March 2013 Update
Maria
Furaha na amani! Joy and Peace!
Last time I promised that in my next update I would tell you more about
nursing in Tanzania. In January I received my Tanzanian nursing license,
which allows me to practice as a nurse in Tanzania for the next two
years. Once I obtained my license I quickly
made an appointment with the nursing officer in charge of a local
hospital. I have longed to observe/volunteer in a labor ward in
Tanzania, since I’m a labor and delivery nurse in the US and the
Orthodox health centre does not currently offer inpatient services
such as maternity care during childbirth. The nursing officer welcomed
me warmly and introduced me to the nurse-midwife in charge of the
maternity ward. “Are you a midwife in your country? You’re a nurse. But
you have experience with labor. Do you conduct
deliveries? How soon can you start? Today?” I was grateful that not
just the nurse-midwife in charge, but also the staff midwives, appeared
so eager to get to know me and to put me to work. After doing
administrative tasks at the health centre for so long,
I eagerly changed into scrubs and donned my brand-new, white, plastic
apron. I wrote my name across the top in permanent marker, just as the
midwives do. I slipped into plastic sandals, as “street shoes” are not
permitted inside the maternity ward. Soon, though,
I learned that for a birth one quickly changes into knee-high, rubber
boots!
Like most hospitals here, the hospital is not one large building
comprised of multiple floors and separated by specialty area. Instead,
the hospital is a series of buildings connected by cement walkways with
tin roofs overhead to provide shade from the sun
and protection from hard rains. The maternity building consists of
several rooms that encircle an open atrium in the middle. There are two
nurse’s stations—one for triage/admitting patients, and one for
discharging mothers and babies after birth. The admissions
nursing station is located between the labor/delivery room, some
post-partum rooms for complicated cases, and a physician’s office where
consultations for outpatient pregnant women take place. On another side
of the building there are two wards, one of which
is reserved for post-partum mothers and their babies and the other
which houses pre-term women with pregnancy complications.
Each ward is a large room with two rows of beds running the length of
the room. Next to every bed sits a metal nightstand consisting of a
single drawer and a cupboard underneath it. Mosquito nets hang from the
ceiling over each bed, which the new mothers share
with their newborns. Relatives who stay at the hospital to cook for the
mothers and to do their laundry sleep on the cement floor, usually on
top of a straw mat or a colorful piece of cloth called a kanga. The
operating theatre, as it is called here, is in
an entirely different building so any women who need to be transferred
for surgery leave the maternity ward on a stretcher and are wheeled
along a long stretch of cement walkway, past the public kitchen where
patients' relatives are cooking meals, and into
the surgery building. In between the maternity ward and the surgery
building, across from the public kitchen, laundry consisting of kangas,
sheets, and patients’ clothing hang on clotheslines, drying in the sun.
Some laboring women walk around outside, biding
their time until they are in advanced enough labor to be admitted,
while post-partum mothers sit outside nursing their babies, chatting
with one another. Fathers are not permitted inside the labor room, nor
are any other guests, due to lack of space. Instead,
they wait outside or else return home to wait for the call that the
baby is born and that the mother has been transferred to the post-partum
unit where family and friends are allowed to visit.
The actual labor and delivery area is a rectangular room with four metal
delivery tables on one side, and sinks and shelves of supplies on the
other. Divided by metal partitions and with sheets hung in between them
from clothesline in an attempt at privacy,
the tables are positioned with the head pushed against a wall of
windows. An aisle of space runs across the room, at the foot of every
delivery table. The tables themselves (I can’t describe them as beds)
each hold thin plastic-covered padding, which is then
covered with a long plastic piece of sheeting. On top of this a woman
will place her personal kanga before lying down, using it as a sheet.
The tabletops are much higher than a traditional bed, to make it
possible for the midwife or doctor to catch the baby
while standing at the “bedside.” A simple wooden stool allows women to
climb on and off the table, but I’ve been surprised at how many women
manage without it! Next to the last delivery table in the room stands an
infant resuscitation station. It consists
of what I think looks like a changing table, a metal scale for weighing
the babies, a lamp which is used not to provide light as it was
intended, but to give warmth to the newborns. On a shelf sits a suction
canister and an oxygen tank. Hand held bulb suction
devices shaped like penguins can be used, if needed. Infant sized
ambu-bags and masks sit nearby, as well. Infant resuscitation
guidelines, printed in English and laminated, are taped to the wall.
Around the corner in another small room sit the autoclaves,
where instruments, gauze, and towels are sterilized. At the opposite
end of the labor room, a small room with a large sink, scrub brush, and
three large tubs of bleach water, soapy water, and rinse water is where
the midwives wash the plastic padding, sheets,
and dirty towels after births. The plastic sheets hang outside on
clotheslines to dry in the sun, until they are needed again.
