Vaccine Production Lines

This morning all our purchased bedsheets and gloves, plus surgical instruments (thanks to Anika’s aunt) arrived at the clinic and we received the sweetest handclap in gratitude. We also discovered 2 more volunteers from Projects Abroad were starting at the clinic, a grand total of 6 altogether in our tiny labour ward. To the postnatal clinic! Anyone who knows me will most likely have heard of my dream to vaccinate a production line of small African children from preventable diseases. Today dear friends, my dream came true.

Again, I’m so incredibly impressed at the efficiency and documentation of postnatal care. Women come equipped with health records of their baby’s birth weight and one by one each baby is weighed on a communal set of scales. The midwives then council mothers on their baby’s growth; either congratulating weight gain or reinforcing feeding techniques. Family planning services are recommended to women after their 4th baby I think, and this service is free of charge!

Then there’s the immunization schedule:

·      Polio and BCG (tuberculosis) at birth

·      Pentavalent, a combination of diphtheria, tetanus, whooping cough, hepatitis B and Haemophilus influenza type b prevention at 2 months

·      Vitamin A and Measles at 9 months

One midwife observed each of us perform an intramuscular injection and from then on we were left to draw up and vaccinate baby after baby. Watching bubs cry has never been more satisfying! My heart also leaps at the thought of herd immunity, by which babies who are unable to receive a vaccine are somewhat protected from disease transmission by healthy bubs who have the privilege. Also witnessed a neonatal screening test and HIV test performed on 4 year old twins Brenda and Belinda; still wrapping my head around the comprehensive screening! HIV neg by the way.

Heading back to labour ward, we heard the suction machine first. Through the wide open door to the delivery room we could see a huddle of midwives bent over the resus table. I had been expecting it, but seeing a flat baby always brings a lump to my throat. With no idea of the circumstance, I navigated my way in and tried to feel a fetal heartbeat at the umbi, but all pulses were absent. Looking around at the midwife 'bagging' the floppy body, I asked if anyone had attempted chest compressions. The midwives looked at me blankly – “what’s that?” Immediately I began chest compressions, instructing the head midwife when to ‘breathe.’ It felt pretty useless, but I really wanted to try as the mama was watching the whole thing unfold. After several rounds and no response, I asked how long since delivery. I was not expecting 15 MINUTES.

Not a word had been spoken to the mother in those excruciating moments. No doctor was present when the head midwife declared “eh, no life!” and flopped the wrap over his porcelain face. “Pole Mama.” “Sorry Mum.” That was the explanation. The baby boy was left on the table whilst clean up took place.

When the doctor arrived, he took one look at the offensive smelling and horribly discoloured placenta and declared Chorioamnionitis, an infection of the fetal membranes. Thankfully this was communicated to the mama soon after. With no words even in English to give to this mother, I stroked her arm before leaving the room. When her husband entered, I heard her wails echo through the clinic. These poor babies, whilst taken home by the family to be buried, are not cradled or even viewed by their parents. All the while the baby lay fully visable to the ward through the open door.

Trying to piece together all the unknowns, I later asked Dr Japhet whether the baby suffered Intrauterine Fetal Death (IUFD) from the infection. No fetal heart had been monitored throughout labour. The doctor assured me that the midwives were aware of the death, but could not explain to me why they proceeded to attempt resus for 15 minutes. This alone breaks my heart. Chorioamnionitis is a treatable condition.

I’m learning to distance myself from the shock, otherwise it hurts too much.

Breech Twins & Neonatal Resus

MONDAY

Filled with honey toast, ginger tea and unhealthy trepidation, Anika and I turned up at the clinic 8am sharp. Unsure of the fallout we tiptoed around, however handover went on as usual.

I could do the handover for most women without even have attended their birth:

“Mama, Gravida 3, Para 2 now 3, had baby boy, Apgar 9/10 and then 10/10. Blood loss 200ml. Perineum intact.”

Every single woman is the same, interchanging bub’s gender.

I was surprised when the doctor called a collaboration meeting that involved all the midwives and doctors. Through the haze of broken English and Swahili we gathered that the doctor was impressing on staff the varying experiences of pain, highlighting the significance of psychological impact in birth and the need to be ethical and supportive. I feel that if even 1 staff member takes this feedback on-board, I’m self-assured that it was worth taking the fall to provide a positive birth experience for future women.

Our slow morning of dusting and cleaning was interrupted with the arrival of a gorgeous baby girl. Deliveries are starting to blur into one another these-days and Anika and I are super efficient at prepping and often accouchering deliveries whilst the midwives walk in and out of the room.

When I left home I remember strongly expressing that I refused to leave until I witnessed a breech delivery, but I wasn’t expecting the efficient antenatal care that saw most breech babies detected and referred to major hospitals. Today was our lucky day. Upon performing a VE, gorgeous midwife Digna excitedly told us to each have a go and low and behold we felt a heel and toes – a footling breech! Delivery was imminent and we witnessed a giant bulge of the amniotic sac in which we could see 5 teeny toes. When the membranes ruptured, Digna tickled baby’s feet and watched them retract a little: “alive!” she declared. We’ve been taught that breech delivery should be hands off until necessary, but I was not surprised when after two little knees were visible they were gently grasped, pulled and rotated until we saw a trunk and arms. With a screech from Mama the head burst free within the minute, a beautiful baby girl equipped with a good set of lungs.

