In order to teach nursing in Malawi, I am required by the
Malawi Nursing Council to complete a four-week orientation in “general
nursing.” Originally, the council wanted
me to complete this experience at Queen Elizabeth Central Hospital, which is
the referral hospital for the Southern region of Malawi. To say I was a bit
worried about this is an understatement. The acute care setting is not my cup
of tea, and I haven’t been in the hospital for over seven years. Thankfully, my
counterpart rescued me and arranged for my orientation with the District Health
Office at Ndirande Health Center.
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| My uniform. All navy indicates I am an educator. The hat is optional. |
Ndirande is essentially a suburb of Blantyre, and probably,
the largest one. I remember reading somewhere that the health center serves around
200,000 individuals with approximately 20,000 HIV positive individuals. They
also deliver a ton of babies. For my month of orientation, I spent a few days
in each of the six clinics that the nurses staff (or should staff). As there is
a nursing shortage, some of the clinics are left to the HSAs (basically
community health workers) or nursing students. The health center is trying to
become a hospital with an operating theater (for C-sections) and adult and
pediatric wards. Of course, this costs money and requires physician coverage,
which is challenging with an even larger physician shortage. I enjoyed my time
at the health center and have been impressed, for the most part, by the nursing
care. I have especially been impressed by the charge nurse and matron, who
happen to both be KCN graduates. Here is
how my day would typically go:
7:30 AM: Arrive at the health center and wait in the labor
ward for morning report
8:00 AM (ish): Receive morning labor report from night duty
nurse and possibly short stay (urgent care) report if the Clinical
Officer/Medical Assistant is still around and it is Monday, Wednesday or Friday
8:15 AM: Head back to the labor ward to await my assignment
for the day. The charge nurse assigns nurses to different clinics everyday except
the labor ward, which is a two-week assignment.
8:30 AM: Head to my designated clinic and start the day.
Each clinic has its own routine, which I will summarize below.
12:00 PM: Head back to the labor ward after clinic is
finished. This could be anywhere from 10:30 AM to 1:30 PM depending on the day
of the week and how busy each clinic was.
12:00 PM-1:00 PM: Lunch
1:00 PM- end of day: CPD (continuing professional
development) presentation if it is Wednesday; discussions with students from
other colleges; or sitting around until it is time to knock off (usually 2:30
PM-3:30 PM)
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| Postnatal and Family Planning Clinic |
Postnatal Clinic
(20-30 patients per day)
Postnatal Clinic shares a space with the Family Planning and
VIA (cervical cancer screening) Clinics. VIA is done only a few days per week
depending on if the nurses that know how to do it are working. I haven’t really
figured out the schedule. It is supposed to be 2-3 days per week, but I have
only seen it 2 times in the past month. Women and their babies come for
postnatal checks at 1 week and 6 weeks. They typically arrive around 7:30 AM to
get their place in the queue. All of the clinics run on a first come first
served basis, except if a woman comes with her partner. In that case, she goes
to the front of the line. I like that this is encouraging women to bring their
partners, but it unfortunately doesn’t happen that often. Every morning there
is a health talk usually given by the nursing students or nurses. The talk is
for all women attending Postnatal and Family Planning Clinics. Prior to the
talk, the women sing. I’m guessing the songs they sing are about health, but my
Chichewa skills are not sufficient to translate songs yet. The talks are
typically 20-30 minutes and are focused on birth control with some other topics
depending on the audience. After the health talk, the mothers line up to get
their babies weighed. After the babies are weighed, they are brought into one
of two exam rooms one-by-one for their assessment. I observed a large variation
in assessment skills. For the newborns, some nurses just felt the skin
temperature (the primary way to assess for fever here) and looked at the
umbilicus. The more educated nurses did a more detailed assessment including
conjunctiva, mouth and genitalia, but they were not close to the full assessments
to which I am accustomed. The use of stethoscopes is very limited in all of the
clinics and is definitely not a part of routine assessments of newborns or their
mothers. As far as assessing the mothers, sometimes, the nurses didn’t assess
them at all depending on if they reported any problems. Other times, there was
an assessment of conjunctiva, breasts, abdomen, and lower extremity (LE)
pulses. The genitalia would usually only be assessed if there was a report of a
tear and no speculum exams were ever done. Blood pressures were also rarely
taken in the postpartum women despite a large incidence of
pre-eclampsia/eclampsia in Malawi. In one case, a woman was having significant
LE edema (2+ pitting for my medical fans). The nurse did an excellent job
educating on how to alleviate dependent edema, but didn’t take a blood
pressure. When I suggested taking her blood pressure, the nurse shook her head
and said it wasn’t necessary. Because I was there to observe, I didn’t press
the issue. I’m hoping after some reflection, the nurse will act differently in
the future.