As a referral hospital for the entire region of the country, this
maternity unit cares both for women with healthy, uncomplicated
pregnancies and also for women with complications either of the
pregnancy or those that occur during labor, birth, or post-partum.
Approximately 50% of all births in Tanzania occur in the home, without a
skilled attendant. Uncomplicated births often take place in the home or
at birth centers in the more rural areas. Other than the women who live
in or very close to Bukoba, who may choose
this hospital as their preferred birthplace, the patients consist of
women who have been transferred from remote areas due to complications
which can’t be handled in the home or health centre. Approximately 16
births occur daily at this hospital, or 480 births
per month. The nurse-midwives work rotating shifts, alternating between
mornings (7am-2:30pm), evenings (2:30pm-7pm), and nights (7pm-7am).
Mornings and evenings two to three nurse-midwives staff the entire
building. At night it’s only two nurse-midwives.
One assistant medical officer, our equivalent to a nurse-practitioner
or physician’s assistant who has special surgical training, holds
morning rounds with one nurse-midwife, checking on the post-partum
mothers and babies and writing orders either for continued
care or for discharge home. In the afternoon he or she holds office
hours for the women with complicated pregnancies who are either already
admitted to the ante-partum ward or are still outpatients and have been
referred by the nurse running the prenatal clinic.
If needed, the nurse-midwife covering the labor ward will consult the
AMO for complications, especially if a caesarean section is necessary.
As I understand it, at night there is one AMO on call and “in house” at
the hospital, and that one person covers not
only labor and delivery but also for the entire hospital. If emergency
surgery is needed for any type of patient, whether adult, pediatric, or
obstetrical, that single provider is the one and only surgical
specialist available.
I asked a lot of questions as I got to know the staff and my new
surroundings. I’m so grateful to the nurses, midwives, assistant medical
officers, and physicians who patiently answered me, showed me around,
and explained their policies and procedures to me.
Since Kiswahili and English are the two languages used in government
settings in Tanzania, and because secondary education and anything
beyond it are conducted in English, healthcare professionals generally
speak and understand English very well. Although
I could communicate easily with my professional colleagues, my
Kiswahili was put to the test with most of the laboring mothers. I’m
happy to say that the language classes I took in my first year, as well
as my everyday use of Kiswahili, have paid off. Although
I’m sure it was far from perfect, I was able to understand and speak to
the women I cared for, although occasionally I had to ask a staff
member for help with translation. I also really enjoyed acquiring new
Kiswahili vocabulary, including medical terminology.
Some of it I knew—“Sukuma” means “Push” and is written on doors all
over town, so it wasn’t all that surprising when a laboring woman used
the word. My favorite phrase that I learned involves one of the standard
questions asked all over the world: “Is the
baby moving?” Except in Kiswahili the phrase used is: “Mtoto anacheza?”
which literally means: “Is the baby playing/dancing?” Every time I hear
the question I imagine a baby clapping its hands and doing a little
shuffle inside the womb! It makes me smile.
In my first few days I stayed close to the midwives, mostly watching
them to learn how they work. I figured out where medications,
instruments, and supplies were kept and how to read a patient’s chart.
One morning when the labor room was surprisingly empty
I attended morning rounds for the post-partum mothers and then sat in
on private consultations with outpatients. When the labor ward was busy,
though, I helped out with whatever I could do to assist either the
mothers or the midwives. Sometimes I provided
simple care—massaging a laboring woman’s back, pouring her tea, or
helping her get dressed after giving birth. Quickly, though, the
midwives realized I had labor experience and started asking me if I
wanted to examine women to check the fetal heartbeat, take
maternal vital signs, do cervical exams, weigh newborns, etc. On my
second day the midwife turned to me and said, “Do you conduct
deliveries?” I told her that although I knew the basics and could step
in if necessary, in America I don’t routinely catch babies,
clamp cords, deliver placentas, or do any type of suturing. I do have
other skills which nurse-midwives use, though, such as basic infant
resuscitation and post-partum assessment of both mother and child. The
midwife let that sink in for about a minute before
asking, “So, do you want to conduct the next birth?” I said no, I’d
rather watch her. So for the rest of the shift I carefully watched as
she caught several babies, and I helped with all of the basic nursing
care I’m used to doing back in America. I also tried
to help out with the cleanup after births. Back in the US, nurses
rarely clean patient rooms anymore. We do some basic tidying of the
room, but there are housekeepers who actually empty the trash, disinfect
the bed and bathroom, mop the floors, etc. In Tanzania
the midwives do it all—care for the patients and clean up afterward. I
scrubbed and disinfected the beds, padding, plastic sheets, towels, and
instruments. I mopped floors and took out the trash. I even learned
where to dispose of placentas.