So fixated on how smoothly the delivery progressed, I thought I’d heard incorrectly when Digna announced “Now next baby.” Undiagnosed twins. It hit me how this news may be considered a burden in a society where raising children puts a huge financial strain on the family; Mama’s reaction was quite indifferent. Digna explained how she considered the possibility of twins from the shininess of the mother’s stretch marks and talked wistfully about how an ultrasound machine would have immediately indicated malpresentation and the pair. An abdominal palpation or fetal heart might have shed some light! Baby number 2 was cephalic and 40minutes later joined his sister, both sharing the same weight of 2.8kg. Mama only had a tiny laceration which didn’t require suturing, and within 15mins of delivery she was snoozing soundly whilst her excited relatives cooed over the bundles.

The other laboring mother who had meanwhile shared the delivery room during the twin delivery was shuffled onto the main birthing bed and neatly popped out her bub, lucky thing got to observe 2 deliveries whilst hers was pending.

TUESDAY

Today was Hannah’s first day of placement, and I was bursting to show a fellow uni student this set-up worlds away from our own. In an attempt not to crowd the delivery room, I went about my cleaning duties whilst Anika and Han assisted in the delivery room. An hour later, I poked my head inside to find the girls and our favourite pocket sized midwife Hawa still coaching the mama to push with no head on view in sight. After an hour pushing for a multigravida (woman with previous pregnancies) back home, doctors would advise intervention. No such luxury is available here however – even monitoring of the fetal heart rate during second stage is considered unnecessary because even if signs of fetal distress are blatant, the midwives are powerless to assist delivery any quicker.

Anika conducted the delivery and did a fantastic job of encouraging the mama in Swahili. Just in case, I prepared the suction, oxygen and resuscitation equipment as none of us had any idea of the condition of this poor squeezed baby. Anika finally managed to deliver the tiny girl through the thickest mec I’ve ever seen, and immediately the situation looked grim. Throwing Hannah the suction, I told her to suction immediately, however being used to complete supervision back home, she hesitated for a moment waiting for the midwife’s instruction. It became very clear to me that we were running the show and I was determined not to watch this baby go downhill under the casual proceedings of the staff.

When suction was ineffective at stimulating the baby to breathe, Anika cut the cord and Hannah and I whisked bub to the resus bench while Anika tried to comfort the mother and complete the rest of the delivery.

Tiny champion

At this point adrenaline kicked in. Working like a well-oiled machine, Hannah monitored bub’s heart rate whilst I dived straight into positive airway pressure with the doll sized ambu bag. I thank God that we’d been so comprehensively taught neonatal resuscitation only months ago at uni, because we were able to sequentially work our way through the process of 30 seconds bag and mask - assessment. At one point when her tiny heart rate dropped to 58bpm, dangerously far from the normal 110bpm, I thought for a millisecond we were going to lose her. Her body was limp as a ragdoll, her skin colour almost unidentifiable due to all the meconium. One midwife pressed a set of adult sized nasal prongs in bub’s nostrils, however after observing no respiratory effort in 10 seconds I pulled off the prongs and attatching the O2 back to the ambu bag continued resus.

I remember looking over at Mama who was tear stained with fear and smiling encouragingly at her, before whispering to Anika “this baby is still so flat.” After 2 more rounds of positive airway pressure, her heart rate picked up to 65bpm and I was so relieved not to have to administer chest compressions (only required if heart rate under 60). With the midwives stepped back and watching us, Hannah and I gave another round of oxygenated positive airway pressure and finally we were blessed with a tiny grunt. Slowly, her heart rate crept up to 105bpm, and despite significant abdominal effort, she breathed on her own.

Words cannot describe the relief that washed over me.

I also surprised myself this morning. I assumed I would be frightened, panicked and emotional in such a situation, but in fact we worked methodically and rationally. I remember rubbing her tiny body over and over whispering “come on baby, come on baby” in a voice that didn’t shake with fear. What an experience.

Midwifery: Massage experience required.

The day goes on. Around lunchtime we had 2 women in the delivery room, both 8cm and such sweethearts. When the midwife left the room, we implemented the tiniest aspects of midwifery care from home by I massaging the mama’s backs whilst Hannah encouraged upright positioning. It turned out to be quite hilarious in the end with each woman wanting what the other was receiving in terms of massage and swaying. We had the room in fits of giggles and for the first time in weeks I rekindled my passion for assisting women on their journey.

Soon enough, I assisted with the delivery of another girl, healthy and perfect to mama Sauma and I really valued having the established rapport with her as opposed to meeting women at the point of upmost pain.

Just as the only thought consuming my mind was that of lunch, Anika made a discovery of a 6 fingered 2 day old baby that was brought in for a – shall we say limb excision? The midwives tied a suture around the 6^th finger on what we learned was a hereditary condition and assured us that in 2 days, “drop off.” Only in Africa would you consider removing fingers like docking a puppys tail. Only in Africa.

