December 2013 archive
We were up before the sun:
but unfortunately the airport staff were not and we had several frantic phone calls to our contact in the control tower to try and get airside and off away to Qacha’s Nek before the heat and the wind picked up!
Eventually we succeeded and took off around 6.30am local time:
with a very excited passenger in the back, the Secretary General of the Nurses Association:
The views were astonishing – really the most beautiful of all the land we had flown over so far in the trip:
We had to quickly reach a relatively high altitude of 11,000 feet so that we could safely pass the very mountainous terrain and reach Qacha’s Nek on the extreme other (Eastern) side of the country, in a flight that took only 40 minutes.
The approach was beautiful too:
but the landing a little tricky given a strong crosswind and narrow runway. I definitely breathed a sigh of relief once we were on the ground!
The Secretary-General and I left Ross with the plane and, under strict instruction to be no longer than 1 hour or we would jeopardise the arrival to next destination, jumped in a rickety taxi to the hospital just along the main street.
Although we were expected, understaffing meant that it proved difficult to bring all the maternity staff together for a meeting, and so we rather went with the matron to the labour ward to meet them!
The hospital itself was a new, red-brick double storey building, and had been built with American funding. Like the other government clinics and hospitals I had come across in Lesotho, despite a new building, functionality was not there in terms of adequate human resource and medical equipment and medications, and I had to ask myself yet again how it could be that funders could decide to build a hospital at great expense and because of huge need, but not look at its longevity in terms of function. Frustrating. Equipment and human resource were controlled centrally and not locally within each hospital, I was told.
But despite the challenges there were smiles!
I even found one nurse who had worked for several years in the North East of England!
I heard more about staffing in rural parts of Lesotho like Qacha’s Nek. Seemingly there were enough positions for midwives and doctors, but not enough practitioners to fill them because there were overall not enough practitioners and there was a preference to work in the urban areas with no incentive to work rurally. Most medical doctors, including district medical officers, were of foreign nationality and the thought was that they had less of a voice in terms of healthcare structure and management because they were not local. Nurses and midwives were having to use their own money to buy e.g. batteries to be able to use the haemacue machine that calculates a bedside haemoglobin level. Medications were a problem, as they had been in Berea. The nursery was functioning, but staffing for it was a challenge. And there was no Obstetrician/Gynaecologist, so any difficult problems had to be transferred to Maseru, either by road (5 hours through the mountains) or by air transfer if Mission Aviation/Lesotho Flying Doctors were able to help.
And so a blood pressure monitor powered electrically was very gratefully received!
These midwives and nurses were also thirsty for more interaction with their colleagues from other clinics and hospitals with more regular meetings and training sessions. There was no confidence that this would ever happen. But despite the difficulties the matron was very happy to report a very conscientious workforce, motivated to do the best they could for their patents – somewhat different to the disillusionment I had come across at Berea the day before.
Back at the plane, Ross was waiting patiently:
Such a beautiful place and a beautiful morning to sit and have to wait!
It would be a fairly short 15 minute flight along the valley to Nkau. We got airborne without difficulty – thankfully it was still early in the day with fairly low wind and temperatures:
As we approached Nkau we saw again the main East to West road, and did a flyover the runway to check its suitability for landing and the wind direction.
It was an easier landing this time!
A clinic worker came running up to us, thinking we were Mission Aviation and with some parcels to go to Maseru! Of course we would take them in due course but started our walk to the clinic first!
Outside the clinic, there were a few shops, and one rather bigger mobile phone store:
Mobile phones really are the answer…how can we use them maximally for healthcare benefit?
The clinic at Nkau was an ongoing joint venture by Partners in Health and the Lesotho Government. There were maternity, paediatric and general medical sections including TB screening with an X-Ray facility. They didn’t appear to have any staffing issues and the midwife we met had chosen to work there because the salary was better than in the pure government sector. She also didn’t have any major equipment or medication issues and felt she was able to offer a high standard of care to her patients who often trekked for 2 days and about 60 kilometres to reach the clinic from their villages.
She also worked closely with a nominated member of one of the local villages who was employed to encourage women to give birth in the clinic rather than at home, even accompanying them to the clinic if necessary. To this end, there were ‘waiting homes’ where women came to stay towards the end of their pregnancy so that when labour started they were already at the clinic:
They were all very jovial and eagerly waiting for their new babies.
