From MIDWIFERY MATTERS, Issue No. 116 - Spring 2008
Lisa Common
In the autumn edition of Midwifery Matters I wrote about my experience of organising a midwifery placement in Zambia. I thought you might like to hear how it went.
At the University of Nottingham, student midwives have an opportunity to observe the delivery of midwifery care in a different organisation. This placement can be up to four weeks long and the student takes responsibility for making all the arrangements with the receiving organisation; setting realistic aims and objectives; and meeting all costs involved. I was lucky enough to receive funding from the Iolanthe Midwifery Trust (www.iolanthe.org) and the University of Nottingham Alumni Association.
I had arranged to visit a HIV/AIDS charity called SAPEP, based in Monze, Zambia with a midwife colleague. Africa became a natural choice for my elective as I wanted to experience healthcare in an environment that contrasted with the consultant led, high-tech and well resourced facilities in which I train in Nottingham. Some of my preconceptions about the healthcare system in Zambia were challenged and I have learnt a great deal in such a short period of time.
We arrived in Lusaka, Zambia's capital city on 8th September last year. I was in Africa for the first time in my life and it felt like the start of a remarkable adventure. Driving through the streets of Lusaka and the market they call ‘Soweto´ with completely unfamiliar sights, sounds and tastes was amazing. We headed to the bustling bus station where passengers ‘negotiate´ the price of their seat and then wait for the bus to fill to bursting before departure. Eventually we arrived at the little town of Monze, about three hours away, into the scorching 38ºC midday heat. We had arranged with SAPEP to meet us from the bus, but there had been a mix up on times. This is where we first experienced the kindness and hospitality of Zambians. People at the bus stop saw that we were lost and immediately tried to help us. They offered us their mobile phones to make a call, they tried to figure out where we were heading and how we could get there and eventually a Catholic nun in a 4x4 truck who, by an amazing coincidence, happened to be a midwife involved in developing maternal health policy across Zambia, loaded up both us and our backpacks and drove us in to town to find our hosts.
Our time spent with SAPEP was extremely helpful in gaining an understanding of the challenges faced by Zambia. Zambia is working towards achieving the Millennium Development Goals (MDGs), designed to free men, women and children from the dehumanising conditions of extreme poverty and to give everyone the right to development by 2015.
The latest figures make stark reading (UN, 2005):
• 16% of the adult population is HIV positive.
• 46% are living in extreme poverty and 28% in extreme hunger.
• Maternal mortality has climbed to 729:100,000.
• Only 44% of births are attended by skilled health personnel.
• Progress towards increasing gender equality and empowering women in education and work has faltered.
• Literacy rates are falling and for girls there is a high drop-out rate from education beyond primary school.
• Child mortality remains high with 95 out of every 1000 children dying before their fifth birthday.
Zambia is rapidly losing its natural resources, and water and sanitation services are not improving fast enough. Trade is constrained by problems with transportation, storage and communication; more development aid is needed and, most importantly, access to fair trade markets. In a nutshell, Zambia and its people are suffering terribly.
SAPEP arranged for us to travel out into the rural district on motorbikes to see the work of their charity and meet local people. Tarmac and road-signs are not a feature of the rural infrastructure, so we spent some of our time lost among the grass and trees, hunting for the tracks that would lead to our destination. The pace of life is very different from the UK, and I became very aware of how much my life is ruled by the clock. People would wait for us under a shady tree and not be cross with us if we arrived late. Quite the opposite, they welcomed us with open arms and offered us comfort and food. I learnt how important it is to take time with greetings and to shake hands in Africa. The people were extremely generous with their time and we were never rushed to ‘get on´. We learnt a few phrases in Tonga, the local language, which always seemed to be appreciated and greeted with surprise. These are simple but important learning points from my time in Zambia.