A Monkey Stole My Sweet Potato!

After hours of glorious sleep and comic relief of Bridget Jones, the weekend began. Mama Liz’s 15 year old nephew Sam is returning to boarding school tomorrow so he took the opportunity to show Anika and I the family farm. A gorgeous strip of vegetation, you’d never guess was only 40m from the highway. We walked serenely amidst the greenery, cows, a shed packed to the rafters of chickens (dinner! said Sam) and a quarry staffed by 14 year old Massai girls who’s lack of standard schooling only enables them only to have an income from manual labour. Sam warned us not to take the dingy looking route past the creak home, warning us of thugs. I pointed out a man lingering on the corner and asked jokingly “like him?” In upmost seriousness, Sam replied “yes, but I don’t think he’ll try and rob you with me.” Oh to feel safe with a 15 year old guardian.

Our final night together, Sam, Liz, Pam, Jess, Anika, Hlin and Monica and I (all Mama Liz’s temporary children) went to the cinema complex, where we discovered the outing to be more significant than the movie itself. Stuffed with a mars bar milkshake and popcorn, we headed into the 10pm session of Immortals. How half the group managed to sleep through the brutal murder, eye gauging and 3D blood splatter is beyond me, but Sam (who’s favourite movie is the Notebook) seemed to enjoy himself. It’s going to feel so lonely without him and cousin Thomas at the dinner table each night.

Rising early on Saturday, we managed to fill almost an entire bus of mzungus on our way to the neighbouring town of Moshi. With no guide in organised, we arrived, divided our large group and ventured on a coffee tour at the base of Mt Kilimanjaro. With only a small hinderance of a flat tire which required 5 Tanzanians to change (how many Africans does it take to change a tyre again?) I was really intrigued to learn the details of coffee farming from our 24year coffee expert Kasee. In the backyard of a fellow coffee farmer, we all helped to make identify coffee beans, pick, shell, crush and brew the first cup of coffee I’ve consumed since being here, delicious!

Perhaps the greatest adventure of the trip was the voyage home, and not the part where I sat next to an albino African woman toting a black baby. We arrived in Arusha at dusk, but night fell almost immediately and our group of 8 was left huddled on the roadside trying to flag down a dala. Afraid to split up the group in different dalas, we waited uncomfortably as countless vans drove past. When local women started warning us to go home as we were unsafe, I’ve never felt so vulnerable.  Aware that group muggings are not uncommon here, I was so relieved to bundle all of us into a single taxi and see the welcoming sight of Mamas fortified red gates.

Determined to have a chill day, Anika and I went to volunteer house Sunday morning to check in on fellow uni pal Hannah who arrived the night before.  The new arrivals make a group of 28 newbies, so the morning was filled with introductions and sharing of life stories. We organized with Hannah to spend the afternoon at Shanga River House, a small bead factory which uses recyclable glass and is prided on employing 97% of staff who are physically challenged, providing them with practical skills, a secure income and on top teaches Swahili sign language to improve communication with the deaf community.

 

After a dabarcle getting there (2 blue dalas what both heading the same way so of course choose the wrong one) we stepped over the crushed glass threshold into the whimsical place of Shanga. Glass of wine in hand, we feasted on delicacies of fresh SALAD, fish, beef, chicken, soup and slice whilst watching monkeys frolic around in the trees; amusing until one jumped onto our table to steal Anika’s sweet potato and Hannah’s donut. The tour of the bead factory gave me an even greater appreciation of the perseverance of the workers as I observed women with hand deformities sew. I was inspired by the creativity here, watching wine bottles transformed into stunning necklaces, keyrings, glasses, mobiles and even lanterns. I love the idea of a sustainable project employing over 50 disabled staff, as only 2% of Tanzanian’s disabled population are able to find work.

Feeling full and content, I was almost able to forget about the clinic tomorrow.

The line between safety and savagery

If my previous blog seemed a tad emotional, apologies but my tears caused an uproar over the past week.

Today Anika and I ventured into town with the intention of “losing ourselves.” Over the next 5 hours of dodging traffic, hi-5ing locals and watching our feet turn black with dirt we

•       Discovered the schedule for the Rwanda Trials we’re keen to observe
•       Shopped in the touristy seen one seen em’ all marketplace
•       Sussed out the cost of flights for Zanzibar
•       Satisfied our cravings for milk products at Africafe where 98% of customers are Caucasian and the menu involves burgers, fries and shakes, however iced mocha on powdered milk isn’t quite as appetizing.

So dear old night shift commenced. The first surprise the doctor failed to mention was that another volunteer from Denmark has been doing nights for the past 2 months... she'd just finished school. As luck would have it, we endured a very slow shift where we learned that midwives sleep in between deliveries, only waking to admit women (from their bed) or to deliver.