And so we walked back to the ‘plane with another package of samples needing to be processed in the laboratory in Maseru:
We were soon on our way! There was a fair degree of turbulence but we didn’t have a long flight:
We were starting to watch the fuel tanks by this stage…running low but purposefully low – we had wanted to be as light as possible for these tricky flights.
The bad news was that as we landed and requested refuelling we were told there was no fuel! Oh dear, time for plan B. But was there a plan B?!!
We asked the help of one of the charter companies operating out of Moshoeshoe International but they couldn’t/didn’t want to help. And so it was time to ask the military! After some slightly nerve-wracking conversations they agreed to help; their airport was on the other side of town – a 7 minute flight away. We reckoned we would just about make it, so off we flew:
with special permission to leave for South Africa directly from there.
Our friends from the Mission Aviation Fellowship (MAF), based at the military airport, were the first to greet us and very curious to look at our aeroplane! It took some time, but we eventually fuelled and even payment was straightforward thanks to them exchanging some local cash for us!
Next stop Port Elizabeth, South Africa. Lesotho had been a very worthwhile stop – busy but very worthwhile! We left about 2pm and had a smooth ride South through rural Eastern Cape:
By now we were tired but kept each other going! Shortly before Port Elizabeth we hit bad weather – storms were brewing. The tower cleared us for an instrument approach and we descended through the clouds:
Luckily we had a clear view of the runway in the end:
We paid all of our bills on arrival – quite a novelty! But it did give Dr Mabenge time to fetch us and deposit two very tired pilots at their accommodation!
Time for take-away!
At the Lesotho Wellness Centre, we started with a meeting at 10am to discuss the day’s plans. Madame Doreen had been instrumental in arranging my visit to Maseru:
The president was out of town and so she and the Secretary General worked hard over the space of an hour to arrange meetings and visits to fill my day and fulfil my objectives.
Should we do a day trip tomorrow to some very remote, mountainous areas?
We jumped in the car and headed to the Mission Aviation Fellowship, based at the military airport, to seek some advice on airstrips.
Qacha’s Nek and Nkau it would be, with a very early departure time of 6am!
From there, it was North to Berea District Hospital:
Sister Leleka gratefully received 2 blood pressure monitors and a midwifery pack:
and then showed us to the maternity block where we met the on-duty Basotho midwives and the Congolese doctor:
The maternity team’s challenges at present were numerous. Staffing was a huge problem, with 3 midwives covering the unit from 7am until 5pm and then only one until the night shift started at 8pm. And if there was an emergency? No extra pair of hands.
There had been no oxytocin medication for the past month meaning patients requiring augmentation in labour needed to be referred to other hospitals with long journey times and also that ergometrine was being used for the third stage (delivery of the placenta) – until that ran out too. There were no abdominal swabs meaning that no caesarean sections could be performed in the otherwise well-equipped theatre:
Patients requiring caesareans had to be transferred elsewhere too.
I found the neonatal intensive care unit; here the equipment was present but the functionality not. The staff I met didn’t know how to use the incubators and even if they had done then they would have been unable to staff the area:
What a shame! Premature babies and babies with difficulties at birth had little chance of survival here.
From Berea we drove the short distance to the General Practice of Dr Molise, the President of the Lesotho Medical Association. His clinic was in the high street of Berea, next door to the huge Chinese supermarket that had recently sprung up and where we grabbed a drink on the way. Dr Molise kindly spared some time between patients to see us. He was Lesotho born and South African trained, and one of only a handful of doctors of Basotho Nationality working in the country. Many of his colleagues were from Zimbabwe and the DRC. I was interested and astounded to hear that there were not many speciality doctors in the country, with no Psychiatrist and no Obstetrician/Gynaecologist for a population of 2 million people. Local doctors do undergo speciality training but don’t often come home on completion, preferring to stay in their country of training. And of 280 registered doctors, only 40 belonged to the medical association. Not such a cohesive group, but nevertheless the association was working with the nurses association to increase multidisciplinary, collaborative working. Medical students were also now being trained in Lesotho, with the help of the University of Harare in Zimbabwe for clinical placements in the final years.
