after months in hospital for healing of bedsores and trying to stabilise her pelvis she too was ready for theatre on monday.
The fact that she was even alive was a miracle. As it turns out in theatre we heard that actually the real story was she was trampled by a hippo, hence her fractured pelvis. Andrew repaired her unusual fistula and she went back to the ward.
We had a good chuckle because next day she was wearing a t shirt with a hippo on it and some swahili and Andrew said he wanted to write - I SURVIVED THE HIPPO  !

2 lives radically changed by skilled surgery. What a joy to catch a glimpse of this again.

It is always so good to be in a place where you are learning new things. And here there is certainly much that I am learning everyday. Also to have a collegue like Andrew is such a priveldge. Last week we had a C/S for Fetal Distress and as I have said before speed is not our strong point. Well my nature is to keep pressing everyone to go faster but Andrew in his calm way just gently chivves everyone along and then sits patiently on the stool waiting for the staff to be ready. But I know as he is sitting there he is praying for the mum and her baby. So what is the end result from fetal distress out comes a perfect little person crying away, no sign of distress. When will I learn that it should always be prayer first.Yes one can pray and work but working with a man of such faith has indeed been and is such a privilege.

Every One Counts

While here in Arusha I have been attending the Vineyard church. It is like many churches a random assortment of people drawn from Tanzania and all over the world who are here to do the thing they believe God has put on their heart to do.

There are a number of people at the church who run orphanages . And it is so lovely each week to see an eclectic mix of families, adopted families, foster families etc. A grandpa from America or Australia with a little toddler snuggled up and fast asleep on his shoulder. He looked more content than the toddler!

Well for the first time in the 4 months I have been there a lady stood up on Sunday with one precious little baby in her arms. She had been abandoned in a drain. As the woman was saying this she was weeping, you could just feel her love and compassion for this little thing. And as she stood there she simply said I am not sure if any of you know anyone who would give this little girl and there was a year old boy too, a home?

I thought a bit of a strange request almost like an auction but filled with love!
Well to cut a long story short during the time of sharing  a woman stands up just to say she has come with her friend from Nairobi. They both travelled to Arusha as God had told them this was the time to visit. The lady had tried for many many years to have a baby. Lots of pain and heartache for her.
Anyway there and then in the service she had the little girl on her lap, was giving her a bottle. And God had brought her here on this very weekend to collect the baby He had assigned for her.
I am reminded again that nothing is random with God. He is working out his master plan even when it looks like nothing is !
I was thinking also about that verse where he says look how I care for the sparrow and the lilies etc, how much more is his eye on every little baby.

This brings me to a patient I will call Anna. I met her 9 weeks ago when she was 20 weeks pregnant. She is a 42 yr old lady who has had 3 pregnancies but no live children. In this culture here for a woman to not have born children is a great great sadness, you need to prove you are a woman with your fertility. For many reasons she just touched my heart so deeply. She was admitted with severe pain and we thought she was losing this baby too at 20 weeks. She has a very large fibroid in her uterus and  it was expected that she would not carry the baby past the first trimester. Her plight just touched me and I have been praying so fervently that God would not let her hope be disappointed. Anyway by the Grace of God alone she is now 29 weeks pregnant. A miracle in itself. I am so praying that she will be able to carry the baby for a few more weeks then the chance of survival here in Tanzania would be good.

Some patients just seem to creep into your heart.  And she is right there deep in my heart. I am so scared for her and to be honest for myself too, that she will not see the fulfillment of her hope. What can we do but trust and pray, God knows. Every little one counts with Him and he knows the days and hours and years he has planned for this little one. And I just pray for her that she will be spared another sorrow.

