I have longed to observe/volunteer in a labor ward in Tanzania, since I’m a labor and delivery nurse in the US and the Orthodox health centre does not currently offer inpatient services such as maternity care during childbirth. The nursing officer welcomed me warmly and introduced me to the nurse-midwife in charge of the maternity ward. “Are you a midwife in your country? You’re a nurse. But you have experience with labor. Do you conduct deliveries? How soon can you start? Today?” I was grateful that not just the nurse-midwife in charge, but also the staff midwives, appeared so eager to get to know me and to put me to work. After doing administrative tasks at the health centre for so long, I eagerly changed into scrubs and donned my brand-new, white, plastic apron. I wrote my name across the top in permanent marker, just as the midwives do. I slipped into plastic sandals, as “street shoes” are not permitted inside the maternity ward. Soon, though, I learned that for a birth one quickly changes into knee-high, rubber boots!
Like most hospitals here, the hospital is not one large building comprised of multiple floors and separated by specialty area. Instead, the hospital is a series of buildings connected by cement walkways with tin roofs overhead to provide shade from the sun and protection from hard rains. The maternity building consists of several rooms that encircle an open atrium in the middle. There are two nurse’s stations—one for triage/admitting patients, and one for discharging mothers and babies after birth. The admissions nursing station is located between the labor/delivery room, some post-partum rooms for complicated cases, and a physician’s office where consultations for outpatient pregnant women take place. On another side of the building there are two wards, one of which is reserved for post-partum mothers and their babies and the other of which houses pre-term women with pregnancy complications.
Each ward is a large room with two rows of beds running the length of the room. Next to every bed sits a metal nightstand consisting of a single drawer and a cupboard underneath it. Mosquito nets hang from the ceiling over each bed, which the new mothers share with their newborns. Relatives who stay at the hospital to cook for the mothers and to do their laundry sleep on the cement floor, usually on top of a straw mat or a colorful piece of cloth called a kanga. The operating theatre, as it is called here, is in an entirely different building, so any women who need to be transferred for surgery leave the maternity ward on a stretcher and are wheeled along a long stretch of cement walkway, past the public kitchen where patients' relatives are cooking meals, and into the surgery building. In between the maternity ward and the surgery building, across from the public kitchen, laundry consisting of kangas, sheets, and patients’ clothing hang on clotheslines, drying in the sun. Some laboring women walk around outside, biding their time until they are in advanced enough labor to be admitted, while post-partum mothers sit outside nursing their babies, chatting with one another. Fathers are not permitted inside the labor room, nor are any other guests, due to lack of space. Instead, they wait outside or else return home to wait for the call that the baby is born and that the mother has been transferred to the post-partum unit where family and friends are allowed to visit.
The actual labor and delivery area is a rectangular room with four metal delivery tables on one side, and sinks and shelves of supplies on the other. Divided by metal partitions and with sheets hung in between them from clothesline in an attempt at privacy, the tables are positioned with the head pushed against a wall of windows. An aisle of space runs across the room, at the foot of every delivery table. The tables themselves (I can’t describe them as beds) each hold thin plastic-covered padding, which is then covered with a long plastic piece of sheeting. On top of this a woman will place her personal kanga before lying down, using it as a sheet. The tabletops are much higher than a traditional bed, to make it possible for the midwife or doctor to catch the baby while standing at the “bedside.” A simple wooden stool allows women to climb on and off the table, but I’ve been surprised at how many women manage without it! Next to the last delivery table in the room stands an infant resuscitation station. It consists of what I think looks like a changing table, a metal scale for weighing the babies, a lamp which is used not to provide light as it was intended, but to give warmth to the newborns. On a shelf sits a suction canister and an oxygen tank. Hand held bulb suction devices shaped like penguins can be used, if needed. Infant sized ambu-bags and masks sit nearby, as well. Infant resuscitation guidelines, printed in English and laminated, are taped to the wall. Around the corner in another small room sit the autoclaves, where instruments, gauze, and towels are sterilized. At the opposite end of the labor room, a small room with a large sink, scrub brush, and three large tubs of bleach water, soapy water, and rinse water is where the midwives wash the plastic padding, sheets, and dirty towels after births. The plastic sheets hang outside on clotheslines to dry in the sun, until they are needed again.