Family Planning (20-60
patients per day)
In Family Planning Clinic, after the aforementioned health
talk, the nurse collects the patients’ health passports (book with what should
be all of their health information) in the order they are in line. Then, they
enter the exam room individually for the family planning consult, which
primarily consists of Depo, Depo and more Depo. The clinic does have two types
of implants- Implanon and Jadelle (the new Norplant), but only one nurse knows
how to insert/remove Jadelle and nobody (except me) knows how to insert
Implanon. This leads to patients being told to come back to clinic another day
for implant removal/insertion. I removed Jadelle on a woman who had been trying
to have it removed for over three weeks and another woman who had gotten
pregnant on Jadelle (likely because of interaction with ARVs) and was in for
her 6 week post-partum visit. I was able to demonstrate Implanon insertion once
to the Matron. She was very enthusiastic about learning the procedure and is interested
in having a training (stay tuned for updates on this project). The only other
forms of birth control available at the clinic are pills- combined and
progestin only. In my three days in Family Planning Clinic, we had no Depo for
one entire day. It had been ordered, but had not been delivered by the District
Health Office. The shortage of medications and other supplies is a common
occurrence in Malawi. The phrase that is used in Malawi when something is not
available is, “it is finished.” When Depo “is finished,” women are given the
option of using another form of birth control or coming back another day for
Depo. Most choose to return another day for Depo. Most of the time when they
return, they are now late for their Depo. In the US in this situation, we would
just do a pregnancy test and give the Depo if not pregnant. Because the clinic
is often out of pregnancy tests, the women would have to pay out of pocket for
one, which rarely happens. The alternative is to have the women prove they are
menstruating with a cotton ball. Without proof of menstruation or a pregnancy
test, women are turned away without an alternative form of birth control. The
fertility rate in Malawi is 5.7 (expected number of children per woman). At
this rate, the population of Malawi is expected to more than double by 2040
from around 16 million to over 40 million. Already one of the poorest countries
in the world, this population growth in Malawi is not sustainable. Family
planning is the answer. Thankfully, there is a new family planning initiative
in Malawi with the goal of increasing modern contraceptive use. I am hoping the
focus will be on IUDs and implants. Chabwino,
I will now step off the soapbox…
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| Family Planning exam room |
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| Price list for methods at private clinics (1USD=530K). Methods are free at public clinics. Lupu=IUD |
Antenatal Clinic (20-50
patients per day)
This clinic is run by Blantyre City Council, which causes
some disconnect between it and the other maternity services. During the three
days I was at the clinic, there was only one nurse and approximately 10 nursing
students. The nursing students had not done antenatal care previously; therefore,
the one nurse had to see the patients and supervise the nursing students (and
the mzungu). The clinic starts in the
same manner as the aforementioned clinics with singing and a health talk. The
health talk is significantly longer, lasting around one hour. After the talk,
the patients line up to be weighed (returning patients) or to have their height
taken (new patients). The returning patients then move on to blood pressures,
while the new patients are weighed. The whole process is much like a dance-
everyone moving to the various stations while maintaining their position in
line. There are also tetanus immunizations given and HIV tests done somewhere
in this process. Then, the nurse and nursing students start to see the patients
in one of four exam rooms. I was working with two students in one of the exam
rooms. I was impressed that the women are instructed on self-breast exam at
each visit. This is the best method of breast cancer screening in Malawi, where
resources are limited and cancer screening is low priority. One of the most
frustrating aspects of antenatal care in Malawi is the use of McDonald’s Rule
to calculate gestational age. In America, fundal height (FH) is about equal to
gestational age (GA) after 20 weeks. We use FH to monitor growth, but not to
calculate GA. In Malawi, they use FH to calculate GA using the formula: FH x
8/7. This is apparently called McDonald’s Rule. This formula has caused many an
issue when it comes to determining if someone is post dates. For example, if a
woman has a FH of 31.5 cm, GA will be calculated at 36 weeks based on the rule.
Now imagine she is actually 30 weeks pregnant and she presents to the hospital
10 weeks later to deliver at 40 weeks. Based on the last calculation in her
health passport, 36 weeks+10 weeks= 46 weeks. Does this make sense? It doesn’t,
but a resident told another GHSP volunteer that a woman was 46 weeks pregnant. I
understand using FH as an approximation of GA when there is not a reliable LMP
and limited access to ultrasound. However, it is often used in place of a
pregnancy wheel when there is a reliable LMP. I attempted to teach the students
that there are a lot of reasons that someone could be measuring larger than or
smaller than expected, and if there is a reliable LMP, use it. I had a
fantastic time working with the students. In the future, I hope they will hear
me saying, “Does that makes sense?”
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| Miracle, one of the students in Antenatal Clinic |
I realize that this post is not only overdue, but also
verbose. I am breaking it into two parts inspired by Back to the Future Day. Up
next on Part II: ART Clinic, Under 5 Clinic, and Labor Ward.