SAPEP initiatives are delivered by volunteers who live in the rural communities, understand local needs and are accepted by local people. This support is often coordinated through an infrastructure of Anti-AIDS Clubs. The clubs organise activities such as home-based care for vulnerable people, school outreach, support for orphans, income generating activities such as chicken or goat rearing, and planting gardens to grow crops. They organise and participate in educating their communities about HIV/AIDS, the importance of knowing your HIV status and the prevention of mother to child transmission (PMTCT) of HIV. This is done through organising events such as plays, puppet shows, sport and dance competitions which attract the community and a wide audience who can then be exposed to health promotion messages.
I saw an example of how this works when I was given an opportunity to help a nurse at her antenatal booking clinic in Nampeyo, a rural district about an hour´s ride out of Monze. The nurse never knows how many people will turn up to her clinic and when 12 arrived – we clearly had a lot of work to get through. Booking is very similar to the UK with history taking, BP, urine, weight and blood tests recorded on an antenatal card. The nurse counts out a supply of folic acid and iron tablets for each woman and provides tetanus medication if indicated. The nurse will see women four times during their pregnancy and will refer any high risk women to Monze Mission Hospital, usually two weeks before their due date. Women in this area will give birth at home, usually with the support of their mothers, sisters or a traditional birth attendant. All the work is done outside under a tree, as the interior of the clinic is essentially a place where people sick with tropical diseases and AIDS related illnesses receive palliative care.
Once we completed all the bookings and obtained blood samples from each woman for their syphillis test (compulsory in Zambia), the SAPEP Anti-AIDS Club performed a play as part of an antenatal lesson. The simple play involved a woman whose husband forbade her from attending for antenatal care and she ended up having a difficult labour and a baby who was sick and had sores. Her friend was assertive with her husband and did attend for antenatal care and had a healthy baby in good condition. The club members then facilitated a discussion which involved asking the women watching whether they would take a test to find out their HIV status if their husband forbade it. Only two of twelve women raised their hands. The club then explained PMTCT and how their baby could have a future free from HIV with appropriate care. The nurse later counsels women about HIV testing and offers them the result within 20 minutes. By providing women with simple information, SAPEP is having a major impact on HIV transmission rates in the areas in which they operate. In 2002, SAPEP reported that sexually transmitted diseases reduced from 33 per zone to an average of 8 per zone in the two year period from January 1999 to December 2001. So their work is really making a difference to the lives and life chances of the next generation. We were told that because much of the communication in rural areas is by word of mouth and that our presence as visitors from the UK would be helping to reinforce the importance of antenatal care and getting tested to protect the next generation from HIV.
The time I spent at Nampeyo also brought home to me why women do not have their babies in hospital or with the assistance of trained assistants. People do not have cars – they are lucky if they have a bicycle. The tracks are rough, there are no street lights and they are very, very far from town.
From a midwifery perspective, the maternal mortality rate in Zambia is horrifying; 7,290 per million maternities (UN, 2005) compared to 70 per million (direct causes) in the UK (Lewis, 2007). The crisis is fuelled by a shortage of skilled practitioners to attend births and, undeniably, is implicated in nearly 1 in 10 children not reaching their 5th birthday. Life expectancy for a baby born today in Zambia is just 40 years.
It was also possible to see how traditions, customs and other factors influence the spread of HIV/AIDS. These include:
• Stigma – couples choose to remain ignorant about their HIV status and avoid testing for fear that they will be ostracised by their community or their marriage will dissolve. Women in particular fear that their husbands will leave them if they test positive during pregnancy and this can be a barrier to accessing antenatal care.
• Adultery – gender inequality is extremely problematic from a HIV/AIDS prevention perspective. Women and girls are expected to be submissive and, traditionally, are not permitted to refuse to have sex with their husbands. If men fail to provide adequate material support for their families, women and girls are often forced into commercial sex arrangements with other men. Increased beer drinking can also lead to unfaithfulness.
• Polygamy – extramarital relationships pose a threat of sexually transmitted infections to everyone involved in a polygamous marriage.
