Here are photos of a super cute baby boy (with permission from his mom) who delivered Friday morning just before handover. He was weighed in the early morning light, then wrapped in a colorful, new Chitenge (printed fabric) that his Mom had brought for his first swaddle.
After my first call night, I have a few reflections on babies. I hung out with Dora and Loveness in the labor ward and got to witness two SVDs. To state the obvious, this does not make me an expert. About the babies: Firstly, they are super-duper absurdly cute. Secondly, it’s rainy season in Malawi and evidently that includes raining babies. The nurse midwives informed me that we are in peak baby season, which means that the 4 beds in the Ndirande labor ward produce about 200-250 deliveries per month in the winter months. During the rest of the year they average around 100-150 per month. I guess people must stay inside a lot more as the rainy season drags on, thus causing busy labor wards 9 months later. A similar phenomenon occurs in Seattle where we tend to witness baby booms every summer.
We in the medical profession often like to overstate our importance in the birth process. Women have been delivering babies in caves, huts, forests and meadows since the beginning of time, so how different can a birth experience be from one place to another, right? For the most part, the labors and deliveries I observed at Ndirande seem exactly the same as at the “Hotel Swedish” in Seattle. However, there are a few differences that strike me as shocking. First and foremost, there is the silence. During my first day I toured the labor ward and asked, are there any women laboring today? The nurse midwife pointed to a curtain, behind which apparently a woman was laboring in complete silence. She was near completely dilated and uttered not a peep. As a reminder, there are no anesthesiologists, no epidurals Tylenol is the only “pain killer.” Elizabeth informed me that women are instructed by their families that they are not to make noise during labor, lest they disturb the health workers whose work station/sleeping area shares the room with the 4 labor beds. In addition, there are no monitors and women do not routinely get IVs placed in labor. That means no background of galloping fetal heart beat and no incessant beeping of occluded IV lines. Fetal auscultation is done with a metal fetoscope. The only Doppler on the Ndirande campus was brought a month ago by our Swedish team, mostly because we are not reliable enough at auscultation with a fetoscope. In summary, the labor ward is silent aside from the conversations of the nurses around the work station.
Finally, after visiting the labor ward for rounds and borrowing supplies for over one week, I heard one woman make a few groaning noises while in labor, similar in scale to what one might hear in a public restroom if the person in the stall next door had too much cheese the day before. The utterance of those few groans provided some relief to me that Malawian women were human, albeit with more “mind over body” power than I previously thought humanly possible. And then, with one more push, she delivered a 2.7 kg baby, followed by a big gush of meconium stained fluid. The infant was hoisted to her belly by a nursing student, who dried the infant with a chitenge and clamped and cut the cord. He cried vigorously and I let out the breath I didn’t realize I was holding for those few seconds. A meconium delivery is treated with more fanfare in Seattle. Mec deliveries are attended by a neonatal nurse in addition to the L&D nurse assigned to the baby, and usually involving suctioning and monitoring if not a brief intubation to suction beyond the vocal cords. The newborn is whisked to the neonatal resuscitation table and ideally suctioned prior to taking its first breath to prevent meconium aspiration. At Ndirande, there was no whisking away or suctioning, no additional helpers. In fact, the one nursing student attended the birth, did infant care and cleaned the bed. She delivered the placenta, carried the baby to the scale, swaddled the baby in a dry chitenge, and then gave the baby a dose of a milky liquid solution that I didn’t recognize. It was Nevirapine, the first of 6 weeks of Nevirapine he would receive because his Mom is HIV+.
At 6 weeks, he would be tested for the HIV virus and could stop the Nevirapine if no virus was detected. I learned at the Ndirande ART clinic that the vertical transmission rate is 1-2%, and HIV+ women on ART are now encouraged to breastfeed because too many babies had died of malnourishment when breastfeeding was prohibited for fear of transmission via breastmilk. At 6 weeks, seronegative babies are started on Cotrimoxazole (Bactrim) for prophylaxis (in case of transmission via breastmilk), which is continued until they complete HIV antibody testing at 12 and 24 months. After 24 months, they are done breastfeeding so their risk of mother to child transmission has passed, the Cotrimoxazole is stopped and they declared HIV free. I can just imagine the neonatology and pediatric infectious disease consults that would likely accompany this child’s birth and neonatal care in Seattle. But like anything, practice makes perfect and Ndriande has neonatal HIV care down pat. Based on the long lines at the ART clinic every morning with moms with babies strapped to their backs with chitenges, there is plenty of opportunity for practice here.
I left my first call night feeling a little dazed and extremely grateful for the opportunity to learn from the vast experience of the providers here. Elizabeth drove me to the Hutchinson homestead in the morning, and as always she was full of curiosity and thoughtful reflection about our role here as supporters of the ministry of health’s clinical and educational functions. Dr Makwero’s vision for family medicine in Malawi is truly inspiring. I am learning so much, thanks to the Malawian doctors and clinical officers who do this hard work day in and day out. In my week of work I feel a shadow of the weight of what they experience routinely. For example, we have diagnosed 4 third trimester fetal demises in the week that I’ve been here. Supporting Ndirande to become a family medicine model for comprehensive, decentralized health care will improve access and outcomes. Dr Makwero and her team of clinicians need foot soldiers, assistants and colleagues to help materialize this vision, and I am so grateful to play a tiny part in it.