Around 7am, the great saga began. A lady was pushing unproductively for over half an hour, and obstructed labour was obvious. A combination of fatigue, psychological distress and overwhelming pain was all contributing to what is considered “poor maternal effort” and despite all her strength she was unable to deliver even the head. I understand that in such a situation, the midwives must do anything possible to safely birth babies, but the violence that ensued absolutely tortured me. When intense fundal pressure (pushing externally on the uterus) was ineffective, the staff began punching the uterus in an attempt to drive the baby out. When the mother cried in pain, she was slapped across the back of the neck, chest and face and punched in the leg whilst retorts of “You’re not trying hard enough!” fell on the mothers tear stained ears. With tears in my own eyes, I held my hands over the mother’s thighs to stop the beating, and could only manage to whisper “stop.”

At last the poor baby was finally delivered to the relief of every person in the room – miraculously she was fine. The mother refused sutures to repair the 2^nd degree tear that had resulted, and at that point I was ready to leave. As soon as I crossed the gates I became inconsolable.

Perhaps the worst part of this entire scenario was that the doctor ran after us to share unrelated news with us when he realised I was sobbing and demanded to know why. I should have lied, but in the moment I explained how overwhelmed I was – bad decision. He insisted on taking action... I really hope this doesn't bring about any trouble. 

Rust in all it's glory.

The following night however, my faith in midwives here was heightened with the discovery of Gasto, the only male midwife I’ve come across here. He was patient and kind to women; when they reached out to him, he’d take their hands warmly. When a lady showed up at 2am with swollen feet and contracting, Gasto connected oedema with possible pre-eclampsia (condition of high blood pressure in pregnancy), monitored her blood pressure closely, dragged out the policy on management of pre-eclampsia and ensured the delivery room was stocked with Mag Sulf, medication used to combat the seizures which can result in serious cases. To our relief, the woman was fine and Anika and I each got a catch; Anika’s catapulting onto the bed in the space of 3 seconds.

Thursday night was a combination of a delivery production line and Swahili lessons. Anna, one of the midwives decided that she would only communicate in Swahili, and devoted the entire night to teaching us lengthy phrases that at 3am flew in one ear and out the other. Keen to learn Swahili medical lingo here, I asked her “What’s amniotic fluid?” Shocked, she responded “see the fluid? How can you have studied 3 years and not know fluid!”

After asking Anna to practice VEs, Anika and I took over the assessments for the night. Excellent practice for determining full dilatation and early stages. Often, we were left unsupervised, and when I declared a woman 1cm, thick and posterior, Anna was satisfied and refused to double check. I spent to rest of the night observing her for signs of second stage paranoid I’d miscalculated her assessment, but on her next review 4 hours later she was a perfect 5cm.

In between the high turn over of deliveries, a woman’s husband after a short visit asked the midwives to assess his wife. As no postnatal checks are performed, it’s up to the women to speak out about any complications. Upon pulling back the blanket, I was shocked to find her lying in a pool of blood. A post-partum haemorrhage is classified as blood loss of 500ml or more, and this woman easily had over a litre (despite her record saying 200ml when I checked the following day). When we massaged her fundus, clots double the size of my fist were evacuated. Moving her to a new bed, she fainted into my arms so I had to lift her, bloodied clothing and all, into bed. The midwives acted quickly and got some fluids running which was great, but I'm not sure what the outcome may have been if her husband had not alerted us all.

As we were leaving after I’d caught an uncomplicated misichana mzuri (beautiful girl), we encountered the clinic’s only female doctor who had been held accountable for the horrible birth we’d witnessed days ago. For 10minutes we endured her wrath – I don’t think she was paid for the shift and for that I felt terrible. Her main gripe was that I cried, with the grilling always circling back to “this is Africa, what do you expect? I don’t understand why you would cry! Would you rather I be nice and let the mother and baby die?”

I regret allowing my emotions to overwhelm me as it was never my intention to point the finger at anyone. The cultural barrier is still tricky, and now my greatest fear is that we will not be welcome at the clinic. The upcoming 3-day weekend is much needed!

Verge of Tears

I spent the majority of today on the verge of tears. I’m so thankful this week was my second so that I was mildly prepared for the insanity.

The clinic was in absolute chaos upon our 8am arrival. 10 babies overnight, 5 labourers, and the most staff I’ve seen together at one time all yelling, dusting and changing bed sheets like we might return them if not used immediately. Out of habit I peered into the delivery room and saw a lone swaddled bundle on the resus bench. During handover, I caught a glimpse of the tiny bluish baby being put skin to skin with mum to combat prematurity as the doctor explained. As lungs are one of the last organs to develop, premies often suffer respiratory distress and even from the end of the bed we could hear the baby gasping for air. It’s routine here for all small babies to be pumped full of antibiotics to prevent infection and was to be transferred to the Neonatal Intensive Care Nursery at Mt Meru. Sounded like a good plan to me but in the meantime I asked if the clinic had oxygen to assist bub’s breathing.

“Yes, of course we have oxygen.”

“Can we give some to this baby?”

“We will at Mt Meru.”

So off we go I assume. I should have realized that even in urgent situations, Tanzanian time still prevails. Handover continued for over an hour, midwives answered social phone calls and the floor was mopped before we finally prepared to transport.

