Week 3 successfully negotiated

We are working with a group of midwives at Muhumbili National Hospital for the next two weeks. This is the public tertiary referral centre for Dar es Salaam and is a large institution with 1,500 beds, employing 300 doctors/specialists and 900 nurses and midwives.  Over 1,000 patients visit the hospital each week of which about 24% are obstetric referrals.  Interestingly an article in the East African Journal of Public Health  (Simba, Mbembati, Muserru & Lema, 2008) indicated that the majority of these referrals were inappropriate. It has been our experience that the smaller hospitals do not necessarily refer the really sick women and babies.

Entering Muhumbili National Hospital Campus
 

16 participants presented for class on Tuesday.  Having missed Monday, they asked if they could come in on Friday which was a public holiday (we were not aware of this fact until Tuesday - I'm uncertain if they only announce these events closer to the time or if they plain forgot to tell us).  Having said yes to this, they also wanted to attend on Saturday to make up for missing the first day. We are such a soft touch and enthusiasm like this just cannot go unrewarded. 

Eager participants

Creating realism

Shoulder dystocia workshop

Breech manoeuvres

Taking our education responsibilities seriously

Elegant bathroom facilities

A component of the education we provide is to go into the clinical setting with the participants. My immediate impression was that compared with Armana it was so quiet.  I have been told that the lower activity reflects the cooler months, which are June - August.  As a consequence business is much more brisk for maternity from February - April. 

Antenatal clinic waiting and parent education area

This group of midwives is fantastic. They are keen to learn and seem to enjoy having us in the clinical area with them as well. We took the opportunity to teach the midwives about the resuscitation cot that had been donated to them without any instructions, go through neonatal resuscitation and examination of the newborn on a baby that one of the participants had helped birth a couple of hours previously.  It was great as 3 midwifery students and a medical officer were there as well.

 

Consulting with an antenatal client

 Demonstrating neonatal resuscitation skills

Privacy and hand hygiene in labour ward

 Brooke was welcomed into the obstetric theatre 

There are a number of great leaders and champions for the cause in this group.  It will be sad to say "kwaheri". Two days before the final presentation of certificates then its the serious business of planning for the next program.

 

 

 

 

Ref:

Simba DO,  Naboth AA. Mbembati NAA, Museru, LM. & Lema, LEK. (2008). Referral pattern of patients received at the national referral hospital: Challenges in low income countries. East African Journal of Public Health 5(1): 6-9. 

I feel so blessed

I started the day at about 4am thinking about the things I don't like about Dar es Salaam as I had woken up incredibly hot, sweaty and grumpy - no air conditioning or even ceiling fans.  All the power was off which could mean one of several things: a general power failure, a tripped switch, a blown fuse or failure to pay the power bill (it's a pay as you go system)!!  Whatever, it didn't make for a happy little vegemite.  By the time the natural light came it was obvious the generator must have no fuel either as Hamisi the groundsman, is normally very prompt at switching over.  Sunday is the staff's day off and as Friday had been a public holiday it seemed we were destined for a long hot day without even the benefit of communication as the internet modem is reliant on power too.

Brownie/girl guide memories kicked in and I was able to make Hamisi tea and toast by virtue of the fact the the hotplate is gas.  Also boiled myself a couple of eggs.  The eggs here are novel.  Despite the chickens being free range it is virtually impossible to distinguish between the yolk and white.  That being said they taste fine - especially with vegemite toast.  Vegemite the cure all for everything.

 

Tanzanian boiled eggs (ignore the vegemite)

 

Semmy arrived just after 9am to collect Narelle from the airport.  Our usual transport  - the Rav 4 has something mechanical wrong with it but luckily there is an ambuIance at the house that has not yet been passed on to its selected clinic.  I decided to take advantage of the air conditioned vehicle ride to the airport to cool off.

 

On the way to the airport there were so many beggars especially amputees, older women and men, others with disabilities and children.  There is no social security and I believe the GDP is about  US$578 per capita per annum.  If you don't have an income you dont eat.  Children complete school after year 7 unless there is someone who can support ongoing education.  Without education there is limited capacity for work.  It is Muslim society (90%)albeit a tolerant one, but women on their own would find it much harder to find work as well.  There is little option but to beg.  It made me heart sore but one person is unable to change that  status for everyone.  We observed one youngish man smoking a joint on the side of the road.  It's not legal but he made no effort to hide it.  He looked so hopeless and you could see why. His left leg had been amputated above the knee.

 

This is why I feel blessed.  Those inconsequential things I experienced today mean nothing in comparison to the hardship experienced by the people here.  The power and airconditioning is back on, there is food in the fridge, Narelle is back safely and by this stage Orzanna will be home too.  What more do we need?

Zanzibar

 

We decided to spoil ourselves with the weekend away. Zanzibar is fabulous, in a real tropical unspoilt way. Flights, transport to and from the airport, 2 nights accomodation, breakfast and dinner only US$341pp.

