End of service musings, ruminations, cogitations

I recently read an article that one of my midwifery friends posted on Facebook discussing the impact of traumatic births on healthcare providers. This article was particularly striking as it discussed the psychological toll that traumatic medical events have on healthcare providers, citing a Danish study that examined the effects of a traumatic birth on midwives and obstetricians. The one thought crossing my mind as I read this was how these traumatic events were being described as a singular event for an individual provider. They repeatedly referred to this event and the traumatic birth in a way that is disharmonious with the reality of my current context, Malawi. If I had read this post 10 months ago, I would not have paused on these words, wondering if someone had forgotten an “s”. However, the experience of the midwives and obstetricians in Malawi is that these events occur far too often. This article left me wondering about the magnitude of psychological toll endured by an average healthcare provider working in a resource-limited setting, where traumatic medical events are unfortunately the norm.

The reality of our jobs as healthcare professionals is that at some point in our careers, we will have a negative outcome. The reality in resource rich countries is that most of the negative outcomes occur despite having exhausted all possible treatment options. However, this is not the case in resource-limited settings, where life-saving blood products, antibiotics, or intravenous fluids are often out of stock (“finished”), or there is no oxygen due to a power outage. The psychological toll is substantial when you know you did everything possible to prevent the negative outcome. How about if you couldn’t do everything possible because of a lack of resources? How about when the negative outcomes are occurring weekly, or sometimes daily, as opposed to a handful of times in a career? I wonder how much these factors contribute to the brain drain of healthcare providers, in particular physicians, from Malawi and other resource-limited countries.

Having attended morning report in the OBGYN Department several times in the past few weeks, I have become acutely aware of the issues of maternal and neonatal mortality in Malawi. Being the epidemiology geek that I am, I knew Malawi’s numbers (maternal mortality, neonatal mortality, infant mortality, fertility rate, etc.). However, it is one thing to know a statistic and another to feel the magnitude of the issue. Malawi has made great strides in the past several years to improve both of these health indicators, but still has room for improvement in order to meet the Sustainable Development Goals.

I have fortunately become involved with a practice improvement project that is attempting to address this issue of negative birth outcomes by introducing the use of an affordable fetal heart rate monitor called Moyo. These devices are pretty amazing in that they are portable, can monitor both fetal and maternal heart rate, and can trace/graph fetal heart rate for 30-minute intervals. Currently, midwives use a Pinard fetoscope (think small megaphone) to monitor fetal heart rate. All my midwifery friends have probably successfully heard a fetal heart with this device, but I have failed on multiple attempts. It is definitely not easy to use and can take time to find the fetal heart rate. The Moyo monitors will hopefully ease the task of monitoring fetal heart rate, while allowing for closer monitoring in patients at high risk of fetal distress (i.e. bad outcomes). I am excited to be working with an amazing team on this project. Hopefully, we can improve the quality of fetal monitoring on the labor unit, and ultimately, decrease negative birth outcomes.

As my service winds down, I find myself more contemplative regarding the goals of our program. I truly believe in the need for increased human resources for health (i.e. nurse and doctors) in the countries in which we are serving. However, if we increase the number of nurses and doctors, but do not have adequate resources, are we ultimately improving the quality of care? 

I leave you today with many unanswered questions. This blog post is far more cerebral than the previous ones. I apologize for the lack of photos accompanying my thoughts today. You will have to stay tuned for elephant/zebra/rhino selfies.

GHSP Lemonade

They say, absence makes the heart grow fonder. I hope this sentiment applies to my blog absence for the past too many months. The power has gone out yet again on campus, and I am left without Internet. I figure now is an excellent time to write that blog post I have been intending to do since November. As many who have lived abroad know, the novelty of living in a new country wears off and eventually everything becomes routine. This is one of the things I was pondering on my 20-minute walk to campus this morning. I was reminiscing about how the sights, sounds, and smells of my commute are no longer new or strange. Each journey, I pass two construction sites and familiarly greet the workers. They always reply with a wave, a smile, and an appropriate greeting for the time of day. As this has become the reality of my new life, I find it harder to translate my experiences into blog format. The lack of Internet today has inspired my written verbosity (although power outages and lack of internet happen to be nothing new). Last time we met, I believe I was sharing my experiences during orientation at a health center in Blantyre. I do believe I promised a part 2 to that post, but that will have to be postponed in favor of playing catch-up.

