So its been a while…. The internet in Masasi has been so bad that I am only now managing to post something I wrote 3 months ago!! More to follow. Hopefully.
There is a lot to write about but I think first I really want to tell you about what its like working out here – and what life is like for mothers and their babies here in Masasi. Maybe the best way is to tell their stories as it may be more interesting to read than a dull diary of what I have been up to!
All of these mothers are happy for me to tell their stories and use the pictures (if they manage to load up).
A dispensary 30kms away…
A 30 year old woman, who already has 4 children (including twins) starts labouring at home two or three months or so before she thinks she is due. Her village is about 30kms away from the hospital. Her husband is working in the fields as the rainy season is due to start and he needs to prepare the ground for planting. She walks to the local dispensary (a small building, usually 2 or 3 rooms, in the village where a basic health care worker is) with her mother. It’s a very basic room, a bed and a paraffin lamp, but the healthcare worker has had some training in attending births. She labours, with no pain relief, and delivers not one, but two babies just after midnight.
Both are boys and both cry after they are delivered and weigh just around 1 kg each – tiny. She thought she had a big bump but no scans (they are never done here) and only 2 antenatal visits mean she is not really aware of how her pregnancy is progressing. The health care assistant then tries to deliver the placenta… but there is another baby – triplets. Due to its position this baby cannot be delivered and so they phone to get the ‘ambulance’ to pick her up. Here in Tanzania healthcare for mothers and children under 5 is ‘free’ and there is supposed to be a hospital vehicle that can pick them up (not always working, sometimes no petrol available or no money to buy the petrol).
Luckily this time, the car comes – which is great – but it takes a while to get to her.
The first I hear of anything is when the Bibi (grandmother) walks into our unit at around 1pm the following aftenoon (13 hrs after delivery) with 2 small bundles. I never meet the father. We have already had 5 admissions that morning and our tiny unit is getting full (with 2 or 3 mothers to each of the 7 beds). The mother has been taken to the labour unit.
The first baby is alive, but very cold at 33 degrees and not very pink or active. The 2nd baby is very sadly no longer alive. We start treatment for the 1st baby by starting some oxygen, warming it up and giving IV fluids, dextrose and antibiotics. Basic things but after an hour he looks a little better. We hear that sadly, but unsuprisingly, the 3rd triplet has not survived. 1 hour later the mother comes to the baby unit. She knows 2 of her 3 babies have not survived and although her face is set with grief, we talk to her and she sits down on the bed and starts expressing breast milk.
2 weeks have passed and triplet 1 is doing well. He has no name yet – but thats normal here as mothers don’t usually name their babies for several weeks even when they are born when they are due. He now weighs 1.35 kg and is getting full milk feeds that his mum givies him via the NG tube.
The mothers here are amazing really, and I am constantly humbled by their strength.
‘My baby is not feeding’
Its about 10 am. The usual chaos of weighing (and now thankfully taking a temperature) all the babies from the unit and the ones we are keeping an eye on in the postnatal ward is over. I am half an hour into a calm and organised ward round (and feeling delighted about the calmness!) of our 20 or so patients. The clinical assistant (CA) is there too so doing a bit of teaching on a bad asphyxia case. I’m not sure where the nurse on shift has gone – she will have her mobile phone on her as always and I’ll call her if she doesn’t appear back soon.
A mother from home walks into the unit carrying a baby. This happens all the time – maybe once an hour – they just walk straight on in and ask to see the ‘Dactari’. This can drive me a little crazy as quite often its outpatient type things – rash, colic, not feeding well and they should really be seen in outpatients (the equivalent of a GP and A+E here). There are no such things as community midwives here or anyone who checks on babies after they are born. I ask these mothers to wait until we have finished round.
Sometimes it’s a baby born at home who is sick, quite often has developed a high fever – then we stop, admit and treat the new baby straight away.
On this day it’s a mother who comes in and tells us her baby is not feeding well. She doesn’t seem very concerned. I ask her a couple of screening questions to see whether or not I really need to stop the round. When was her baby born? – 2 weeks ago. Where was it born – at home. When did it stop feeding? – yesterday. Does it have a fever? – no. What weight is it? – small. My kiswahili is not great, but can thankfully manage these questions!
That’s enough to get me to have a quick peek before I ask her to wait until the ward round is over. The baby is tiny. And its blue. And its not breathing. And its cold. ‘Perhaps a little more than not feeding’ I think to myself grabbing the stethoscope and ambubag and putting the baby straight onto our resuscitatire.