Triple Blessing

So yesterday was a very hectic day in the labour ward. It always amazes me how it seems to be all or nothing.
Anyway the ward was full with 5 woman in labour. I had just assisted one mum with her birth, she had walked in ready to push, assessed another lady who needed to go to theatre for obstructed labour and then came to the final Mum who had to deliver.
My 2 colleagues were busy with a Mum on the other side.
This mum was so emaciated. I asked my colleagues what her HIV status was as they had checked it on admission. I presumed her to be positive as she looked  so skeletal. But gladly she was HIV neg.
She was a maasai mummy, who was not able to speak in swahili. Fortunately the lady in the bed next to her, who had just delivered was able to speak maasai to her. So this is how it went. My very limited, broken but improving swahili to one mum, who translated into maasai and spoke with the other Mum. Occasionally one of my colleagues came to give some clear instruction.
I still have to remind myself that I am not in a movie sometimes with this Mum lying there in her maasai shukra and lovely beads and earrings looking like the authentic masaai lady, which she was.
Well this Mum was ready to push. We had a vague suspicion that there may be twins inside, but then after looking at her I thought maybe her tummy looked big cause she was so thin - how wrong I can be!
Well out popped the first little boy, screaming away. I felt and as suspected there was definitely a second baby inside. After breaking that baby's waters she slipped into the world. Poor Mum was feeling a little overwhelmed at the sight of 2 of them. Before I gave the oxytocin injection which helps contract the uterus post delivery, I thought let me just check there is not a 3rd one. Well surprise surprise there was. Another little girl arrived bottom first. Well by this time the [poor Mum was overwhelmed.
After the placenta was delivered and she was tidied up. I weighed them one at a time. Their weights were 2.08kg, 1,78kg  and  1,27kg. After weighing they were all put skin to skin on their Mummies chest to keep warm as we needed to transfer them to a special care baby unit.

After the initial shock I think Mum felt like the hero of the day which she surely was. Staff from all over the hospital came to inspect. While she lay there her Mum fed her some much needed lunch.
I went to get my camera to capture the moment but alas it said Battery exhausted - I thought to myself , the battery is not the only exhausted thing in this room. 

New Blankets, New neonatal unit and replacement blood

It was with great excitement that we got new blankets for all our patients in Maternity.
This hospital is built for the summer so now in the chilly months the patients are so grateful to be able to snuggle down with their babies and keep warm.

This little newborn snuggled close to its Mum (Kangaroo Care) and having a jolly good feed.

Mum and baby nice and warm.

2 Lovely medical technology students have spent the last month with us, fixing and calibrating all our equipment. It is such a blessing to have them as it is very hard to get things repaired and calibrated here in Tanzania. They also took on the job of transforming a little room we had  in anticipation of it being used as a neonatal unit. They painted , made curtains, tidied and sorted as and we are so very grateful

We felt the crosses on the curtains very appropriate for a Lutheran mission hospital

Nothing like coming to Arusha on holiday to see your family and the crazy midwife friend phoning to beg you to give blood. David brother of my friend Andrew here, is rhesus blood group. We were needing negative blood for a lady who had been on the ward about a week but had now become more critical and she was really needing blood.

So bless David, he came to donate, supported by his brother and nephew he came to donate before setting off on his safari!

Some of the joys

As the weeks go by there are just so many things to reflect on. One learns the all important lesson in life about celebrating the small joys. For example all the paper work in the labour ward used to be kept in a draw - a total nightmare. We now have the most fantastic wooden box making life so much easier for us.

Beautiful order!

 The chaos before

We have a number of lovely students with us on the ward. This is Josephine with a big smile on her face having just recieved her first baby at Caeserean Section. It is so good to be reminded of the struggles one can have in the beginning. Learning how to put sterile gloves on, learning to scrub properly before going int  theatre, how to keep things sterile in the theatre. The joy of teaching and seeing others learn is so great.

Salomne, Pendo, Myself and Doarh

It has been so great over the last months not only getting to know the midwives but all becoming friends. Much laughter is had as I battle away with my Swahili as they patiently teach me. Everyday there are little things that look like progress, that make us feel we are moving towards excellence. Yes the truth is sometimes you take a few steps back but all in all we are moving forward. Change is coming, everyone will be so proud of the work that they have done.

Yesterday I had the joy of helping a beautiful first time Mum Mary have her baby. It was one of those births that as a midwife just makes you love what you do. She even understood my limited Swahili, she was calm and birthed beautifully, oh those things make my heart just so glad!

Prepared

I am coming to the end of my second month here in Arusha. So many thoughts, feelings, emotions and much to reflect on. The setting of Selian hospital is so lovely. Wards are all set around a large open square of grass and beautiful big trees are scattered around bringing shade. So for me even driving to work feels like a blessing compared to the dramatic drive I took each day in Freetown to PCMH. I must admit at the moment it is actually quite cool, so the open hospital is pretty chilly, but I am sure in the heat of summer it will be a real blessing.