Then, on February 15, it happened. A lady having her second baby labored
at the far end of the room. She was breathing heavily through her
contractions and rocking back and forth on the delivery table to cope
with the pain. Then her water broke and she started
to get much more active. The midwife examined the mother and said,
“She’s six centimeters. She still has some time.” With that, she walked
out the door and went to the nurse’s station to do some charting. Any
experienced labor and delivery nurse knows that
a woman having her second baby can go from not being in very hard labor
to being ready to push in just a few minutes, especially once her water
breaks. I was sort of surprised that the midwife didn’t want to stay
closer, but I didn’t really worry about it
either. However, I wasn’t going to follow the midwife to sit next to
her and watch her chart when a woman was actively laboring and all alone
without even a support person nearby! I’d been rubbing this lady’s back
for the past hour anyway, and she seemed to
like having me nearby. When I would step away from her she’d grab my
arm and pull me back, and when a contraction would start she’d place my
hand on her lower back, her non-verbal way of asking me to put pressure
there.
She was quiet, though—she didn’t say much. She didn’t cry out, she
didn’t even really moan. But I noticed how much she was wiggling her
feet and rocking her hips back and forth. Pretty soon I heard her hold
her breath during a contraction. She didn’t even really
grunt, but I know that sound—it meant she was pushing. I took a quick
peak under her kanga and saw that no baby was coming yet. I told her I’d
be right back and dashed out of the room to try to tell the midwife
that we should get ready for a birth. I looked
at the nurse’s station—no midwife. I heard grunting from the labor
room. I ran back. The mother had been lying on her right side, but as I
approached her she turned over on her back. As she did so, I glimpsed a
baby’s head being born. I reached behind me,
grabbed a pair of sterile gloves, ripped them open and begged her to
wait as I pulled them on. There was no time to do anything except put
some pressure against the head to prevent the baby from coming too
quickly, and to yell for help. “I need a midwife!
There’s a birth! The head is out!” From out in the hallway I heard a
soft and non-challant, “What did you say?” Meanwhile, the baby’s head
was out and I was feeling for a cord around the neck. “A BIRTH! RIGHT
NOW!”
The midwife walked in and her mouth dropped open. “Oh! The head is out!
Okay, can you deliver the rest?” She grabbed a pair of gloves and the
mother pushed again. The baby’s body slid out before the midwife got her
gloves on. I untangled the baby from the cord
wrapped around her body and placed her on her mother’s chest, grabbed a
kanga which had been covering the mother, and started to wipe the
baby’s face, head, and body. The baby started crying, and the mother
started saying, “Asante sana, Dada…” over and over.
“Thank you, Sister.” Hands shaking from the adrenaline rush, I accepted
the clamps the midwife handed to me, and after the cord stopped pulsing
I clamped and cut the cord, tying it off with a small, sterile rubber
band that is specially made for that purpose.
Later, after weighing the baby, putting eye drops in her eyes to
prevent infection, and wrapping the baby in a brand new kanga of her
own, the midwife showed me how to deliver the placenta and we checked to
make sure it was complete and that no repair for
mom was needed. Then we helped Mom up, got her cleaned up, dressed, and
gave her baby to nurse while we got ready to transfer her to the
post-partum unit. “Congratulations! You’re a midwife now!” smiled my
Tanzanian mentor. Before the day was over I caught
a second baby, this time because the labor ward got busy and two women
gave birth at the same time. By the end of February I’d caught six
babies and I’m officially hooked.
My time at the maternity ward was wonderful, and it gave me a real
insight into the way women in Tanzania experience pregnancy and
childbirth, at least within a clinical framework. Some of you may know
that I am currently in Uganda, not Tanzania. My final role
as a missionary in East Africa, before my term of service ends in
April, is to serve as a doula and mother’s helper for fellow OCMC
missionaries James and Daphne Hargrave as they prepare for the birth of
their first child in a couple of weeks. You may remember
that I have been contemplating my future and whether to renew for a
second term in Tanzania or to return to the US. After much prayer and
contemplation, I’ve decided to return to the US to pursue a graduate
degree in nurse-midwifery. I am very interested in
continuing missionary service, and my goal is to return to the mission
field in a developing country, quite possibly in East Africa, as a
nurse-midwife within the next several years. Although I don’t have many
details about plans yet, I will remain in Uganda
through mid-April, helping James and Daphne as they adjust to new
parenthood. God-willing, my skills and experience as a labor and
delivery nurse will also be of use during Daphne’s labor, although I am
more than happy to leave the baby-catching to Daphne’s
nurse midwife! Please pray for James, Daphne, and their unborn baby,
and for Felice and me as we attempt to help them as much as possible.
Thank you for reading and please feel free to ask questions! I’ll try to
write some more updates in the coming weeks
as we wait for baby!
Love in Christ,
Maria