And so we hit the road again:
We were headed to the Roma School of Nursing and Midwifery to visit the student midwives and tutors there! Our journey was about 90 minutes back South towards Maseru and then East through the beautiful sweeping shallow valleys of the Basotho lowlands, and where most of the country’s population live.
We sped past the President of the Nurses Association who was heading back into town after a visit to Swaziland; luckily we spotted each other, reversed, and had a chat and photo session by the edge of the road:
The midwifery school gave us an energising welcome, despite the fact we were running late and they had been waiting a good couple of hours to receive us:
I told them all about Flight For Every Mother and we discussed, in particular, the urban-rural divide of healthcare workers in Lesotho, unskilled home deliveries and the clinical aspect of the second stage (pushing phase) of labour. There was definitely some motivation going on in that session!
The Secretary General and I stopped for chicken and beer before heading back to (a different) Motel where Ross was waiting and where we slept early in anticipation of our very early flight in the morning!
The Swaziland Wellness Centre was set up in 2007 on the background of many Swazi nurses leaving the country to practice overseas and a desire by the Nurses Association to understand why. A questionnaire showed that many nurses and midwives felt that they had to leave because of a positive HIV diagnosis and an unwillingness to queue alongside their patients to receive treatment. Moving forward with this information, and with the help of the International Council of Nurses, the Wellness Centre was set up. It acts as a primary care centre for nurses and midwives and 5 immediate family members, dealing with acute as well as chronic illnesses medically and holistically, and now has a great deal of financial support from the government.
I visited the Wellness Centre this morning on my way to the airport. Muzi headed up the centre and had been influential in organising my visit!
It was quite overwhelming to receive some gifts:
And nice to be able to exchange something from Flight For Every Mother:
It really had been a cohesive visit and I felt that we had stimulated so much discussion and movement in terms of maternal health.
From there the airport beckoned. It wasn’t too difficult to persuade security that our Swazi friends should see us to the plane:
And from there, still with the same training aircraft in the circuit as when we had arrived, we were off on our 3 hour flight to Maseru in Lesotho:
There were lots of thunderstorms to dodge, as demonstrated by our ‘strike finder’ instrument:
As we flew South-West through the Free-State and towards Lesotho, the mountains became more numerous and classically flat-topped:
Could we squeeze through gap between storms to reach the airport at Maseru?
We just managed!
We were directed not to the 3.2km North to South runway, but to the much shorter East to West runway on account of the wind. It was quite difficult to spot but we got there in the end.
Finding our welcome party was a bit more tricky. We weren’t really sure if anyone would be there waiting – I hadn’t managed to check my emails for 24 hours. We found a van from the Wellness Centre in the busy airport car park but no driver. Was this too much of a coincidence or was it for us? We walked around and asked around and finally found our man, the driver! Accommodation had been tricky for the Lesotho Nurses Association to find on our behalf given that it was the ‘Top of Africa’ Mountain Rally the following weekend, but they had finally managed after many attempts and we arrived at a guesthouse in the town of Maseru for the night. Tired as always and with no supermarket within walking distance I made the short journey to buy some provisions and we had a picnic supper with the internet as company!
An early start saw us at the Mountain Inn for a UNFPA sponsored breakfast training session with many of the midwives and doctors i had come across during my hospital and clinic visits the previous week:
Dr Hassan from the UNFPA introduced the session and spoke about 3 things he saw as a priority to improve maternal health – family planning (contraception), the training of midwives and patient access to care.
I delivered a talk about my experiences of the Flight For Every Mother project in Swaziland and beyond, followed by maternal collapse and haemorrhage. Much discussion was stimulated, in particular about the issues of accountability, training of doctors, midwives and nurses and documentation.
As we waited for the Minister of Health to come and address the audience, I went on to run a haemorrhage drill. This was received with much enthusiasm and requests to the Ministry of Health officials for such training to be incorporated on a regular basis. What a great feeling for me to have inspired in that way! The Deputy Minister of Health went on to promise further dialogue on maternal health and invited opinion on who should take this forward. The nursing and medical unions were nominated and I suggested adding a patient representative. The Ministry of Health and UNFPA (United Nations Population Fund) would be there to support too. May 5th 2014 – the international day of the midwife – was chosen as the date to have made significant change by. I said I hoped to be present on this day!