Like any old cowboy, it I so good to be back in the saddle. After 4 months at home with no mummies or babies to care for, it is so wonderful to be back on the ward. I feel again just the privilege of being able to care for these women. I know many woman in the world work hard and are ill-treated but I have a sense the burden on the Massai woman is very great indeed. You get the feeling that there is not a lot of joy in their lives. So be able to just sit there and rub their back, hold their hand , offer them care, is such a privilege for me. You can see  their hard work in their hands and feet. They work hard, they walk far, and life is hard!

Dorah, the head Midwife at Selian was very welcoming. It is always that tentative thing in the beginning about forming the friendships. Trying to make the staff realise you are there to help and be on their side rather than swooping in and changing all.

So many times in my life I have been amazed how God always prepares you for what he asks you to do. I am so mindful as I arrive here that what has happened in the preceding years both in South Africa and Sierra Leone has all been preparation for this next part of the journey.

On my second day in the hospital there was a lady who very sadly lost her baby at 18 weeks. It was a challenge to get the placenta out as it was so small and friable but also the extra challenge was that her Female Genital Mutilation (FGM) really was quite extensive. As I was working away, I realised how great God is, that I had worked in Sierra Leone where this too was common practice and therefore I felt more confident dealing with it here. If this had been my first experience of caring for a woman with FGM I think I would have been totally freaked out. I thanked Him for his graciousness to me at that moment.

A few weeks ago we had a woman who had had a C/S with her first baby and now was in labour with the second. The midwife who was on duty with me was very doubtful that she would be able to have a vaginal birth. The midwife gave the Mum about a 5% chance of succeeding. Well, after a day of careful monitoring, and lots of questions along the way, the Mum finally had a fully dilated cervix. Andrew needed to help us with an assisted birth at the end, but the midwife was so surprised and delighted that the labour process had actually worked. She arrived at work 2 days later, still bubbling over with reflections of that day and the way the woman had laboured.

As with everything in Africa it is small small. No great giant steps taken in a hurry. Rather little by little, working alongside, supporting, teaching and mentoring we hope to make Selian the very best place in all of Tanzania to birth a baby!

Arusha Luthern Medical Centre (ALMC)Nursing School

A little while ago I went with Lillian and Juliana 2 tutors from the ALMC nursing school to see the site of the proposed school which is due to open in September. The school is going to be held in a secondary school for the time being until a site is located and building is completed. It is very interesting in Tanzania, the Tanzania Nursing and Midwifery council are not only interested in the curriculum and teaching of the school, but the school has to provide accommodation for all the students as well.

The school hopes to open in September with 30 students. I am involved with them as we are hoping that their students will come to Selian to do their midwifery practical. That will be great for us to have more hands on deck but also I will do clinical supervision with them, while they are doing their midwifery block.

We also had the great privilege of having Euni Siminson coming to see the sight with us. She is a very gracious more mature lady that has been a missionary in Tanzania for the last 57 years. She and her husband came here from the USA and she was really the person who got Selian Hospital up and running all those many years ago, in collaboration with the Lutheran Church. Anyway, she was so excited to come and see the site, as she is having some students from the Masai Girls school being sponsored to train as Nurses through the Eunice Simonson Scholarship.

Juliana , Euni and Lillian in the dormatory corridor 

In the Nursing students kitchen

 She heads back to the US shortly to a ceremony to announce this programme, so it was so lovely including her in the future plans. 

A Tale of 2 Theatres

Friday was a routine day in theatre for Andrew and his team. They had a few 4^th degree tears to repair and then had a hysterectomy planned. After his first 2 cases in theatre, Dr Winnie informed him of a lady who was in labour that had now got obstructed.

So we ended up going to theatre for a Caesearean Section with this lady. I was interested to watch the end of the hysterectomy once I knew our baby was safely out.

 Prayers before Surgery starts

Dr Mruma teaching a junior Dr C/S

Our baby is nearly here

The end result of the operation in ourtheatre

So we had the safe arrival of the sweetest little boy in our theatre. I then went over to Andrew’s theatre to find them in then midst of removing a few fibroids. Fortunately, they did not have to do a hysterectomy. The first one was about fist size and 2 smaller ones. Great for me to watch some surgery that was not obstetrics.

But I had to admit we had a much cuter specimen at the end of our procedure, this precious little boy compared with the fibroid s that Andrew and Team had!

Andrew and Dr Winnie busy at the TableThe end result of their surgery! Fibroids removed

My Masai Ambulance

I arrived at work this morning and the night midwife called me to see this baby. It had been born 3 weeks ago at home and had been admitted over the weekend with these massive necrotising lesions all over its little body.