Keen to experience the NICU, Anika and I bundled into an ambulance with the schoolgirl mother and baby and waited for another 20minutes before realising another passanger was coming – a mum 10cm dilated on the verge of pushing. Holy moly I thought, something must be seriously wrong to risk delivery in transit. When I found out the diagnosis was “caput” (swelling of the fetal head which I think rarely results in complication and resolves itself) I was so frustrated.

No attention was paid to the flashing lights and sirens as people ambled across the street whilst mama was gripping Anika for dear life and yelping. The midwife meanwhile was demanding she resist pushing until arrival. The teenager was gripping her gasping baby and sliding all over the place. To top it off, her five relatives had come along for the ride. When we finally arrived, I escorted the pushing mum to labour ward where she was given 30mins to deliver or c-section poor thing.

Then came the NICU where these miniscule fighters were laid out in open, rusty cribs. Multiple babies shared beds and in place of incubators for warmth, the room is instead heated. Babies are given nasal oxygen only with no sign of nasogastric tubes so not quite sure how they’re fed. Our premie looked glowing and healthy compared to the frail creatures surrounding him including 30 week twins and a 26 weeker. The fact they are alive is miraculous.

Back in the clinic, the delivery room was buzzing. Two women each occupied a bed; one was attempting to deliver and the other was being whisked away minutes after deliver by the midwives to clear her bed.

The aforementioned young women was pushing and pushing with no progress. In Aus we might suggest a position change (off her back for goodness sake!) or consider vacuum extraction. To my absolute horror, the midwife roughly stretched the skin to the point of tearing and reached her hand inside to physically grip the head and pull. Not surprisingly, bub was born unresponsive with poor tone, grey in colour and no respiratory effort.

Hands down the most frustrating part of this whole experience is witnessing simplistic care when effective equipment is available! Back home, the policy for an unresponsive baby is to first stimulate, and then assess and clear the airway. Whilst the clinic has working suction some midwives aren't familiar with it and prefer not to use it. For 4 excruciating minutes I watching the midwife rather gently pat the baby on his mothers stomach, and only when his nose was cleared did a weak cry escape him.

I was shaken and about to walk out when another woman flopped onto the second delivery bed to begin pushing. Whilst Anika conducted that delivery, I was cradling and monitoring the first baby. His poor mama aged 20 had a fear of needles and was refusing to let the midwife repair her second-degree tear. I felt tears in my eyes as the midwife shoved her legs apart yelling how she must obey. The needle of local anaesthetic was waved threateningly as the mum desperately tried to bat her away.

The new mum could not be convinced – and by this point who could possibly blame her – and was allowed to return to bed. No pain relief administered. No education on care of tears. No ice to reduce swelling. Everything I value in midwifery care, especially fostering a trusting relationship based upon woman centred care was stripped from this woman. It's definitely a cultural experience I am trying to come to terms with.

Before leaving for the day, we asked to observe a tubal ligation as part of the clinic’s free family planning service. Having never seen one back home, I can only assume it’s a laparoscopic procedure. Everyone seemed very concerned about our footwear, although I found the brief hand-washing to be a bit more frightening. The doctor was so friendly, and made such an effort to talk us (and the mama who was wide awake and flinching) though the entire procedure. We got a shock when out flops a fallopian tube onto mum’s abdomen! It was hand tied with a piece of thread, snipped with those rusty scissors and finally poked back inside. Simple as that.

Night duty tomorrow, may our babies be many and healthy!

Massai at a Glance

What an adventure filled weekend. Anika and I teamed up with a group of med students (Aussies of course) and arranged to visit the volunteer house security guard Zaki’s Massai village. My only experience of Massai so far is of men dressed in the distinctive vibrantly coloured robes paired with staff-like sticks walking around town. I just discovered that every 7 months the Massai hold circumcision ceremonies in which the entire tribe must walk a designated path every night and I was lucky enough to witness the procession. Admittedly I was hugely intimidated when I hopped out of a taxi one night to find a mob of stick yielding men marching towards me, their eyes and teeth glowing in the dark.

During the 3 and a half hour journey to the village, we slowed to avoid a huge roadblock which turned out to be a horrific motorbike accident. I’ve never witnessed anything so raw; a crowd had gathered of wailing women and unattended bodies were strewn across the road – one of which I’m certain was dead. The med students questioned amongst themselves their ethical obligation to assist, but I remembered what another volunteer told me when they came across a corpse on the street a few weeks ago: “Don’t ever put yourself in a situation where you might be questioned for your actions, you’ll certainly face moral dilemmas but you already attract enough attention without endangering yourself.” Feeling awful, we drove on knowing that no ambulance was coming and feeling slightly less secure crammed into an over-packed van without seatbelts.

I was so impressed how Zaki was able to navigate us for hours of off-track driving through dusty nothingness to at long last the Massai village. Quick run down of Massai culture – Massai are Kenyans who live nomadic lives in small communities eating only the cattle and goats they herd. Women walk for 12km for water and sleep with all their children (husbands sleep apart) on cow leather inside huts made of mud, cow manure and sticks. Children are educated in the Massai language and may only marry other Massais, girls often at the ripe age of 14 or 15.