She has a heart rate. Not a good one but its there. My clinical assistant wanders over (yep…wanders). I resuscitate , give oxygen, she starts breathing. I put in a line, give her some fluids and antibiotics. I revise resuscitation with the CA. She weighs the baby – 1.1 kg….i wonder to myself what weight the baby was when it was born?
I restart the ward round keeping an eye on the new one. The nurse returns back in the room. I cross my fingers that the electricity stays on so the heater and oxygen concentrator work. It does. This baby survived. And no complications after a couple of weeks – at least so far. Little miracles.
Its early in the day. I just got to work – about 7.30 am. I arrived at the hospital and am supposed to head off to ‘morning report’.
Morning report could take a whole blog entry in itself, but basically its an hour of nurses, sometimes one of the other 2 doctors here, and clinical assistants reporting on what has happened overnight, any deaths (although they often forget the babies) and a big long list of expenditures of the hospital, what drugs and supplies we don’t have and a long period of other comments from staff. Most of which, in my opinion, does not require almost all of the staff of the hospital to be present, as there is plenty of patients that need attention. Anyway, sorry for the diversion…
I decide to head to the unit first just to check things are ok before I head for an hour of morning report.
A new admission has just arrived. People often turn up first thing in the morning, as travelling later in the day or at night is diificult and often dangerous. This mother is upset and has her 4 week old baby with her. The baby is very sick, has not been feeding and has been hot for 3 days. He has a temperature of 41.1 0 C with a very fast heart and respiratory rate. He is not active or alert. He is vomiting. It is the strangest colour dark yellow/orange that I have ever seen come from a babies stomach.
We start treatment immediately and I put an tube into his stomach to get out all of whatever this funny looking vomit with powdery bit in it. I ask if anyone has ever seen it before. The lovely nurse on shift, usually helpful and chatty, looks at the mother quietly but doesn’t say anything to me.
After several minutes the nurse eventually says it might be ‘local medicine’. I ask the mother, several times, she denies it. Normally the other mothers in the room are quiet when a very sick or severely asphyxiated baby comes in, but something unusual happens…I think they realise this baby is very sick. They start talking to this mother firmly and demanding she tells me the truth. The mother quietly tells me for the last 3 days since her baby became sick she has been giving her baby powdered local medicine. She has no idea what its called or where it is from. She got it from someone in the village. Her village is not very far from the hospital.
Sadly, despite everything we do this baby dies a few hours after admission. Overwhelming sepsis and likely posioning from local medicine.
Primary education is free for all Tanzanians. Not everyone goes, and many don’t finish. But secondary education you have to pay for so not many can afford to go. The official statistics are that only 1 in 4 secondary school aged children actually attend secondary school.
There is a lot of evidence out there showing that educating women to secondary level has a significant impact on infant and child mortality rates. There have been so many times I see this practically in reality. Pregnant women do not attend free antenatal care. They deliver with no skilled attendant at home. Mothers bring their babies and children in too late. Mothers take their premature babies home when they are not ready, because despite a lot of explaining they don’t seem to understand. Mothers who feed their older children only on maize porridge made with water and nothing else and wonder why they are malnourished because they are not hungry. Mothers of older children who think I am not a good doctor because I don’t always give them lots of medicines (although i guess this also happens back home in the UK!). Think I will stop there… its an endless list really.
So maybe really concentrating on sendingshould be doing to impact child and neonatal mortality in Africa is concentrating on sending girls to secondary school, not trying to make a single neonatal unit run better in rural Tanzania…!
So maybe a nice story to finish. Sorry if any of the above stories are too much – they seemed crazy at first to me, but these things happen all the time here.
On my 2nd day in the hospital in Masasi, back at the end of October, a 1 kg baby girl was born. We never know for sure the gestation of premature babies born here. It was the mothers first baby. The baby had cried at delivery and got the usual premature baby care here – hat, heat, IV fluids, antibiotic cover, NG feeds. And she did great. Not much respiratory problems – which is amazing. 1 epsiode of probable sepsis but apart from that she did very well. Her mother was super at looking after her, although a little shy and I think nervous about this tiny baby of hers. Here the mothers do all the caring and feeding, and sleep in the same bed as the baby unless they are very sick on the resuscitaire (we have no cots). The nurses take the occaisional temperature, put in IV lines, and give drugs.