As a referral hospital for the entire region of the country, this maternity unit cares both for women with healthy, uncomplicated pregnancies and also for women with complications either of the pregnancy or those that occur during labor, birth, or post-partum. Approximately 50% of all births in Tanzania occur in the home, without a skilled attendant. Uncomplicated births often take place in the home or at birth centers in the more rural areas. Other than the women who live in or very close to Bukoba, who may choose this hospital as their preferred birthplace, the patients consist of women who have been transferred from remote areas due to complications which can’t be handled in the home or health centre. Approximately 16 births occur daily at this hospital, or 480 births per month. The nurse-midwives work rotating shifts, alternating between mornings (7am-2:30pm), evenings (2:30pm-7pm), and nights (7pm-7am). Mornings and evenings two to three nurse-midwives staff the entire building. At night, it’s only two nurse-midwives. One assistant medical officer, our equivalent to a nurse-practitioner or physician’s assistant who has special surgical training, holds morning rounds with one nurse-midwife, checking on the post-partum mothers and babies and writing orders either for continued care or for discharge home. In the afternoon, he or she holds office hours for the women with complicated pregnancies who are either already admitted to the ante-partum ward or are still outpatients and have been referred by the nurse running the prenatal clinic. If needed, the nurse-midwife covering the labor ward will consult the AMO for complications, especially if a caesarean section is necessary. As I understand it, at night there is one AMO on call and “in house” at the hospital, and that one person covers not only labor and delivery but also for the entire hospital. If emergency surgery is needed for any type of patient, whether adult, pediatric, or obstetrical, that single provider is the one and only surgical specialist available.
I asked a lot of questions as I got to know the staff and my new surroundings. I’m so grateful to the nurses, midwives, assistant medical officers, and physicians who patiently answered me, showed me around, and explained their policies and procedures to me. Since Kiswahili and English are the two languages used in government settings in Tanzania, and because secondary education and anything beyond it are conducted in English, healthcare professionals generally speak and understand English very well. Although I could communicate easily with my professional colleagues, my Kiswahili was put to the test with most of the laboring mothers. I’m happy to say that the language classes I took in my first year, as well as my everyday use of Kiswahili, have paid off. Although I’m sure it was far from perfect, I was able to understand and speak to the women I cared for, although occasionally I had to ask a staff member for help with translation. I also really enjoyed acquiring new Kiswahili vocabulary, including medical terminology. Some of it I knew—“Sukuma” means “Push” and is written on doors all over town, so it wasn’t all that surprising when a laboring woman used the word. My favorite phrase that I learned involves one of the standard questions asked all over the world: “Is the baby moving?” Except in Kiswahili the phrase used is: “Mtoto anacheza?” which literally means: “Is the baby playing/dancing?” Every time I hear the question I imagine a baby clapping its hands and doing a little shuffle inside the womb! It makes me smile.
In my first few days, I stayed close to the midwives, mostly watching them to learn how they work. I figured out where medications, instruments, and supplies were kept and how to read a patient’s chart. One morning when the labor room was surprisingly empty, I attended morning rounds for the post-partum mothers and then sat in on private consultations with outpatients. When the labor ward was busy, though, I helped out with whatever I could do to assist either the mothers or the midwives. Sometimes I provided simple care—massaging a laboring woman’s back, pouring her tea, or helping her get dressed after giving birth. Quickly, though, the midwives realized I had labor experience and started asking me if I wanted to examine women to check the fetal heartbeat, take maternal vital signs, do cervical exams, weigh newborns, etc. On my second day the midwife turned to me and said, “Do you conduct deliveries?” I told her that although I knew the basics and could step in if necessary, in America I don’t routinely catch babies, clamp cords, deliver placentas, or do any type of suturing. I do have other skills which nurse-midwives use, though, such as basic infant resuscitation and post-partum assessment of both mother and child. The midwife let that sink in for about a minute before asking, “So, do you want to conduct the next birth?” I said no, I’d rather watch her. So for the rest of the shift, I carefully watched as she caught several babies, and I helped with all of the basic nursing care I’m used to doing back in America. I also tried to help out with the cleanup after births. Back in the US, nurses rarely clean patient rooms anymore. We do some basic tidying of the room, but there are housekeepers who actually empty the trash, disinfect the bed and bathroom, mop the floors, etc. In Tanzania the midwives do it all—care for the patients and clean up afterward. I scrubbed and disinfected the beds, padding, plastic sheets, towels, and instruments. I mopped floors and took out the trash. I even learned where to dispose of placentas.
