The Ripple Effect

Driving home from the hospital today we (my two midwifery colleagues and I) compared maternity care here and that available at the State tertiary referral hospital in Perth. We all agreed that if women who refuse treatment could see what happens when there is no treatment and found a balance between the two extremes, then perhaps they would have a different view of the service they can access so readily and at no cost in Australia.

We saw orphaned babies in the nursery because their mothers had died, we saw many women with eclampsia (seizures in pregnancy or after birth due to high blood pressure), a woman who was having continuous seizures due to a cerebral vascular accident 20 days after giving birth, 2 babies with Spina bifida, many preterm and small for gestational age babies, sick babies with infections, seizures, birth asphyxia. I saw 2 babies being wheeled out of the nursery because they had died. It really was overwhelming.

In a situation like this it is quite common to feel so overwhelmed that you become stuck in a state of inertia. The images are shocking to all your senses: sight, sound, smell. I’ve found that I need to focus on one thing that I know I can do. So for instance, in the nursery this morning, where the room is kept at 34 degrees centigrade because there is not enough room for incubators, I saw a mother struggling to express breast milk to feed her baby. So, I gathered up the course participants in my group and we proceeded to offer her some education and practical help. Soon other mothers sitting nearby (the room is so small and the mothers are crammed on a wooden bench down the middle) were asking questions and looking at us like sponges wanting to soak up information which may help them as they care for their sick, small and preterm babies. I was delighted to see the students teaching and sharing information with the mothers that they had learned in class. Needless to say they all achieved a pass in their breastfeeding and care for the small for gestational age or preterm baby!

I just want to add here that I have never sweated so much as I did in the neonatal room. There were rivers of water streaming down my face and body. If I had just given birth and was anaemic too, I would have fainted and been lying on the floor…

In the maternity ICU we went through the case histories of the eight women there. One after the other had been referred due to having seizures. A number of them had lost their babies (fresh stillbirths) and most had had very little antenatal care. I remember last time I was in Tanzania, I read the book “Call the Midwife” which gave me great insight into the state of maternal health in postwar Britain. I recall thinking at the time that the issues faced by those English women are what these African (and PNG) women that I have come across, deal with in 2014. Many deaths of mothers and babies can be prevented through quality antenatal care, family planning, birth with a skilled attendant, breastfeeding supposed and infection prevention and control.

The sister in charge of this ward gave us some great education about the cases she deals with on a daily basis: With very little medical support, few resources and hardly any equipment. There are no IV pumps so that the dangerous medications being given can be properly titrated. There is only one ventilator and cardiac monitor between 8 patients. And there are only 2 nurses between 8 acutely sick patients. I tried to encourage her and offer some support. I got the feeling she was moved by what I said.
So, to end this blog post, what shall I say? My senses are overwhelmed. My heart breaks for the suffering of the people. I feel for the staff. But I am also so encouraged by the improvement in the knowledge and skills of the course students. The level of care & kindness is delightful to see and they have told me that they feel more confident in their midwifery practice. They are also inspired to go back to their clinical areas to be good role models for others and provide quality education and support to the mothers in their care.

The pebble has been dropped and the ripples are spreading…one midwife at a time, one mother at a time.

Sadness

After a week in the classroom teaching theory, today was my first day in the clinical area. On arriving at the large hospital we saw a man holding a small baby wrapped in a kanga matching the one worn by his wife who was walking a few paces behind. It was obvious he was carrying a dead newborn. He was standing tall and carrying the child with dignity and grace. I felt a deep sorrow for this family.

Later this morning I cried with a mother whose baby had died in the night, 2 days after a planned caesarean. Her first baby had been stillborn at term. She looked at me with puffy eyes from all the tears she had shed and said, “I have no baby. I want my baby. I have deep deep pain in my heart.” This while mothers with their new babies were busy in the beds nearby. My heart broke for her. All I could offer was to pray for her and she immediately said, “yes please” and bowed her head.