 

The four muskateers - leaving on a Cessna

 

The ferries have not received rave reviews in recent history so we opted for a Cessna flight across the water doted with numerous islands.  Our first view was of Zanzibar Town on the west coast. Ali, the taxi driver was there to meet us and it was airconditioned bliss while absorbing the sights.  My first impression is the relative appearance of "affluence" compared with the mainland.  Not affluence in the sense of Park Lane but in relation to people in similar circumstances.

First view of Zanzibar Town

 

Working bullocks

 

Zanzibar dula dula

 

Spice Tour

 

We had been advised by the manager of GHAWA to avoid Dar es Salaam city and Stone Town - the old part of Zanzibar city especially after midday prayers on Friday as there had been some unrest and more was expected. This was disappointing but we managed a Spice Tour instead.  It was so much fun. I was fascinated to hear that the clove tree technically belongs to the government here. Individuals can grow and use the plant but they may only sell back to the state. 

 



Enormous snails

 



Spice tour guide took a shine to Narelle

 



Natural make-up

 

Nutmeg - a star wars spice!

The tree climber

Colubus Monkey Reserve

The Zanzibar red colobus monkey is endemic to  Unguja, the main island of the Zanzibar Archipelago. It is now classified as an endangered species and the reserve we visited is one of the few places at which the population has stabilized  - numbering about 2,500.  Locals  call this monkey "kima punju" which means "poison monkey" in Swahili because of their strong smell. This has caused people to hold negative views about the monkey and even to say that it has an evil influence on trees that they feed on, ultimately causing them to die from their saliva. Our guide was of this opinion too and also told us that if dogs ate the monkey their hair fell out and they got sick and died.  They look really cute though and we had one old lady follow us around, striking poses here and there.

Colobus Monkeys

 



One cool old lady - just hanging around

 

Kichenga Lodge

Our hotel was in Michamvi on the east coast, far from the party crowds but I think the staff and residents felt the party had moved in when we arrived. Girls just like to have fun! The hotel was small and fairly basic but had everything we required for the weekend.

 

One of our rooms and balconies

 

 

 

Views from the balcony

 

First thing we had to do was swim. The tide was quite far out but the water beyond that, in front of the reef, was an incredible shade of aqua. Orzanna and I decided to strike out for the reef. There seemed to be a sand bank of sorts out there as there were people off boats walking along it. About 2km later the reef only seemed marginally closer and the tide had started to turn so we turned back taking our time looking at starfish and unintentionally treading on rather lethal sea urchins. A bit of backstroke, then freestyle, breaststroke, and so on taking advantage of the incoming tide as one does. By the time we got back towards shore there seemed to be quite a number of people swimming and waving at us, so being friendly people we waved back. We discovered they thought we were drowning and had just about every resident and staff member wading out to save us. It was hilarious. What a way to meet people. Not so funny for our other friends who succeeded in imbedding a number of sea urchin spikes in their feet in their rush to get out to us. The Masai on the beach were wonderful at removing them with papaya and acacia thorns.
 

Tide's out

 

Sundowners prior to dinner - mezzanine floor
 

 
Plenty of food
 

Fun times

 Al Rahma Hospital

Unfortunately fun times were short lived and Saturday morning we headed off to the private hospital in Zanzibar city as Orzanna was very ill. We initially thought malaria, however it didnt seem to be that according to the cursory glance afforded her by the Russian trained doctor.  She had a drip, and antibiotics while Brooke rushed to the airport to get a flight back to Dar.  By 5pm, she and Brooke were flying back to the mainland leaving Narelle & I to soldier on.  Someone had to do it!!

 

Fun times are over for one

 

The trip back was a little subdued however we knew what we had to do..............



 

Not letting the side down

 

We solemnly promised we would

Masai watchmen

 

The next day it was serious relaxing because we were each doing double the work... for the team.

 The pool when you are tired of the ocean

 

Taste of paradise

 

We had to say goodbye to Zanzibar mid afternoon and head back home. Final preparation for the new course was required and of course to find out how our friend had fared.

 

 

 Sad to leave especially as Leo wasn't the pilot this time

Out of the frying pan.....

I negotiated the first week successfully, thanks to a very confident colleague.  The weekend brought the arrival of two more midwives.  One who is undertaking her Masters research here and one who had a week's R&R for a friend's wedding in Hong Kong. 

 

This may be interesting - 4 women in the house as well as a very sensitive maid.

 

We get a preparation week between courses. It is also the time to do clinical and get a feel for the practice in  each of the hospitals so we can speak to the midwives with some awareness of their circumstances and of course it serves as my orientation.  Monday was spent updating lesson plans and lectures and doing running repairs on the abdomen and emergency pants. Then it was the opportunity to visit both Muhumbili where the next course is and Armana again.

 

The contrast between the hospitals is quite marked.  Muhumbili would be our equivalent of the tertiary referral hospital and Armana a regional centre.  However Muhumbili have about 20 births a day to Armana's 100 - 120!  There is little time for the niceties in life at the latter. The women labour alone (without family support) but in a communal room, and quietly accept the decisions made by the staff without much, if any, consultation.  They spend the entire labour lying down and birth flat on their backs so work extremely hard.  When we suggested that getting them upright may help shorten the labour we were laughed at and told that they didn't want to drop the babies on the floor in such positions.