From there I was asked to do a quick live TV interview for the local Swazi network, and then Becky and I spent an hour or so with further interview questions for me. By now I was definitely becoming more comfortable with being in front of the camera and having to think less hard about my responses!
And then it was ‘bye to Becky who was leaving for London, and lunch for me – this time a lunch to raise the profile of the Girl Child Education Fund with representation from the Nurses Association, Save the Children, sponsored girls and local business. Various speeches detailing the importance of the Fund were heard, and I was asked to give one too (at the beginning of the journey such a last minute request would have phased me but by now this was a common occurrence and so fairly simple to execute!)
Encouraging regular donations of any size was the suggested way forward so that more girls could be sponsored and empowered through education.
I am a product of a sound education. Not only have I been empowered professionally and socially, but I also developed the belief along the way that I could execute a project like Flight For Every Mother of my own accord. One very lucky girl!
We rushed from there to the Ministry of Health as we had just heard that my debriefing meeting would be at 4pm, so it was back in the car to Manzini!
The Minister was keen to hear about every aspect of my visit; I expressed my gratitude for such a warm welcome in Swaziland and such a well organised and broad reaching visit, and then took the opportunity to discuss the issues from Matsangeni Hospital and Siphofaneni Clinic that I had picked up. ‘Let’s try and take forward the clinical training ideas too,’ I urged!
I caught up with Ross, now back from his flying course, at the Peace Hotel after his longish drive from Barberton! We were both pretty shattered and shared a pizza before falling asleep! The weather was looking fine for our flight to Lesotho the following day.
Muzi, who was heading up our visit to Swaziland, enforced a day of rest today! Just as well, because it was very stormy with high winds and rain and there were a number of accidents on the roads. Becky and I did venture out of the Peace Hotel for dinner, though, and ate curry at Happy Valley!
Today was the day to visit a Swazi school – Siteki Nazarene School – and to talk to one of the sponsored students of the Girl Child Education fund. Education of girls is hugely important; it lowers teenage pregnancy rates and improves the lifetime reproductive health of females, empowers women in relationships and means that they are less likely to suffer violence at home, and improves their chances of earning their own income being financially independent in their relationship.
I met Nomfundo Mamba who was 17 years old and whose ambition it was to be a veterinary nurse. She was doing well at school, in particular in agriculture and biology. Her brother , also her guardian, would be furious if she jeopardised her schooling by falling pregnant, she told us, and anyway she was enjoying her studies and would consider childbearing much later on in her life, and definitely after marriage.
Nomfundo was very grateful for her opportunities via the Girl Child Education Fund of the International Council of Nurses. She showed us around her school – a boarding school for the most part – with single-sex dormitories and classrooms per academic year group with blackboards at the front of each. The girls studied harder than the boys, she told us!
Tiny Dlamini, who was accompanying us, had also managed to organise a visit for Becky and I to a rural village not far from Siteki, so that we could visit a pregnant woman at her home and complete our picture of the journey of a patient from a typical rural homestead to clinic to hospital. And so we met 17 year old Petzile, 7 months pregnant, and her extended family:
Petzile’s typical day, in contrast to Nomfundo’s day of studying, involved trekking 3 times to the river 30 minutes walk away to find water, household chores of cleaning, cooking and making the local alcoholic brew to sell, and looking after other found children living in the same village.
I tried my hand at stirring the local brew – a very stiff and strong smelling liquid:
Petzile was somewhat regretful about her education; she had left as a young teenager because of a lack of funds. She hadn’t been planning a pregnancy but she was happy enough. Her boyfriend was away working; the nearest clinic for pregnancy care was 2 1/2 hours away by walking and local taxi – that was on a good day. She had kept all of her appointments so far but wasn’t really sure how she would travel in labour. Her grandmother, Gogo Mazilla, had some ideas. I got the impression she had left a little sum of money aside for when the time came.
The matriarch of the village was Petzile’s great-aunt. She was in high spirits and was dancing away to the music on the radio of our car:
She insisted I took one of the reed mats made in the village:
Those were wonderful scenes of exchange and kindness.