Something special happened with this mother though.
Because she was in the unit for so long one day I asked her if she would teach a new mother how to tube feed her baby and do kangaroo mother care (basically skin to skin, baby to mum, to keep them warm). Initially she asked me for money. A common response to a mzungu here. I am not sure if she was joking. I did the usual explanation that I was a volunteer this year, that I wasn’t paid and did it because I like children and just because I was white I wasn’t doing cash handouts etc etc. She seemed a bit timid to help the new mum, so I didn’t think anything else of it.
However after a weekend away (swimming in the sea and having a wee break) I was standing outside the window of the unit and looked in. This mother was going around the room talking to, laughing with and encouraging all the new mums who has come in over the weekend. She was showing them what she did with her baby and teaching them and helping them tube feed their babies and reminding them they needed to feed every 2 hours. It was just brilliant. She was doing much more than I could do because they were all in it together, and they also got the emotional support from each other.
Her baby was discharged after 7 weeks. She weighed 1.9 kg – mum had no more food for herself and no- one else could support her to stay in the hospital any longer. But she came back every week for a review (and lots of chat with the nurse on shift and other mums). Her little one is now 3.1 kg, looking chubby, and doing great. I asked her if she wanted a job to help in the unit. She laughed and said sorry, no, she was too busy.
It is in a beautiful setting. Mangoes fall of the trees and hit the corrugated iron roofs and make me jump. All the time.
I think it has around 250 beds, but usually around 150 patients. It suffers from many of the usual district-general-hospital–in-rural-Africa problems. Not enough staff. Not enough trained staff. Poor motivation amongst the staff. Not enough money. Not enough drugs. I am the 2nd ‘doctor’ (or MD as called here) in the hospital. The rest of the medical staff are made up of medical officers and clinical officers (2 or 3 years training). Some are pretty amazing and very experienced and skilled in all sorts – surgery/ c sections etc etc. Others are not.
The lab. It can do a haemoglobin. Most of the time. They can do a blood group. They can do malaria and HIV rapid tests. They can check sputum for TB. That’s it. No cultures. No urine disptick or renal function. No other fancy tests. They have a posh-looking CD4 count machine (for HIV) but its not working at the moment.
Imaging. There is an Xray machine. Currently there is none of the fluid used to expose the films so they have not done any for a week or so. There is an ultrasound – I think it actually may have come out of The Ark.
We have electricity. Most of the time. When it goes off the generator is supposed to go on. But it needs fuel. And that is expensive. I have yet to hear it switch on.
We have water. Yippeeeee! But not running water. But I have a bucket with a tap on it and soapy stuff – actually works just fine. And then I have meths – 70% alcohol watery purple stuff which is the equivalent of alcohol hand gel. I have no idea what will happen to my hands – maybe they will turn all hard and purple too. So maybe I could use them to fuel the trangia on my next camping trip back in scotland.
Welcome to NICU. Its been here about 2 ½ years. Its pretty small but its great that its here. Neonates in many places are regularly not considered. Its not really NICU, more like special baby care. There is one nurse on shift at any one time. Dr Martin (the previous doctor here) was a genius and made sure that the staff don’t get rotated onto another ward, such as male surgical, after they have been trained in babies. That happens a lot here otherwise.
There is usually between 10 and 20 babies here at any one time with about 100-120 admissions a month. Unlike in the UK the mothers stay with their babies and do all their cares. We don’t have incubators so it means that premature babies can get Kangaroo Mother Care (KMC) to keep them nice and warm (basically keep the baby skin to skin with mum all the time).
We have 2 resuscitaires. One works only as a warmer. The other one does not work but is a nice platform to put babies on to put in cannulas etc.
There is an oxygen concentrator. It works quite well, when the electricity is on. We had no thermometers until last week when I got some money from the hospital to buy some (my first tiny success!). We currently have enough antibiotics (and a spare stockpile is stashed away for when the next shortage happens!). We lack some other essential drugs.
So far I have seen a lot of babies with birth asphyxia, neonatal infections and prematurity/low birthweight in keeping with what is recognised to be the 3 major causes of death in neonates. Babies with birth asphyxia can be pretty badly affected here for a multitude of reasons – lack of antenatal care, little monitoring during labour and mothers may have been in obstructed labour for a long time at home before they decide to come to hospital as only about 30% of women deliver in the hospital. A grim reality is that NICU here has between 10 and 15 deaths per month – which is about the same as I have seen in my entire career so far.
