The forgotten victims of maternal mortality

Blantyre has been wet and miserable recently so we've been trying to find things to do in the city instead of traveling out.  

We found a great orphanage called open arms that we've been volunteering at, playing with the children, helping to feed them etc/  the orphange take in newborns till the age of three some have lost both parents, some just the mother but the father is unable to care for the child for the first few yrs and so the orphanage will look after them and then help to reintroduce them into their community and extended family if they have any. 

It got me thinking what happened to their mothers- and yes although not all of them died during child birth a significant proportion had- leaving the baby defenseless.  The statistics are that if a mother dies during child birth her new born baby is up to 10 times more likely to die in the first two years of life!  And lets not forget the other children that the mother leaves behind of varying ages.  

                                          What a cutie- i want to bring him home!

                                                Malnourished- drink up little one

3 months reflection

So I've been here for just over three months now, most days Ive really enjoyed it and other days I've just wanted to run away and wondered what I'm doing here- overall its been pretty tough going but I've loved it!

Malawian women are some of the nicest i've met (the patients not always the staff), their smiles will light up the room and their gratitude is plain to see and the level of poverty is unmistakable and being able to offer help however small in this settling is so rewarding.   

Its difficult to work under these conditions, the level of staffing is so low and resources scarce.  It would be better if the same things was missing then you could work around it and just do without but its the constant change that makes it difficult, no antibiotics today plenty tomorrow, lots of blood today none next week, cant operate today because -( insert any of the following) no gauze, no sutures, no gowns, lights are broken, tables broken.......On the wards its bp machines broken, no thermometers, no urine bags ( its amazing how many ways u can use a glove),  no pregnancy tests, no urine dipsticks, no gloves!  I thought it was just inefficiency at first- and wondered why they didn't just order things before they ran out- but after digging its a far bigger problem- the central medical stores that supply the hospitals have also run out! Partly because of corruption theres talk of some of it being sold off to private clinics and partly poverty the government just cant afford any!

Then there's the staff- when i first got here i thought they were all lazy and unmotivated, i was frustrated because when ever i asked for observations to be done or medicines to be given or babies to be monitored on labour ward it doesn't happen.  They would complain that they were tired and it would be 10 am, and by lunch time they are napping at the desk!  But these nurses often have to get two jobs to make ends meet and still find it difficult, some have to get two mini buses to get to the hospital and  when you consider that the government hasn't paid them ( again no money) for the last two months i wouldn't want to do any work either, and yet they still turn up!  I still think more can be done with the little that available if every one was just more motivated  and pulled their weight but i'm not sure how without better working conditions this will change. 

Although i've not worked in O&G for that many years, in the UK I had never seen a mother die, i have only seen 1 baby born dead and its heart breaking how many die here unnecessarily!  It really is hard to stomach or even get your head around- you come in to hospital not because you are sick but just to have a baby- something normal and natural but then u never leave- it just shouldn't happen. 

Now here comes the sales pitch to all my medical friends:
What they need here among other things is doctors and although a system cant survive purely on volunteers in the interim while they train their own doctors and specialists it works! 
As well as being hugely rewarding and teaching you about global maternal health, u will leave really appreciating the NHS, the hours and be motivated on your return.  Its a great learning opportunity, i've delivered vaginal breech's, twins, delivered two sets of triplets in two months, done numerous c-section-most pretty difficult.  You learn to rely on your clinical skills and examinations because you cant order a CT, MRI or even simple blood tests like LFT's ( well u can when they have reagents but you will get the results in a week so whats the point)   If gyne is your thing the operating opportunities are also vast.  So if you want to annoy the deanery by asking for an oope and come out you wont regret it- get in touch and i can give you more information! 

Its been a bad 10 days!

Its true what they say- bad times come in waves. we had 3 maternal deaths in the last 10 days alone :(

The first had been refered from a health center having been fully dilated for 2 days!!  2days!! when she got to us she had a macerated fetus still inside, a necrotic vagina and most probably a vesico-vaginal fistula which is a devastating complication of obstructed labour where the pressure of the babies head erodes a hole between the mothers bladder and vagina, causing her to leak urine constantly, be prone to lots of infections not to mention the social implications.  A rapid c-section was done, but the mother died of the complications and sepsis.

The second arrived having already ruptured her uterus,  Im not too sure of her history as i wasn't involved but i heard the tear in her uterus was very extensive and tore down into her bladder, she had lost a lot of blood, we did a hysterectomy and she went to ITU but died the next morning.

The third patient died while i was oncall- it was very sad as it was the first patient who has died that i was directly involved with.  she  was on her 5th pregnancy, she came from home already fully dilated and delivered in the admissions room a fresh still born baby.  she was taken to a bed and then had a massive postpartum hemorrhage- when i was called she already looked like she was in shock, had an unrecordable bp and was lying in about a liter of blood.  w started aggressively resuscitating her, took v\blood tests and gave her lots of fluids. on assessment her uterus wasn't contracted and we thought this to be the cause - we started massaging it to help it contract and giving her medication to do the same- in the uk there are about 4 different drugs you can use here there is only 2 so we are already disadvantaged.  All this helped to slow down the bleeding but it did not stop, we decided then to transfer to theater, to see if there were any products and possible do a hysterectomy if the bleeding didn't settle soon.  we also ordered blood but was told only one unit was available.
in theater the bleeding didn't improve and we couldn't find her pulse - we started chest compressions and she came back, wed called the consultant who arrived and we decided to operate on opening her abdomen it was clear why she was bleeding- her uterus had ruptured- straight into the broad ligament and there was massive bleeding into the retro-peritoneal space.  Id never seen anything like it- we quickly removed her uterus and with the help of a general surgeon we stopped the bleeding.  In total she probably lost 6 L of blood which is almost all the blood she has!  With out more blood she was surely going to die- we managed to find 2 more units but no more :(  I remember a similar case who survived but blood was more available and she had 8 units in total.  blood is a strange thing here sometimes its plentiful and other times very scarce, although there is a blood donation drive in Malawi. 

My consultant the next day asked why she died and i said lack of blood- his reply was no- lack of family planning and in this case he may have a point!  After 5 pregnancies the uterus becomes tired and thin, is less likely to contact properly after delivery and more likely to rupture.

Family planning in still very underutilised in the developing world, there are many teenage pregnancies ( a major cause of death of girls in this age group) and many women who have more than 5 or 6 babies which put them at risk of great obstetric compications. 

Heres hoping thats the bad patch is over for awhile.