My Month at Ndirande Health Center

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. 

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)

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…

 

Family Planning exam room

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?”

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.