The mum was a masai woman sitting there on the bed with her red tartan wrapped round her and her decorative earrings hanging from her overstretched lobes.
This poor little thing was so ill looking. Had a roaring temperature and was so wasted. Immediately after assessing the baby we got the mum to express some milk so that we could top the baby up. Despite being on the breast all the time the baby was not actually sucking effectively.
The Mum was a champion expresser. In no time at all she had 30mls and again was a dab hand at cup feeding her baby.
I just love it when you think you are really going to need to teach a mum how to do something, and then you ask her to do it, via an interpreter of course and she is a total pro!
So off the mum went diligently expressing and feeding her baby every 2 hours.

They needed to be transferred to Mount Meru Hospital , which is the regional hospital as we could not offer the care they needed.
So there I am cruising along in my little Rav 4, with Dorah my midwife colleague heading off to Mount Meru hospital with these 2 beautifully clad masai ladies in the back. And a little masai baby bundled and snuggled right up with its Mum.
 The Granny was telling Dorah how she had never been to Arusha despite only living about 40km away. She felt very apprehensive about travelling into town.
I was chuckling to myself because between Dorah, a Tanzanian midwife, these 2 masai ladies and myself, a South African we managed to all get the giggles about Granny being overwhelmed by the sights of Arusha.

At the hospital we left the mum in casualty to be seen by the Dr. Dorah and I then went to see the neonatal unit and labour ward. Amazing what I find interesting . It is a very busy unit. Up to 30 births a night with 4 midwives on duty. The place was light and clean, first impression really not to bad.
The delivery room had 10 beds together. Have to admit I don't think I have ever seen so many labouring woman in one room in my life.
The neonatal unit seemed organised and the nurses were in attendance. I will surely go back to follow up on this little one, but really wonderful to know that  there is somewhere we can transfer babies to that the care looks like it will benefit the babies.

So this is the life here it seems. Always new experiences and trying to savour them along the way.

Dareda Hospital, Mbuli District

Last Wednesday Andrew and I set of to Daredo hospital with Paul and Lucas, the 2 Fistula advocates who work for Maternity Africa at Selian Hospital in Arusha.

Andrew, Paul and Lucas

It was my first escapade into the countryside from Arusha, besides the drive to Moshi which I have done on a couple of occasions.
We were off to visit a hospital up in the mountains to see if it would be a good place for an obstetrician to be based for a few months later this year.

I have come to realise here in Africa ,I think we talk about roads like the British talk about the weather. For the first 25 km or so the road was slightly hair raising but then actually got quite good.

After about 3 and a half hours of driving we arrived on the most beautiful mountain side. There we found the hospital. Started by Sister of Mary Medical Missionary nuns years ago. There are still 3 nuns there to this day.
We met Dr Eliza the Chief Medical Officer .
What emerges as we walk around this little hospital, was truly a soul stirring experience. Andrew said he had never , even in 12 years in Ethiopia of private and government hospitals, seen a one as good as this one. Compared to what I had experienced last year this looked like paradise!
It was organised, clean and tidy. Everyone so friendly as we went around.
The nurses and midwives were busy about their work, touching their patients and interacting with them.A joy to my heart!

 Midwife Valencia and a mum having an Induction

In the post natal ward there was even a Mum receiving blood, and she was having her vital signs monitored throughout the process.  I know many would feel like that should be standard practice but sadly in many places it is not the case.This hospital has roughly 5000 births per year and last year they did not lose a single mother. I could not but help compare it to PCMH in Freetown where I was last year, who have a similar number of births but have maternal mortalities well into the double , if not triple figures annually.

I was so struck in the postnatal ward, every Mum had her baby. I remember the first time I went to PCMH in a ward of 17 mothers only 7 had baby's with them. So many lost!

 A ward full of Mummies and babies

 

One could almost feel the peace as you walked around this place.
A lovely little neonatal unit where there are really trying so hard, but I have to say it would be the ideal place to develop a Kangaroo Mother Care Unit.

 The neonatal unit

The hospital make their own intravenous fluids, so interesting, The theatres were spotless and very organised. Besides being a beautiful hospital the location is magnificent. Settled on the side of a tree covered mountain. Indeed a beautiful place to work.

A beautiful location

As we left my heat felt so encouraged, truly this little hospital was the hope for Africa. It was fantastic and not a single white face in sight I am delighted to say. The Tanzanian staff were there doing it for their own people. What a fantastic sight it was!