Another woman was lucky to survive a ruptured uterus. Her baby was also alive, strong and desperate for a good feed of breastmilk. And another was cuddling a tiny baby weighing only 1.9kg but born at 40 weeks. She had severe pre eclampsia which causes growth restriction in babies during pregnancy. Together with the course student, we advised her about how to help this baby survive: 2-3 hourly feeding plus offering extra expressed milk ‘top ups’. Kangaroo mother also to keep the baby warm and assist with his growth and development. Kangaroo mothercare is a way of placing babies skin to skin with the mother, between her breasts. The baby stays in this position to keep warm, help stimulate and regulate breathing and heart rate as well as promote breastfeeding.

It was interesting that during a discussion with a midwife from the pre eclampsia ward, she mentioned that they are now very busy due to an outbreak of PE. For a moment I had to think through that comment because I immediately thought of outbreak in relation to something such as influenza, Ebola, or hepatitis. This, however, she was referring to the increase in numbers of women presenting or being referred to the hospital due to PE. Then there was lots of discussions about what was causing this outbreak: stress, poor diet and nutrition… I then said that perhaps the reason for the increased numbers of PE patients was due to improved quality of care: better understanding of the disease, better detection and referral for treatment and management. She quietly contemplated that theory as she walked away…

I came home feeling I had experienced and learned so much. I hope the course participants feel the same way too…

Teaching & Learning

I’m sitting in the Midwifery training centre at Muhimbhili Hospital, DaresSalaam. My midwifery colleague is teaching about Hypovolemic shock. Her voice echoes in the room which is tiled and closed while the air conditioner whirs in the background. There is a regular dripping of water from the aircon into a bucket below – yesterday it just dripped onto the floor and we had a slow flood in the room.

It has been lovely to meet up with the midwives who attended the Foundation unit with me last time. They have told me many stories of how they have found the training helpful and they’ve been able to use it in their areas of work. Two nurses told me how they had a woman who was having difficulty pushing the baby out. She was tired and the baby seemed to be staying in the birth canal. They then got her to change position and be more upright and immediately the shift caused the baby to descend and be born. They were very happy to see that this intervention worked.

Another told me that they were now feeling a lot more confident in teaching and advising about family planning. I think what has happened is that they feel encouraged and better equipped to provide quality care. It feels good to hear that positive feedback.

I happened to notice the office of the Tanzanian Midwifery Society so took the initiative to pop in and say ‘Hi’. It was wonderful to meet the project coordinator there and talk about all things midwifery.

Training Midwives in Tanzania

I have been in Tanzania for the past week teaching midwives. This time I and a fellow colleague are delivering the Intermediate course to 16 participants who have already successfully completed the Foundation course which was facilitated in June- July. I started writing on the plane…

I’m on a plane to Dares Salaam. Another hour and we’ll be there. I’m amazed at how calm I feel. This is highly unusual for me. Usually I’m full of tension and anticipation, but this time I feel quite relaxed, unperturbed and remarkably at ease. I believe this is as a result of the prayers of friends. A number of people sent me messages of prayer support. I’ve really needed it. The last few months have been full, a bit hectic and challenging. I’ve had to prioritise my responsibilities, building boundaries around myself to ease the waves of deadlines overwhelming me. For me personally I draw great strength from my faith in Jesus to help me cope with life. Recently in the daily ‘Every day with Jesus’ I’ve been meditating on how Jesus coped with the stresses and strains of life during his ministry on earth. There are some startling truths, especially in regards to looking after one self. I love the fact that he often withdrew from the crowds to pray and meditate. He also spent dedicated time with his disciples to teach them and go deeper. Jesus also never allowed time to run his life, feeling pressured. Rather he showed great peace and calm as he went day to day, teaching, responding to people, healing the sick, engaging in conversation. He never overlooked the poor, needy, sick, vulnerable or outcast despite the stresses and strains crowding in on his life.