Too soon we were back on the dirt road that Petzile would take in labour, which became tarred as we reached Siteki and then drove onto Mbabane.
Day 100 of Flight For Every Mother! What a long way we had come by now!
This morning we said a sad goodbye to Kwame – he had another filming assignment to attend to in Germany! But the good news was that Becky would stay until the end of Flight For Every Mother in Swaziland. I was really pleased that finally we were formally recording some of the project’s activities with the aim of putting together a documentary to raise the profile and interest in women’s reproductive health.
Ross also left – to go to Barberton in South Africa to do an advanced mountain flying course with CC Pocock.
And so Becky moved in with me at the Peace Hotel in Mbabane!
After breakfast we were on the road South to Matsangeni – a rural, secondary level hospital 2 hours away. After leaving the city, the road passed through rolling hills with scattered villages and few other vehicles.
The matron at Matsangeni was Ruth Dlamini and she showed us around the small, single story maternity block. She explained that the nearest referral hospital was 100km away and that the hospital ambulance was non-functional. So a woman in labour who had a problem, such as a distressed baby in the womb, would have to wait for an ambulance to come from elsewhere, if available, and then travel over 90 minutes to reach more specialist care. As there was no operating room (theatre) at Matsangeni transfer in labour wasn’t an uncommon occurrence. The doctors were frustrated that they were unable to keep up their clinical skills by operating and that their patient’s lives were sometimes endangered by these delays.
We ate lunch on the way to our next destination of Siphofaneni. Becky was also keen to do some interviewing in the car on the way! I’m not sure I was so keen!
Siphofaneni clinic served a population 40 min by road to the East of the capital. It had once been a well functioning midwifery-led birthing unit, but now was only able to cater for emergency deliveries. The four midwives staffing the clinic expressed frustration that they were only able to provide antenatal care and that despite adequate skill locally they were forced to advise their patients to travel to the city when in labour for delivery. Their experience was that many women declined and rather delivered at home without supervision – a potentially dangerous situation for both mother and baby.
Within the clinic, the birthing area now housed the cupboards and desks enabling the role-out of anti-HIV and anti-TB medication. The workload that this service brought, together with lack of physical space, was the reason that deliveries could no longer safely take place.
In addition to the logistical issues surrounding delivery experienced by the clinic staff, we also discussed the fact that HIV can’t be looked at as a problem in isolation, but rather in the context of so many other maternal health issues. The midwives at Siphofaneni felt that other significant obstetric issues were sometimes overlooked because of the focus of HIV, and whilst an important problem, other issues deserved attention too. Hope was expressed that now, given such a well established HIV programme and good uptake of anti-HIV drugs, there might be some changes in focus.
Family planning (contraception) was also offered by the clinic. Interestingly, in their experience the progesterone injection was the most popular method, with women giving the reason of their male partners being unable to see or feel the fact that there was a contraceptive method in use – evidence that Swazi women are perhaps unable to discuss such issues with their partners and may not be expected to be in charge of their fertility.
I promised to raise the logistical issues with the Minister of Health at my debriefing session, and with that promise I was on my way.
Time for a night in!
We left Johannesburg a day earlier than planned at the request of Kwame from Franklyn Lane Films. He was already in Swaziland by now and eager to start filming some of my Flight For Every Mother activities.
At Lanseria Airport we met Nomkhosi Dlamini, recently sponsored educationally by the Girl Child Education Fund and now trying to continue tertiary studies in South Africa. We had offered that one of the sponsored girls should fly with us from Johannesburg to Swaziland and to say Nomkhosi was excited was an understatement!
Leaving Lanseria was straightforward and the fees much more affordable than I had anticipated! As Lanseria is to the North of the city of Johannesburg, we didn’t see much of it from the air and we were soon flying East over farmland. It was Nomkhosi’s first ever flight, and I think she was a little unsettled by the turbulence, felt of course more easily in a small aircraft than a larger one. She soon fell asleep!
Ross and I were busy plotting our approach to Matsapha International Airport. Kwame would be there to film our landing. We decided to do three landings to maximise his chances of some good shots!
I did the first two and then Ross did the third.
We had managed to spot Kwame on the first landing and so were able to land closer to him along the runway on the subsequent landings. There was one other Cessna in the Circuit around the airfield, and we later found out that that had caused some confusion within the welcome party!
