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.