There are a number of lessons that I have learned from this series of studies lately which I’ve been trying to apply to my life:
1. Be willing to forgive all injuries and offences
2. Have a servant heart
3. Maintain inner strength and peace
4. Look for good in difficult circumstances- find God’s perspective
5. Maintain focused determination
6. Have good time management
7. Don’t get bogged down in self pity

It’s challenging, but achievable with God’s help.

Oncall Midwife

I have always wanted to be a private midwife, providing individualised care to women. Being oncall is part of that role. I’ve been that midwife twice before in Perth, supporting friends when giving birth. But now I find I’m providing this service on the end of the phone. Supporting women in remote villages of Papua New Guinea! And I’m in Perth, one of the most isolated cities in the world because of its geographical isolation from other cities.
Last year I had the most amazing experience to give guidance to Vivien, a village birth attendant from the village of Kambaramba, who was supporting a woman who had been in labour for 2 days and was having difficulty. After a few phone calls and lots of praying, the woman spontaneously gave birth and both mother and baby were safe because of the actions of Vivien.
Well, last month I had another experience of being the oncall midwife and this time it was to Vivien herself. She was expecting her 7th baby, not by choice but by chance, due to the lack of family planning available to women in this remote area. When I was in PNG last month with the charity, Living Child Inc. which I founded last March, Vivien was meant to come to our training in Bunam. Sadly, the boat she was meant to come on broke down and her husband also said she was feeling ‘heavy’ and unwell as she was due her baby very soon.
I spoke to Vivien on the phone a couple of times and she reassured me she was going to go to Wewak to deliver. We discussed the fact it was her 7th baby and so she was at high risk of bleeding after the birth. This birth would also be just 13 months after her last baby was born.
Prior to travelling to PNG on this most recent trip, Vivien’s husband had sent me a text message asking for a carton of condoms because he didn’t want his wife to die because she was pregnant. Sadly this is a common fact for many couples in PNG: if you have sex, there’s a very high chance the woman will fall pregnant, and there’s a very high chance she’ll die. Every day 4 women die in PNG from pregnancy related problems. And from the stories I’ve heard from the people along the Keram River villages, the rate is much higher.
So, on this particular evening, as I was settling down to have dinner with my family in Perth, Western Australia, I had a call from Vivien. “Sara,” she said, “Please help me. I’m in labour for 3 days and am very weak”. I could hear in her voice that she was weak and I was thinking, “why is she not in good labour with her 7th baby. There must be a problem”.
“Where are you Vivien?” I asked, hoping to hear that she was near the Boram hospital.
“I’m at home. Sara, please pray for me”
My mind was racing. This is not good. 3 days of spurious labour. The baby must be in an unfavourable position. I knew it would be dark and it was too late to call Samaritan Aviation as I presumed that Mark, the pilot, would not fly at night.
‘Are the contractions strong Vivien?”
“Not too strong. They come every 30 minutes”. This did not sound like active labour. She was showing signs of a very long latent phase of labour which is not a good sign for a woman who has had 6 previous babies.
Vivien was showing two signs of high risk for birth: more than 5 pregnancies and a long pre labour.
Silently I was praying to God to give me wisdom and the right instructions. It’s actually quite hard talking on the phone to someone who speaks another language. It’s much easier when you can see their face and use signals and actions to emphasise your message!
“Vivien, have some tea or water to keep strong and have some rest. Can you have some kaikai (food)?”
“I’m too weak for kaikai, but I’m taking tea”
“Ok, good. Now you must rest and in the morning travel down to Angoram so that you can get the Saman Balus to Boram hospital. I will call Mark and let him know”
“Ok. Thank you Sara”
“”Can you feel the head low in your pelvis?”
“Yes, the head is down”, she said.
I’m praying for you Vivien.”
I said a prayer over the phone for her.
I came off the phone feeling helpless. I knew as a midwife that it’s not a good sign when a women is in labour for a few days without having strong regular contractions. Something was stopping her from getting into good labour. I was thinking perhaps the baby was lying across the cervix or that there was some placenta in the way. I felt angry too that she had not followed my advice to travel to Wewak, but I also knew that is was always complicated. I was learning fast and from bitter experience that life in remote PNG is hard. They make decisions based on a whole different set of rules and values and I had to respect that.