At our In-service Training (IST) in December, we were asked to share our successes and challenges so far at our sites. We were given fair notice of this, and in all honesty, it caused a bit of anxiety on my part. Having done Peace Corps previously, I was aware that this experience would have its challenges. However, I never anticipated that my challenge would be not having any courses to teach first semester (November-March). We were already starting later than some of the other institutions, and this revelation pushed my “start” back to the end of March. What was I going to do for 5 months? You know that cliché saying, “When life gives you lemons, make lemonade”? Well, I truly feel that this applies in my situation. My successes at site so far have come from my biggest challenge.

How did I make the GHSP lemonade? In the spirit of collaboration, I reached out to my fellow GHSP volunteers seeking any and all advice on how to occupy my time. They responded with amazing opportunities to utilize my skills and passion. As I have been on my reproductive health soapbox before, you will not be surprised to find out that I have been spreading my love of long-acting reversible contraceptives (LARCs).

Target One: The Interns

The OBGYN Department at Queen Elizabeth Central Hospital (or “Queens” as we say) has been amazing. It just so happened that they were in need of someone with experience in family planning to train their interns. In Malawi, the nurses provide the majority of family planning services. With a large physician shortage, many services have been allocated to be provided by the nurses. At Queens, the vision of the OBGYN Department is to have the interns provide family planning to patients on the postpartum unit and after receiving care for a miscarriage. Enter the LARC enthusiast. I had the opportunity to share my love of LARCs with the OBGYN interns in two sessions. The first session was spent discussing LARC use, and the second session was an opportunity to practice Implanon insertion and removal with Implanon training kits. I just want to give a huge shout-out to my former co-workers that so kindly donated these kits, and to my friend Terra who lugged the kits around Africa. You have assisted in planting some seeds.  

Target Two: The Medical Students

Two of my fellow GHSP volunteers are teaching the Family Medicine rotation to 4^th year medical students at a district hospital in Mangochi. The thing about Mangochi is that it is hot. Sweat dripping everywhere kind of hot. The it’s so hot all I can do is sit in front of a fan kind of hot. In Blantyre, we have a lovely breeze that swoops in just when you were about to complain about the heat. In Mangochi, there is no breeze, and the “feels like” temperature is always at least ten degrees hotter. Sounds like a great place to visit in the hottest months of the year, right? In the name of family planning and LARCs, I ventured to Mangochi to assist my fellow GHSP volunteers in teaching the 4^th year medical students. The students rotate through a variety of units and clinics at the hospital. I was tasked with supervising/teaching the students in family planning, STI, and antenatal clinics. I had two great groups of students who impressed me with their knowledge and inspired me with their eagerness to learn. They even had the opportunity to insert a few implants! One of my tasks was to grade an observed consultation. Imagine a small exam room with one patient, two students (one being graded and one interpreting for me), and me, basically melting from the heat. Now, throw in a patient that is very tangential, and you get a recipe for a potential disaster. I was extremely proud of the student who was interviewing the patient, as he was able to redirect the patient multiple times and obtain a fairly complete history. I had been working with this student all week and had one of those “proud mama” moments. If I am ever suffering from doubts of “what am I doing here”, I remember these moments and know that the students make it all worthwhile.

Target Three: Midwifery Students

This past week, I had the opportunity to finally teach the nursing students! My counterpart was asked to guest lecture for the first year midwifery students. When she found out she was unavailable, I was given the opportunity to lecture on another one of my favorite topics, epidemiology. My inner public health nerd was smiling with glee when I found out the topic. Over two days last week, I attempted to make epidemiology exciting for 18 first year students. When I say first year students, I mean first year college students, as in 18-20 year olds. I absolutely loved teaching them, and told them that if the only thing they remembered from my lectures was prevention and promotion, I would be happy. When I walked through the gate at school the other day, I waved to a group of the first year midwifery students. They responded with “Hi Amanda” and then, they started chanting “prevention and promotion”. I had the biggest grin on my face when I walked into my office and knew that I had made an impact.

That is how I have “made lemonade” over the past several months. Throw in a trip home to Minnesota, several trips to Lake Malawi, Batik class, and multiple game drives, and you have a general picture of my activities over the past few months.
 

Lake Malawi

This is how I Batik

Our artwork drying

My instructor Ellis is an amazing Batik artist. This one is coming home with me.

Vervet Monkeys

Zebra Selfie

Elephants-an amazing sight and sound

Antelope and Warthogs

 I am lucky to be surrounded by a great group of GHSP volunteers that not only allow me to teach their students and interns, but also provide tons of support and hours of entertainment.

The Blangochi Crew

Although I make no promises, I am hoping my next update will not be so delayed. Until we meet again…