 

I was the second midwife at a birth 'conducted by one of the previous week's participants. The birth went well but the baby was quite small, born in meconium and quite unresponsive. We successfully resuscitated him and were able to give him back to his mother. He did end up going to the neonatal unit but he is quite a lucky baby as many in a similar situation don't make it. 

 

I helped a woman to birth her first baby, a little girl 2.9kg. It was so lovely. There had been meconium and the little girl required a bit of vigorous stimulation, but she responded well.

 

Oliver with her baby girl

 

There were several other births around the same time and a couple of very distressed young women who had been in labour for a number of hours longer than is reasonable.  By the time my colleague and I left them they had calmed down a lot. One looked as if she may birth normally after we got her kneeling up against the bedhead but the other was heading for C/S.

 

We only observed at Muhumbili but our presence seems to have been accepted which means we have overcome a major hurdle. I am looking forward to clinical there next week.

 

Bit of a hickup this morning as no-one turned up for class.  A misunderstanding I believe they thought it was only next week. They will be there in the morning. Here's hoping.

The Real Dar es Salaam

I haven't been sitting on my laurels in my free time.  This weekend was no exception,  when two of us decided at 9.15 Saturday morning to take a bicycle tour of the city. Afriroots' cycle tour of the city came highly recommended by previous nurses who have lived in the house. We called Anara's number that was on the fridge door and by 10.30, after a little difficulty with the bikes we were leaving from the designated spot in the city.

The transportation was a sight to be seen.  As the Mama I had the sturdy mountain bike with absolutely no spring in the saddle and no breaks that I could see, my colleague had a delightful blue/grey model with the flower on the front axle and a bucket on the front, and poor Arana, our Masai tour guide had to borrow a bike because we had omitted to tell him there were 2 of us (we had erroneously assumed we'd be leaving from a tour centre).  This poor specimen kept losing its chain. While we waited for it to arrive Arana gave us a brief history lesson.

Luxury Bikes

 

The tour took us into the back roads - the “real” Dar es Salaam.  It is a dusty, noisy and at times, quite confronting place, but totally fascinating.  What struck me most was how happy everyone seemed.  We were greeted politely in Swahili by the adults, although there a couple of inebriated men who were less so.  The youths and some of the children seemed to want to practice their English.  In many places we had swarms of children around us chanting "wazungu". Mzungu is the name for a person of foreign decent. It literally means one who wonders around aimlessly!! As there were 2 of us it was "wazungu". I did pause briefly to wonder what they thought of us riding through their villages, however the thought didn't linger long as my body and brain were rattled rather mercilessly along the unforgiving roads, on which it was necessary to focus totally.

 

The backs roads are generally unpaved and naturally not on one level , and the corrugations, potholes, stones and mud would challenge a BMX rider.  We were told of and saw some of the social issues facing Dar es Salaam. We visited a typical post independence house - basically 6 rooms in which 6 families reside,
 

Grandmothers outside a typical house

 

had Tanzanian coffee from a rather suspect looking street vendor (I was more than a little concerned about contracting some ghastly gastric bug at this stop),
 

Local coffee

 

and then morning tea in a sea container - black marsala tea and chapathis. Marsala tea is spicy aromatic tea and very refreshing.

 

Tea in a sea container

 

Arana took us to the markets, including the "Ghost Market" a remarkably well set up, undercover area that isn't used, because the government had not consulted the people and then went ahead anyway and charged huge rents. 

 

Ghost Market

 

We were fascinated by the secondhand shops. Bags of donated clothing and shoes are renovated and resold in large amounts. We just looked here but at the more traditional vendors I bought a kanga that asked God to look after me and my colleague a very nice ketengi. 

 

 

Second hand underwear?

 

Shoes for sale

 

Colourful cloth

 

There is no obvious refuse collection and there are mounds of rubbish everywhere, which contain all manner of unsavoury items.  However the Tanzanians are also remarkably resourceful and turn a number of items into resaleable products. One of the worst piles of garbage was in a river that was also thick with mosquito larvae. Children play in the area, chickens run freely around and peck through the mounds - taking free range that step further.

 

 

 

 Pollution and mossies

 

Mtotos all wanted their photos taken

 

 Mtotos loved looking at themselves

  Roaring coffin trade

 

The 3 hour tour stretched into 6. We did stop for a cold drink before heading back into the fray. The final hour was sheer agony.  The roads had jolted my body to the extreme, the relentless bounce on the unsprung saddle, made me extremely aware of my rear end. I was by this stage very hot, very dirty and exhausted. We passed a rather busy coffin manufacturer, and a fleeting thought was they looked rather comfortable! Arana's bike finally gave up and he telephoned the company for another and we soldiered on. Just when I didnt think I could carry on we were back at the Milleneum Tower where we started. Mimi choka I'm tired - so my nickname is now Mama Checka.

 

However it wasn't over.  The final part of the tour is lunch in what appeared to be a beer garden- at 5pm!  We were joined by the other tour guide January. We selected chipsie mai (spelling?) as the safest option and I must admit it was very tasty. We just had enough strength to negotiate a bajaj back to Msasani Village where the most welcome shower awaited.