Sunday, March 7, 2010

Rural nurse’s tales on safe motherhood

First published in The Sunday Times (Malawi) on February 28, 2010

A few years ago, government banned Traditional Birth Attendants (TBAs) from delivering pregnant women. The move was in line with efforts to reduce maternal mortality thereby part of efforts to achieve Millennium Development Goal (MDG) 5 which seeks to reduce maternal mortality and achieve universal access to reproductive health.

At first, there was apparent resistance to the move partly because of the country’s rich cultural legacy. However, with chiefs joining the bandwagon of those encouraging pregnant mothers to be attended to by qualified health personnel, there has been a change. Thousands and thousands of mothers deliver at health facilities manned by qualified staff. And, Malawi has seen some changes. The maternal mortality rate has reduced to 807 per 100,000 live births from 1,120 per 100,000 live births in 1990.

However, apart from driving the nation towards achieving MDG 5 by 2015, the development has brought enormous pressure on health facilities. The need to bolster numbers of nurse/midwife technicians in such facilities has come to the fore. And the situation is at its worst high in rural areas where most of the TBAs used to operate and but which most nurses shun due to the absence of some luxurious facilities like electricity.

KAREN MSISKA (KM) learnt of the effects the ban on TBAs has brought, particularly on health facilities in rural areas and the personnel working there, from 40-year-old EVALISTA MKANDAWIRE (EM), a community health nurse at Chilumba Rural Hospital in Karonga. There are five nurses there and because of the inadequacy, there is one nurse on duty at a time at the hospital which serves a catchment area of about 15,000 people. At the moment, there are three nurses as one is on maternity leave and another is on relief. Excerpts:


KM: What happens when one is on duty?

EM: If working during the day duty, we begin by getting handovers from the night duty nurse. You are told everything that happened during the night. After learning about what happened, you decide which of the cases carried forward from the previous night to take as a priority and which ones to shelve.

KM: What do you do when on duty here?

EM: First, one has do dust the labour ward and prepare it for delivery. Then, you have to determine if the labour ward can handle an emergency. If some requirements are missing, one has to order for some. From there, you have to find out if there are pregnant women that would get into the labour ward any time. You have to examine them accordingly, and see if everything is fine.

If there is no case, then one moves on to those who already delivered. You examine them and their babies. You look at bleeding, and if everything is okay then you go to pregnant women that have come. You examine them by looking at their weight and blood pressure. We accordingly give medication and mosquito nets. We also assist them if there is a problem. Once done, we book them for the next visit.

Next, we move to those seeking family planning. We teach them everything and ask them questions. Depending on their answers, we give appropriate family planning methods.

After finishing with the family planning crew, we move on to those who have come for postnatal check up. We examine them and their babies and ask if the babies have any problem. Once done, we give them mosquito nets.

Once this is done, we go to the wards. We attend all the orders doctors will have done. We do everything in the wards like giving drugs, look at drips, everything. Then we move to the outpatient department (OPD) and work on everything that needs attending to there.

KM: You say the nurse on duty moves from one area to another. Who attends to cases that emerge in one section when the nurse is in another?

EM: Because of the shortage, as I said, there is one nurse and one medical attendant on duty at a time. So when we are out, we leave things in the hands of the attendant. But since they also attend to other issues, we tell guardians about our whereabouts and advise that should something happen, they should immediately come to tell us wherever we are.

KM: What happens when you are badly needed everywhere?
EM: We always give priority to the labour ward. Whatever happens – accidents, whatever – the labour ward comes first.

KM: What happens when two women are ready to deliver at the same time?

EM: If it happens that way, we help one woman deliver, cut the baby’s umbilical cord, wrap it and give it its mother and move to the other. We do the same and go back to the one we first delivered and continue.

KM: Is this what is supposed to happen when it comes to delivering mothers?

EM: No, it’s not what is supposed to happen. What is needed is that everything should be completed. Everything should be declared alright before leaving the mother. But because of the shortage here, we force ourselves to do it.

KM: How many deliveries do you handle a day?

EM: At first, the work was simpler. We looked at between 35 and 40 deliveries a month. But since the TBAs stopped, we are handling between 65 and 69 cases a month. Before the TBAs stopped we sometimes attended to two cases a day, now we are talking of up to five deliveries on some days.

KM: As someone working under such pressure, how do you view reports that government stopped sponsoring students in Christian Health Association of Malawi (Cham) training institutions and that those at Malawi College of Health Sciences (MCHS) will be paying K300,000 fees?

EM: Definitely, the development means that the number of health personnel will remain on the lower side. This means that the problems we are facing now will continue. This is because the number of people going to study for qualifications in the medical field will be small. Very few people would afford such fees. In the wake of such shortages, what was supposed to be done was scale up training.

KM: What would you say is the impact of this shortage and consequent pressure on the patient?

EM: Because of the shortage, we face a situation where you are on straight duty (day duty) and night duty. As such, there is no resting. But a human brain needs rest to work properly. As a result, we attend to patients in an angry manner since we are affected psychologically. People follow procedures to be attended to but because they face an angry nurse, they are not attended to properly. Consequently, they don’t come to hospital the next time because all they think about is facing an angry nurse.

KM: Why did you choose nursing?

EM: As a young girl growing up, I used to admire nurses in hospitals. I really wanted to help patients the way they did. However, nursing in those days is different from nursing today.

KM: Your last words?

EM: I wish government looked at the issue of accommodation here. Nurses are there for government to send here. But where are the houses? Where will the nurses stay when they come? Besides, those who need to go to school should be assisted so that our numbers are boosted.