‘Lord,” I prayed, “How many times have you brought me to this place where I feel totally helpless. And how many times have you shown me that you are an amazing almighty God who can do the impossible. I’m going to have to just trust you completely.”
I decided to send a facebook message to Mark to warn him that there may be a callout in the morning.
I put my phone next to my bed that night, half expecting a call from Vivien, but hoping that all would be fine and in the morning we’d be able to organise for her to get to Wewak for review.
At 2.30am I woke up from deep sleep to the sound of my phone vibrating on the bedside table.
I could see that there were 3 missed calls from Vivien since 1am.
“Oh no”, I thought, “The spirit is willing but the flesh is weak”. I was angry with myself for not hearing the earlier calls. I jumped out of bed and tiptoed through to the kitchen where my laptop computer is. I closed the door so as not to disturb my sleeping family and rang Vivien via Skype.
Isaac her husband answered.
“Vivien no good”, he said, “She lusim blood”.
My heart sank. Isaac passed the phone on to Vivien and she spoke in a very weak voice.
“Sara, please help me. Me lusim plenty blood”
Immediately I knew there must be a problem with the placenta and that’s why she was losing blood now. It was making sense. She needs to get to the hospital for a c section as soon as possible.
“Vivien, you must get in the boat and get to Angoram where the Saman Balus can pick you up.”
“No,” she said, “Saman balus land behind the school”. She could hardly string the words together. She was very weak and I knew she was in a life or death situation. If the placenta was covering the cervix both her and the baby would die as the cervix tried to open. In these situations the placenta bleeds as it is pulled away from the wall of the uterus and the blood supply to the baby is cut off. The baby dies from lack of oxygen and the mother dies from massive blood loss.
I was now feeling desperate and prayed to God as I spoke to Vivien, to help me give the right instructions.
I told her to tell her husband to call Mark and tell him the situation. I then prayed for her over the phone and sent a text to her with Mark Palm’s number.
There was a part of me that doubted the whole story. Maybe she was stringing me along to get a free flight to Wewak? Maybe I just didn’t know my stuff and was jumping to conclusions about her situation? Maybe I was getting it all wrong and how could I really diagnose a problem over the phone anyway?
I sent a skype message to Mark’s phone telling him that Vivien was now bleeding and needed to be picked up.
An hour later I had another call from Vivien and I could tell she was scared and very weak. She managed to tell me that Isaac was walking somewhere to call Saman Balus. She was asking me to help her and I felt so helpless. Eventually I told her, “God is bigger than me Vivien. Trust in the Lord. Saman Balus will come and get you soon.” And again I prayed for her over the phone.
I then prayed to God as I fell into bed feeling so useless because I wasn’t there to provide hands on care. I told God how helpless I felt and how confused I was about what the problem was for Vivien. I also felt frustrated that I couldn’t get into direct contact with Mark because it was still so early in the morning in Wewak and I wondered whether he would think I was crazy and overreacting in this situation. I told God I trusted that He is sovereign and that he knew exactly how Vivien was. I asked that Mark would get the message at the right time and be able to make a decision about retrieving her.
All of a sudden there was a message from Mark on facebook saying that he hadn’t heard from them yet. I felt deflated. Do I tell him to just get in the plane and go get them or do I trust that God will prompt the right decision at the right time. I chose to trust God and prayed like crazy.
I fell into a deep sleep.
At about 6am my time I woke up suddenly and looked directly out of my bedroom window to a magnificent reflection of sunrise on a tree. Immediately I felt God say to me “Vivien will be ok”. As soon as that thought hit me, my phone beeped to say there was a facebook message. It was from Mark to say, “I’m in the plane going to get her”.
My heart sang for joy as I realised what God was doing.
My family, who had followed this journey with me and felt such sorrow at what was happening, were now joining me in celebrating as we realised that the Saman Balus was on its way.
I prayed for Mark and the mission to rescue Vivien.
It was reassuring to hear that she was very weak and it was good that they picked her up. Then later that morning, I cried tears of thanks when I heard from the Obstetrician at Wewak hospital, that she had indeed had a major placenta praevia. That means that the placenta completely covered the opening of the cervix and there was no way the mother and baby would have survived without a c section.
I felt overwhelmed with thankfulness. Validated as a midwife and reassured of God’s amazing love and provision for his people. I also felt so thankful to God for His amazing gift of connecting Living Child to Samaritan Aviation. What team work!