The only other aeroplane on the apron was the King’s jet! As we gathered our baggage and headed to the terminal we were met by Mr Muzi Dlamini of the Swaziland Wellness Centre and the President of the Nurse’s Association, shortly followed by our friends (with the cameras rolling) from Franklyn Lane, and the Deputy Minister of Health. I had had the heads up that this visit would be very full and formal and now I could see that that would be the case! How wonderful! We started our introductions in the VIP lounge of the airport and from there drove the short distance to the Ministry of Health in Manzini:
The Minister of Health was new and had been in the role for the past 3 days only but nevertheless spoke very eloquently about the link between the education of girls and their future reproductive health. Female sexual reproductive health was a government priority. She quoted some frightening statistics about sexual violence – 33% of women in Swaziland have been exposed to sexual violence by the age of 18 – and about teenage pregnancy – 56% of women have been pregnant at least once by the age of 20.
Over lunch we discussed my itinerary for the next 4 days. I would visit hospitals and clinics at all levels, a school and run a breakfast training session, in addition to social engagements and a end-of-visit debrief on Tuesday morning with the Minister prior to departure.
And so to our first stop – Raleigh Fitkin Memorial Hospital. It was a regional referral hospital, funded by the Nazarene Church in conjunction with the government and the staff were waiting to greet us:
We sat down in the boardroom for a discussion about the hospital, its goals and its challenges. By now I was getting tired and it was somewhat difficult to stay awake through all the formalities! I would get used to such meetings by the end of my visit to Swaziland! Interestingly both the Obstetrician and the Paediatrician were Ethiopian in origin.
A hospital tour followed. The outpatient clinics were a tight squeeze without any patients present (by now it was late afternoon and the clinics had finished) so I could only imagine how busy it must get in the mornings!
Two common threads of discussion from staff were the shortage of professionals with a high patient load, and the impact of HIV. Forty-one percent of maternal deaths were from AIDS-related opportunistic infections such as unusual pneumonias, meningitis and TB – a higher contributor than in just about every other country in the world.
Labour ward was not too busy, although they had just had a baby! In all there were 7 beds for 8000-8500 deliveries per year.
The recent introduction of a asphyxia prevention protocol had reduced admissions to the Neonatal Intensive Care Unit from 45% to 20%. Their were 27 beds for sick and premature babies and these were the only such beds in the whole of Swaziland.
‘No woman or baby should die.’
We had a quick debrief and vote of thanks:
And we were off to our evening reception at the paramedic headquarters. Phew I was tired and there were still more people to talk to and speeches to hear! Oh – and my interview with Kwame went on into the early hours!
I had been eagerly awaiting my visit to the Chris Hani Baragwanath Hospital in Soweto, Johannesburg for a long time – from even before the conception of the Flight For Every Mother project. It is the third largest hospital in the world and the largest in Africa; many of my South African medical colleagues working in the UK had spent their formative junior years working very hard there. It started out as a hospital for convalescing British and Commonwealth soldiers in 1941 and many of the wards still resemble barracks to this day. The maternity department is hugely busy with over 1000 deliveries every month, with most patients coming from the neighbouring township.
At lunchtime, I set about talking about the project to the Obstetrics and Gynaecology Department, headed by Dr Eckhart Buchmann:
There was a lot of curiosity about my experiences. But whom should South Africa be aspiring to be like clinically? What about corruption and its influence on medical aid?
Dr Buchmann promised to deliver the 3 blood pressure cuffs I left to his township clinics the following day. ‘Say hello to my colleagues in Cape Town!’
And with that we were on our way. Back through the metropole of Johannesburg.
Our stop in Johannesburg had originally been planned so that the servicing of the aeroplane could take place over 3 days. Since this had now taken place in Nairobi, our schedule was less well defined and so today both Ross and I took advantage of catching up with our respective blogs, and I did some swimming. It was also good to hear that my friends Kwame and Becky from Franklyn Lane Films were on their way to Swaziland to begin filming. We would join them in just a few days time!
In the evening, our pizza cravings were more than satisfied…I would never have thought that I would be craving pizza after all the interesting foods I had been eating, but I was!