Stepping out of the van, we were greeted with hundreds and hundreds of flies and a procession of jewelry clad villagers chanting and singing in a way I can only describe as hypnotizing.  Adorning us girls with necklaces and taking us by the hands, we were lead (doe eyed I’m sure) to dance, jump, chant and laugh with the Massai – such a joyful experience! After much singing, we were invited to explore the tiny houses which were almost suffocating and very dark (no power of course) and then welcomed with soft drink which the Massai kindly de-capped for us using their teeth.

We had heard it was customary to buy a goat from the flock, kill it and share the meal, so a goat was chosen and Michael went off behind the houses to do the deed whilst the rest of us pondered the fate of the goat and whether to drink the blood, a grand tradition for Massai. Following some tears from Anika, Michael returned to report that we in fact didn’t have to kill the goat but could instead make a donation to each of the families in the village. This news was received much more warmly and thus our goat lived to see another day. Or at least another afternoon until dinner.

In parting, the women decorated the tree branches with jewelry right off their necks for us to purchase, and I’ll admit the presentation made the beads and bangles much more alluring. Always keen to barter, I made some beautiful authentic purchases.

Mount Meru Waterfall Trek

Mount Meru looms over Arusha, and whilst I have absolutely no desire to climb it, the waterfall hike was highly recommended to escape from the dust and pollution of the city. I probably should have considered bringing joggers with some tread or perhaps exercised sometime in the last, say 5 months, but the peaceful walk I envisaged was quickly replaced with 6 hours of pain. Whether stomping up the mountain trail or scrambling down steep muddy cliff faces, I don’t think my heart rate dropped below 100bpm for quite some time. The rash provoking plants we were told not to touch seemed to line the path and inevitably I went sliding down the slope clutching at foliage and ended up itchy and battered. I feel that when guides, foot-holes and rough wooden railings are a necessity, the word “trek” should be replaced with “adventure mountaineering.”

That said, the hike along the river leading to the waterfall was really beautiful; I’m pleased to have seen the lush, green, jungle side of Tanzania. For dry season, I was impressed with the torrent. The hike back was strenuous to say the least, but I thoroughly enjoyed passing the large group of age 50+ disgruntled tourists who were slipping and sliding down the trail. Our guides lead us back down to Arusha through many small townships, and this was really a highlight of the trip. I’d been wondering where all the locals were living after only seeing the heavily gated homesteads on the main roads, so it insightful to observe the variety of wooden houses complete with corn crops and a smattering of cows in the front yard. Some locals wanted money in exchange for photos of their homes and let’s not forget how children flung manure at us when passed by without distributing gifts!

It was clear to see the townships growing closer to the main roads; I’ve never observed so many advertisements for “hair cutz” in my life. I treated myself to ice-cream as a reward for burning all those calories – dairy is a rarity with most products made on powdered milk. I remained in a lethargic state for most of the afternoon, which was spent chilling at home with roomies Monica (Canada), Hlin (Iceland) the neighbouring kids and our homestay siblings until the pinnacle of each day – dinner. Not looking forward to the aches of tomorrow. 

Mtoto Mzuri

Eventful first week in the clinic and I’m still surprised to find myself shocked at the health care here. I was horrified to find that the sheets were never changed, as currently there's only one set per bed. Most sheets were bloodstained; this explains why women have to bring their own wraps to lie on. Speaking of blood, it’s absolutely everywhere. Sheets, delivery instruments, the wall behind the birthing bed!? It’s become somewhat of a crusade to remove the stains. This is not aided when I found out that instruments are wrapped BEFORE they’re sterilized! How this even makes the slightest sense is unknown.

Anika and I tried to inconspicuously ask the head midwife what the clinic needs most, and she was very clear – gloves, gloves, sheets and gloves. Oh and an incubator. In an effort to prove that sheets were a necessary item, we Spring cleaned all 20 beds with chlorine, and judging by the thick layer of grime, this may have been the first time. Word spread quickly of our willingness to donate, so we were pounced upon by the doctor and taken (via ambulance) to the pharmacy to buy supplies. A box of 400 gloves is $5 USD here, so thanks to everyone who helped us fundraise, our money goes a long way!

So highlights of the past few days…

·      Handover between shifts is such a great learning opportunity for us and the midwives. The doctor drills everyone, and despite the midwives being fantastic at their roles, their theoretical knowledge is somewhat lacking on even basic midwifery care. They had no idea why to give medication apart from “policy,” and were unable to distinguish between the different stages of labour.

•       I asked to assist with vaccinations one morning, and was firmly told not to touch anything. However as the days have gone on I have administered oral polio vaccines – baby steps.
•       Mobile phones have top priority here; the best example I have is a midwife asking me to hold her phone to her ear whilst delivering a placenta.
•       Also caught a brief glimpse of Mt Meru Hospital, a large government hospital where we refer patients for c-sections, inductions and for possible complications – the most common being “big baby.”
•       Witnessed a baby being born in a car which was pretty exciting. After swaddling the baby, Anika commented that the baby (born with meconium) sounded like it needed to be suctioned, so the midwife set us up and left us to our own devices. I think we only stimulated the baby to cough up a lot, but the midwife basically told his mum that ‘mzungos saved your baby’ so we received some (undeserved) praise.