Hope

Sara David
“Before Living Child came, I was feeling helpless and overwhelmed from all the people dying in my area. Now I have hope…” said Matthew Akimin who walked all night to attend the training Living Child conducted in Bunam (as spoken to Sara in August 2014).
“Before I met you, I was overwhelmed by the deaths of my mothers, sisters, daughters… I cried out to God for help. And then Living Child came” said local midwife, Rhondy Ktumusi, as spoken to Sara in February 2014.
“I have helped many women to give birth in the village. A baby was born dead, but I remembered what you taught me last year. I rubbed the baby and took the mucous out of his mouth, and he came alive” said Roslyn, a village birth attendant from Bunam, to Sara, August 2014 (Roslyn had a huge smile on her face and her whole body spoke of the pride she felt that she was able to assist this mother and baby).
From hopelessness and helplessness to hope. This was the theme that ran through our most recent visit to the remote village of Bunam along the Keram River in East Sepik Province. It marked exactly 2 years since I’d first visited PNG. During that visit, the feeling I got from the villagers, the women, the men was of hopelessness and helplessness. I remember writing down that they seemed so overwhelmed from the deaths of mothers and babies, that they were stuck in a deep place of sadness and sorrow that they couldn’t get out of themselves. And despite the fact that many times I have felt that we are not doing enough, a momentum of hope has been ignited within their own communities and so the people are starting to do things to help themselves.
For example, this time we noticed a different more positive vibe in Bunam, men had cut the grass on what was the airstrip, hoping to get it back to an acceptable condition to allow an airplane to land for emergency evacuations. Despite the Health Centre at Bunam being closed for over 8 years, Matthew, a volunteer paramedical, was making visits to assist the people. The forms that I had given out to the village birth attendants to record their use of birthing kits, were diligently completed. And there is an excitement amongst the health volunteers (Village Birth Attendants VBAs, Merisen Men/Meri) that what they are learning and then doing is making a difference in their villages.
Although it was very disappointing to have to leave the village earlier than planned due to some unrest,I feel we made the right decision. I certainly got a sense that the locals love Living Child, they want us to come back and that they are benefitting not only from the education, training & resources we are providing, but also from our physical presence: encouraging, supporting, showing love & kindness to them.
The highlights for me were the fact that Living Child in a very short space of time has become a well loved & respected non government organisation (NGO) in ESP! I see our role is to continue to support the locals who have taken LC on as their own, to be able to realise their full potential in providing quality, evidence based maternal & newborn care.
Another highlight was while teaching about the danger signs in pregnancy and when to get help. I divided the volunteers into smaller groups and they had to come up with a song with actions to teach their communities about the danger signs. After a while, they eventually overcame their shyness and presented their tunes. I had not heard them laugh so much! I know they will never forget that exercise because of the amount of fun and laughter experienced by everyone!
Fear of sorcery and evil spirits is the cause of much suffering, especially for women and babies. After teaching about pre eclampsia and eclampsia (a common disease in pregnant women that causes high blood pressure and eventually leads to catastrophic seizures and even death) the health volunteers told me that they now understood why some women had died in their villages. It wasn’t because of evil spirits, but due to eclampsia. I feel this is a huge breakthrough, because if they can then educate their people about the disease process and why it is important to get the woman to a health centre or hospital sooner rather than later, then lives will be saved.