Monday, February 22, 2010

When accurate reproductive health information lacks

Speaking when she received a K2 million cheque donated to the maternity wing at Chilumba rural hospital by Bottling and Brewing Group Limited (BBGL) on January 27, Vice President and the country’s safe motherhood ambassador Joyce Banda emphasised the need for education in an effort to achieve safe motherhood. In Malawi, sources of education are many. However, there is only one reliable source for such: school. KAREN MSISKA asks, is the system up to the required reproductive health standards?

For all the time she had been rejecting sexual advances from her male acquaintance, Viwongo Manda (not real name) had thought of pregnancy – and nothing else – boggling her mind.

She says that when she was growing up, her grandmother always talked about pregnancy as the consequence of having unprotected sex. She listened soundly.

But once someone convinced and demonstrated to her that not every sexual encounter leads to pregnancy, Viwongo, 17, became a different being. And she has seen the other consequences.

“I wanted to see what it means and I had my first sex about three years ago when I was 14. There was no protection as the one who did it with me said condoms were porous so there was no difference between using condoms and not using them,” said Viwongo recently.

“Of course, I did not get pregnant and I haven’t been pregnant in spite of doing it again a number of times. But I have experienced some things since that first sexual encounter.”

She said, while looking away, that she has had sores and “some bumps” in her private parts and, at some point, she experienced extreme pains when passing out urine.

She added that she never sought treatment during any of these experiences.

Viwongo, who says is in Form III at a non residential secondary school in Mzuzu, could be a tip of a problem that is a collection of misled adolescents.

According to a survey conducted by, among others, Youth Net and Counselling (Yoneco) and published by the Guttmacher Institute in 2007, many adolescent youths have a wide base from which they draw information on sexual and reproductive health.

However, the report – titled ‘Protecting the next generation in Malawi: New evidence on adolescent sexual and reproductive health needs’ – points out that most of these sources of information are inaccurate and grossly unreliable. It identifies, particularly, sexually transmitted infections (STIs) as an element where such inaccurate information exists.

“Although about two out of three Malawian adolescents have heard of STIs other than HIV, much smaller proportions of young people are aware of the symptoms that accompany these infections,” reads the report in part.

“Only one in 10 knew that tenderness in the lower abdomen and itching could indicate an STI.”

The report categorises adolescents as those aged between 12 and 19, and states that most of this inaccurate information is drawn from peers. It says up to 60 percent of the adolescents surveyed said they received sexual and reproductive health information from friends.

It further says adolescent girls are mostly at risk as they are targeted by men who are much older than them. The older men are mostly the ones that infect the young girls with STIs as they might have had other sexual partners before.

On the ground, this translates to an overwhelming number of girls. Results of the 2008 Population and Housing Census conducted by the National Statistical Office (NSO) indicate that there are 844,315 girls aged between 10 and 14 and 651,028 girls aged between 15 and 19 in the country.

Thus, according to the survey, there are 1,495,343 girls aged between 10 and 19 in the country.

Since children aged between 10 and 19 are either in the later stages of primary education, in secondary education or in early years of tertiary education, the question whether their inability to have accurate information on sexual and reproductive health issues is a result of absence of such in schools begs.

The Yoneco reproductive health report acknowledges the availability of sex education in schools. However, it criticises implementation of such education.

It says: “Although sex education is now mandatory in all public schools, implementation remains somewhat problematic.

“For one, the introduction of sex education met with resistance from some teachers. Although their reluctance to teach the subject is said to be waning, facilitated in part by teacher training, some teachers continue to skip some topics because of embarrassment or personal beliefs.”

It says the teachers choose only those topics that they are comfortable to discuss openly and leave out those that would bring them discomfort.

Further, the report says that another barrier to effective sex education is that it is not currently a subject that is tested or graded in the country.

Director of Reproductive Health in the Ministry of Health and Population, Dr Chisale Mhango, agrees and says that if the subject is not examinable students will not pay much attention even when teaching was enhanced.

“We have developed the syllabus for life skills but we do not have nurses who can go to teach it in schools, said Mhango in response to an e-mailed questionnaire late last year.

“The Ministry of Education [Science and Technology] has to teach it otherwise many girls will continue to drop out from school because of pregnancy and, worse still, acquire HIV (Human Immuno-Deficiency Virus).”

A snap check with some students at Msongwe Community Day Secondary School (CDSS) in Mzuzu indicated that the subject has been lined up for examination at Junior Certificate of Education (JCE) level this year.

Ministry of Education Science and Technology spokesperson Lindiwe Chide confirmed that the Malawi National Examinations Board (Maneb) will examine Life Skills at both JCE and Primary School Leaving Certificate (PSLCE) levels this year. Life Skills is a subject that has a sexual and reproductive health component in it.

“Teachers have been sent through some in-service training so that they ably teach the subject. Of course, hiccups have been encountered since the subject was introduced,” said Chide in an interview.

“It’s true that some teachers completely refused to teach the subject the time it was introduced but the situation has improved nowadays since the teachers went through the training.”

The Yoneco report recommends bolstering life skills education at all levels, supporting teacher training so that they impart accurate and comprehensive sexual and reproductive health information and increasing health information reaching the youth.

Whether the situation changes and sexual and reproductive health education is bolstered, one fact will always remain. And this is that, as Vice President Banda put it, education will push efforts to achieve safe motherhood a very long way.

As pan Africanist Marcus Garvey said, an educated community knows what it wants and how to achieve what is wants. But communities made of people like Viwongo would never know what they want and how to achieve them.