On a cheerier note, I have sat down with the lovely team of nurses here and we have made a plan for what we want to start working on to hopefully make things a bit better this next year. We have lots of ideas, many of them very simple, but could hopefully make a big difference. I am also very keen for it all to be sustainable, so much as I like clinical work and stealing the odd hug (my rates of being pee-ed or poo-ed on are up – no nappies here!) I have to concentrate on teaching/training and getting the unit to be a bit more effective.
So that’s the introduction to what its like working here so far. I havn’t said anything about the paediatric ward here yet…but that’s probably enough reading about me for one day… H
So finally I am managing to write my first blog! Its been a long yet somehow very short first six weeks here in Tanzania. And so far it has been great…a little crazy, sometimes a little frustrating, at times very sad and at other times incredibly inspiring.
The first few days were spent in Dar es Salaam doing VSO in-country-training with some other volunteers. Some newbies like me just arrived straight off the plane, and others who had been here a while. It was good to meet fellow VSO- ers and especially others working in the southern region. We are a total range of backgrounds, ages and personalities which was great and made it very interesting! Dar es Salaam is a funny place…I have never really been a big fan of cities, and it is certainly not on the top places I have ever been. Although it is by the sea which usually would get a good rating by me, it is totally traffic congested and can take 2-3 hrs to travel just a couple of miles in rush hour. Makes the M8 look like heaven 🙂
We then all headed off to Morogoro – a lovely town inland next to the Uluguru mountains, for kiswahili language training for 9 days. Learning language has never been one of my strong points!
But I tried very hard (not much point me being here if I cant talk much, especially to colleagues and patients). And of course we all got an elaborate certicate in classic Tanzanian style – the certificate being THE most important thing! In general paperwork and multiple forms for even the smallest thing is important here… receipts in triplicate, signatures by several people on several different forms before something can happen. Very similar to other places I have been in Africa and I am sure some of you have experienced this here! I think it may be a remnant of the colonial era.
I then travelled back to Dar and then headed down the coast southwards by bus after some farewells to new friends. The buses have, so far, not been as terrifying as my previous experiences of road travel in this part of the world. And buses are not supposed to travel after dark here in Tanzania (which means super early starts but pretty sensible thinking by the government).
The coastline in the south is stunning. There is very little tourism at all in the southern region which means lots and lots of deserted beaches. Am looking forward to exploring over the next year.
I spent some time in Lindi, at Sokoine hospital and in the hospital in Nyangao en route to Masasi. My placement is part of a project in these regions trying to improve neonatal care in the southern region as the neonatal mortality rate here is very high at 31 deaths per 1000 live births. For comparison in the UK I think it is around 2- 3 per 1000. Although I have to admit I am very sceptical about these statistics in general – as around half of women deliver at home with no skilled attendant and who knows how many births and deaths are not recorded.
So now I am here in Masasi and have been working for just over 2 weeks now. Before arriving I read in the lonely planet that Masasi is ‘a scruffy district centre…a potentially useful stop…’ which I think is not a very fair description at all! It’s a busy small town, with a big market along a tarmac road (which will be useful in rainy season!). The people are very friendly, welcoming and laugh a lot with me learning kiswahili. Its very green and is surrounded by these beautiful granite hills, and there are lots of tress – including cocunut and mangoes. Yum. Myself and Faith (a very lovely doctor volunteer teaching in the clinical officer training school who also likes a cold beer or 2 on a Friday) are the only white people here so we get a little bit of attention. Sometimes I say that I am already married with 2 children…it helps to decrease the marriage proposals…
I don’t yet have a house to stay in, although looking, so am currently staying in a small hostel at a convent, where sometimes there is running water (not just a bucket) and I cook over a little charcoal stove every night. It’s a bit like the bucket BBQ Denry and I use in the summer! I am quite enjoying the slower paced evenings as it takes 1-2 hours just for cooking and eating dinner.
Have a lot more to say, especially about work, but will maybe leave it til tomorrow. Pole pole (slowly slowly….!)
Oooh and I managed to get a post box (only took 2 weeks to get it) so if anybody fancies sending good old snail mail, it would be lovely to hear your news …. the address is: Helen Poole, PO Box 665, Masasi,Tanzania.