Today Anika and I each delivered a baby, mine to a gorgeous young mum called Happy (pictured). The bub was the tiniest I’ve ever delivered at 2.7kg – no specific expected due dates here, but the little man did brilliantly. Also the first baby I’ve witnessed to be born "in the caul" still surrounded by membranes, despite midwives telling me she was definitely rupture of membranes? With my limited Swahili, I’ve learned to say mvulana (boy), misichana (girl) mtoto mzuri (beautiful baby) and hongera (congratulations) and this is more than enough to get smiles from new mums.

I adore it here beyond belief, these women are champions to labour so steadily without even a hint of panadol and such sweethearts!

First Baby!

Orientation day! A grand total of 18 of us were starting placement so we had a great group of Aussies, Canadians, Americans and Finnish to learn the happenings of Arusha with. Without trying to scare us, the directors shared stories of muggings, robberies, prostitution and bag snatching. Way to reinforce the safety vibe. After handing over our $500 work visa – carazy corruption in the government – we headed out for a walking tour of the city.

Despite enduring the scalding sun rays on my poor hat-deprived face, we trekked through the dirt road streets dodging vans, buses and motorbikes. I’m still getting lost every time I go there, every shop seems to sell the same selection of drinks, clothes modeled on exorbitantly wide hipped manequins and cell phones. Highlight of the day was discovering Shopright, equivalent to WalMart bearing the slogan Pay Less, Get More. Filled with delicious western foods, my chocolate cravings will be satisfied.

Also experienced our first taste of the Massai markets and 'overwhelming' does not do this place justice. The souvenirs seem mass produced, and matched with keen salesmen who corner you in their pokey shops. I’ve taken to walking down the aisles and streets avoiding eye contact and yelling POA! over and over in response to MAMBO! (how’re you doing? cool!) These guys all want to know your name, where you’re from (KANGAROOS they all cheer) and perform this interrogation whilst holding your hand. Again, no personal bubble here.

Had my first experience of a dala dala too, a form of transport for locals which involves cramming a van which seats 12 full of about 25 people plus goats and maybe some chickens. The ticket master per say hangs out of the van whistling at people to get their attention and mob you to receive the 30cents for the ride.

We left the group to hunt for an internet stick, and 3 of us ended up wandering blindly around town for an hour. It’s almost comforting to know that wherever you go, there will always be dozens of smooth talking men ready to assist you in a pinch!

PLACEMENT

Filled with anticipation and trepidation, Anika and I were escorted to our first day of placement at the local maternity clinic. The head doctor gave us the grand tour, and I have to say I’m super impressed with the variety of services available. Not only does the clinic contain a labour ward, delivery room and under 5 clinic, but a concrete square for postnatal checks and weighs and a family planning clinic. We were told proudly that out of the 213 babies born to HIV mothers, 99.8% of babies were not infected, so positive!

Stepping into the labour ward, I was again overwhelmed by the large room containing 18 beds, most supporting laboring, silent women. Not a relative to be seen, the women lie on their sides and shake their wrists and slap their thighs, yet not a moan escapes them.

Quick comparison outright.

Autralia – one on one care, Tanzania – 2 midwives to the entire ward.

Australia - single room, Tanzania -  crowded ward.

Australia – Labour support people, Tanzania – laboring solo.

Australia – Encouraged to keep active and walk, Tanzania – flat on back.

Australia – Sterilized equipment, Tanzania – cloth wiped will suffice.

And these were the blatantly obvious. I’ve quickly realized that the role of the midwife is to birth the baby and c’est tout. Women are left to labour without support, and any yelping is addressed quickly with a clap and stern shushs, “Shut up, you’re disturbing the other patients.” Forget breastfeeding support, mothers are expected to deal with any baby issues themselves – the lactation consultants back in Aus seem so very luxurious! We came across a woman who had suffered a postpartum haemorrhage, and we asked the midwife if she was being observed. “Of course she is,” we heard, “every four hours.” After a haemorrhage. Naturally.

Sorry to bombard you with gory details but you are reading the blog of a midwifery student here. Perineums are all often classed as intact regardless of grazes or even minor tears. VEs (Vaginal Examinations) are performed without lubrication and consent.  Anika and I witnessed a lady brought into the delivery room to be examined, roughly examined and told to return to bed. Unsure of my place and overstepping cultural boundaries, I simply held her hand through the procedure, helped her carry her belongings back to her bed and gave her a quick squeeze whispering to her “you’re doing so well.” I know she didn’t understand English, but got a smile out of her. Words of comfort go far here when the health culture is so rigid.  

On I go. I was shocked to find that women have to bring everything they’ll need to the clinic with them. Sure you think, baby wraps, maybe even food. Water and sheets for the labour bed? A little harsh. Baby cord clamp, oxytocic medication (used to assist the delivery of the placenta) and syringe to administer this medication? Astonishing. I was curious as to whether women could even afford this, and the consequences of not being equipped. As it turns out, the wrist portion of rubber gloves makes an excellent substitute for a cord clamp. Off the floor I kid you not.