Then, on February 15, it happened. A lady having her second baby labored at the far end of the room. She was breathing heavily through her contractions and rocking back and forth on the delivery table to cope with the pain. Then her water broke and she started to get much more active. The midwife examined the mother and said, “She’s six centimeters. She still has some time.” With that, she walked out the door and went to the nurse’s station to do some charting. Any experienced labor and delivery nurse knows that a woman having her second baby can go from not being in very hard labor to being ready to push in just a few minutes, especially once her water breaks. I was sort of surprised that the midwife didn’t want to stay closer, but I didn’t really worry about it either. However, I wasn’t going to follow the midwife to sit next to her and watch her chart when a woman was actively laboring and all alone without even a support person nearby! I’d been rubbing this lady’s back for the past hour anyway, and she seemed to like having me nearby. When I would step away from her she’d grab my arm and pull me back, and when a contraction would start she’d place my hand on her lower back, her non-verbal way of asking me to put pressure there.
She was quiet, though—she didn’t say much. She didn’t cry out, she didn’t even really moan. But I noticed how much she was wiggling her feet and rocking her hips back and forth. Pretty soon I heard her hold her breath during a contraction. She didn’t even really grunt, but I know that sound—it meant she was pushing. I took a quick peak under her kanga and saw that no baby was coming yet. I told her I’d be right back and dashed out of the room to try to tell the midwife that we should get ready for a birth. I looked at the nurse’s station—no midwife. I heard grunting from the labor room. I ran back. The mother had been lying on her right side, but as I approached her she turned over on her back. As she did so, I glimpsed a baby’s head being born. I reached behind me, grabbed a pair of sterile gloves, ripped them open and begged her to wait as I pulled them on. There was no time to do anything except put some pressure against the head to prevent the baby from coming too quickly, and to yell for help. “I need a midwife! There’s a birth! The head is out!” From out in the hallway I heard a soft and non-chalant, “What did you say?” Meanwhile, the baby’s head was out and I was feeling for a cord around the neck. “A BIRTH! RIGHT NOW!”
The midwife walked in and her mouth dropped open. “Oh! The head is out! Okay, can you deliver the rest?” She grabbed a pair of gloves and the mother pushed again. The baby’s body slid out before the midwife got her gloves on. I untangled the baby from the cord wrapped around her body and placed her on her mother’s chest, grabbed a kanga which had been covering the mother, and started to wipe the baby’s face, head, and body. The baby started crying, and the mother started saying, “Asante sana, Dada…” over and over. “Thank you, Sister.” Hands shaking from the adrenaline rush, I accepted the clamps the midwife handed to me, and after the cord stopped pulsing I clamped and cut the cord, tying it off with a small, sterile rubber band that is specially made for that purpose. Later, after weighing the baby, putting eye drops in her eyes to prevent infection, and wrapping the baby in a brand new kanga of her own, the midwife showed me how to deliver the placenta and we checked to make sure it was complete and that no repair for mom was needed. Then we helped Mom up, got her cleaned up, dressed, and gave her the baby to nurse while we got ready to transfer her to the post-partum unit. “Congratulations! You’re a midwife now!” smiled my Tanzanian mentor. Before the day was over I caught a second baby, this time because the labor ward got busy and two women gave birth at the same time. By the end of February, I’d caught six babies and I’m officially hooked.
My time at the maternity ward was wonderful, and it gave me a real insight into the way women in Tanzania experience pregnancy and childbirth, at least within a clinical framework. Some of you may know that I am currently in Uganda, not Tanzania. My final role as a missionary in East Africa, before my term of service ends in April, is to serve as a doula and mother’s helper for fellow OCMC missionaries James and Daphne Hargrave as they prepare for the birth of their first child in a couple of weeks. You may remember that I have been contemplating my future and whether to renew for a second term in Tanzania or to return to the US. After much prayer and contemplation, I’ve decided to return to the US to pursue a graduate degree in nurse-midwifery. I am very interested in continuing missionary service, and my goal is to return to the mission field in a developing country, quite possibly in East Africa, as a nurse-midwife within the next several years. Although I don’t have many details about plans yet, I will remain in Uganda through mid-April, helping James and Daphne as they adjust to new parenthood. God-willing, my skills and experience as a labor and delivery nurse will also be of use during Daphne’s labor, although I am more than happy to leave the baby-catching to Daphne’s nurse midwife! Please pray for James, Daphne, and their unborn baby, and for Felice and me as we attempt to help them as much as possible. Thank you for reading and please feel free to ask questions! I’ll try to write some more updates in the coming weeks as we wait for baby!
Love in Christ,