• Child rape – men sometimes believe that there is a ‘virgin-cure´ to HIV. That is, having sex with a female baby or child will rid them of the virus. Despite child protection laws in Zambia, children who inform on their abusers risk abandonment and/or violent punishment.
• Poverty – with high poverty levels, some parents allow their girls into commercial or casual sex for material support for their survival. Unprotected sex is more lucrative than protected sex.
• Sexual cleansing – a ritual where a deceased man´s relative has sex with his widow, in the belief that this will dispel evil spirits.
I also had the opportunity to work alongside the midwifery and obstetric team at the Monze Mission Hospital with its School of Midwifery and excellent scheme to train Clinical Officers to obtain medical licences. These training schemes provide much needed health staff to work in clinics around Zambia. In a clinic we visited near Lusaka, we met a qualified nurse who had sole responsibility for a population of up to 15,000 – this is typical and demonstrates how desperate Zambia is for trained staff and how desperately it needs to keep them. The standard of education is excellent, with students and clinical staff using all the same practical skills and terminology that we are taught in the UK. Additionally, trainees develop confidence in recognising and treating infectious and tropical diseases and responding to neonatal conditions.
However, the equipment is often in poor condition and short supply. A typical example of this is that while Monze Mission Hospital is one of the best in Zambia, even here clinical staff have just one, very old ultrasound scanner to work with and the probe is partially broken so that just two-thirds of an image can be projected on to the screen. Drugs and blood supplies are in short supply or non-existent and there is no pain relief for women unless they are having a caesarean section. There is one resusitaire in the labour ward and one in the theatre, but both are very old and do not have neonatal sized accessories.
In spite of all this, not once did I see the staff despair or moan about their facilities. They were always looking to the future and were optimistic about developing their service. They said it would be great to have electric labour beds, CTGs, automated blood pressure machines, infusion pumps, incubators and so on so that they could improve the comfort and care they could offer to their high-risk women. But what shone through during my time in Zambia, was that they had a passion and enthusiasm to provide care to the women and families that needed it, despite all the challenges they are facing.
Every day I saw something that reminded me how fragile the balance between life and death can be. One day it was a dead baby wrapped and lying in a cot awaiting collection by relatives, on another it was fighting to save a HIV positive woman who was haemorrhaging after birthing her fourth child, and on another it was caring for a woman who was unconscious following six eclamptic seizures and then discovering her fetus had died. The future of Zambia rests on the health of its women and children, and I had an acute experience of what part midwifery knowledge and skills can play in keeping them alive and safe.
Poverty, disease and corruption. Some people feel that there is no hope for Africa and no way to ‘fix´ it. However, Zambians do not think of themselves as poor, but as suffering. They are wonderful, gentle and generous people. With projects like those provided by SAPEP, the traditional beliefs and attitudes are being challenged and they are beginning to make changes at grass roots level within their tribes. Gender equality issues are being addressed and women are being encouraged to access antenatal care and testing. There is a future, but until the developed world stops exploiting resource-poor countries like Zambia, their development will always be stifled.
I hope I have conveyed a sense of what it is like to travel and see a different health system and a different culture. I could talk for hours and tell you all kinds of things but what I really want to do is inspire others to take a leap of faith and see midwifery somewhere else in the world. I have friends who have travelled to India and Ethiopia and both have told me that they would not have missed the experience for the world. I’ve just started my third year as a student midwife and I feel that my life is all ahead of me with so many possibilities. How amazing it would be to work in a place where you are part of making that possible for others, even for a short while.
If you would like to help SAPEP, you can donate to a British charity called PEPAIDS that ensures the money is sent directly to the people on the ground. You can also set up a direct debit from as little as £2. Visit www.pepaids.org to find out more.
Lewis, G (Ed) (2007) The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer – 2002-2005.
UN (2005) Zambia Millennium Development Goals Progress Report 2005. Zambia, Government of the Republic of Zambia and the United Nations Country Team.
This article was originally published in Midwifery Matters ISSUE 116 Spring 2008
AH updated 16 October 2008