Speaking about these gorgeous babies, I asked the midwife if I could do some postnatal observations on the new babies. She simply laughed at me and told me that it was now the job of the mothers to observe their babies, no baseline obs necessary. I should have known since I never saw a single Fetal Heart Rate performed at any point – not in labour or when pushing. How midwives have any indication of complication is beyond me.

THIS IS THE GOOD PART I PROMISE – DELIVERY OF AFRICAN BABY NUMBER 1!

Anika and I soon learned that to get involved, we had to be assertive and get into the action, therefore stationing ourselves in the delivery room. A lady was on the table (so narrow I was so scared she’d roll off) about to push whilst another lady in early labour was examined on the next table in full view.

Keen to assist, I donned my gloves and planted myself in the action so that the midwife allowed me to accoucher. Suddenly, a head was out and the midwife instructed me to pull, no contraction. Thankfully, bub arrived quickly and safely; a gorgeous little boy. The midwife insisted we weigh him right away (because who new what the weight would be in half an hour?) so poor mum was ignored whilst bub was found to be a healthy 3.53kg. Anika expertly wrapped him, and the midwife instructed her to draw up and administer the oxytocic, leaving the baby abandoned on the counter. Chilly in only 1 thin cloth, I proceeded to hold him for the remainder of third stage, in which Anika delivered the placenta by active management used routinely here.  What an experience, excited for what new bubs tomorrow will bring.

Stunned Mullets.

Stunned mullets. That’s what Anika and I resembled as we stepped through the doors of Nairobi International Airport. Sleep deprived from 20 hours of flying, we just stood clutching our 10 kgs of luggage trying to decipher our surroundings. Left or right? The signs were in English but were more than unhelpful. The security guards laughed at our overwhelmed expressions but didn’t make any effort to assist us, naturally. We eventually navigated our way through the airport, and experienced a minor panic attack when our bags were the very last loaded off the plane. Customs was surprisingly pleasant; although we declared 20kgs of surgical sharps and medical instruments, the paperwork was simply tossed onto a giant pile of blue forms from the entire days flights and we were waved through.

We had a lovely taxi driver who took us the scenic route through Nairobi, Kenya’s capital, a bustling city with countless hotels and political shrines. I didn’t feel the need to explore Nairobi more; half freaked out by warnings of terror attacks around Christmas and acceptance of a standard (albeit a combination of dirt and sealed roads) city, we bunkered down in our hotel/casino? for the night. Only in Africa could you order carbonara pasta and receive an Alfredo’s packet mix!

Next morning we caught the Riverside Shuttle bus, and I would highly recommend it as transport to Arusha, only being mildly harassed at the border by jewelry clad women and beggers. I loved being able to experience the variety of Kenyan and Tanzanian towns by road, from tiny slums to skeletons of promising warehouses. We were treated to amazing sights of Massai villages, dozens of Massai (many children) hearding cattle and goats and a colourful array of a Massai marketplace spanning hundreds of metres. Highlight was definitely the 3 giraffes casually chilling about 4m from the highway.

I’ve quickly learned the nature of Tanzanian men. Extremely forward to the extend of marriage proposals, I met a lovely aspiring chef Freddy who not only offered to let me borrow his phone to call our taxi, but also offered for me to let me live in Tanzania with him forever asking Anika if my dad would mind. 

Arriving at Mama Liz’s house was strangely like coming home despite only having seeing photos. Welcomed warmly by Mama, Jess (from Brisbane!) and Pam, we’ve settled in so well. Mama is an amazing cook, soups, chicken, stews, so there goes my plan of shedding this year’s non gym-ified body. Being New Years Eve, we headed out to a bar with volunteers from volunteer house and Mama Zubeida’s for a night of gin (a flask for $2) many many introductions and squat toilets. Happy New Year ! Our homestay gates lock at 10pm however, so we caught a taxi (along dirt, non lit, drunken crowded roads) to crash at volunteer house – any bed will do.

Today we went to church, all 2 and half hours of it in Swahili. And what better way to get there but squeeze 5 people into the backseat of a car. Personal space is most definitely non-existent here, as well as shall say political correctness? Every time we walk anywhere, we’re followed by cries of “mzungu, mzungu!” white person, white person! The dominant religion in Tanzania is Christianity, and the liturgy was incredible. The 2 choirs had stunning voices which brought tears to my eyes accompanied by choreographed dance moves and an albino African man played the keyboard. A 30 minute sermon was super animated that the language barrier was almost inconsequential. Anika’s neighbour kept translating for us and instructing us; at one point we wondered why the entire congregation was looking at us in silence until the woman told us the priest wanted us to introduce ourselves. “Jina langu ni Emma” has certainly come in handy, and Australia is often received with “Kangaroo!”

Although overwhelmed at the culture shock, the upfront nature of people, the constant staring and frequent occurrence of men holding hands, I’m so excited to start orientation tomorrow and continue to be thrown into the Arusha full throttle.