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Midwives, mothers and medicines

3 April 2019

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During a recent visit to Uganda we met Hillaring who as part of the partnership between the University of Manchester and Jhpiego took part in their clinical audit training aimed at improving the quality of care for women and babies.

My name is Hillaring Nakalyango, I am a registered midwife working at the China-Uganda Friendship Hospital, Naguru, where I am currently working on the neonatal ward.

When I was young I would go to the hospital and watch how the health workers were able to help sick people feel better. I remembering seeing the patients, particularly the women who would go in pregnant and leave with a baby. It made me think of my mother – I am the oldest and so I remember her being pregnant – who would one day be working, and then the next day would come back home and the midwife would have given her a baby. I decided I wanted to be the person who gives babies to mothers as I love children. In nursing you might not see your patients after they leave hospital, but with midwifery you treat them, they come back, you watch them grow and it is as though you are part of the family. I wanted to be the person who creates that joy, and because of that I became a  midwife.

In my labour ward there are 11 midwives. It is a combined ward with 28 beds (antenatal and postnatal) a delivery room and a special care unit, where premature and asphyxiated babies share the seven incubators we have. Normally, up to four babies per week are born premature.

The most challenging thing is the scarcity of drugs. A lot of time we find we simply don’t have the drugs we need to give mothers. For instance, when we ask doctors why a mother was not given antibiotics after her membranes ruptured, they respond that there was nothing available. It is a real challenge for us and sometimes we feel there is nothing we can do. We always hope that drugs will become available the next day, though some of our mothers can’t wait that long.

The ward is congested. Every day we see so many patients, yet our capacity is not increasing. We cannot turn people away, so we tell them to stay and we do our best with the little resources that we have. We have mothers recovering from their births on the stairs and in the corridors because we have no beds for them to stay in. Many are there overnight, waiting for hours for their postpartum check-up, after which they will have immunisations before going home.

Another challenge is reporting. I find that some staff will have done everything correctly but have not recorded their actions or observations, which means I have to go and ask them what happened, what they diagnosed and what they prescribed. People are doing good work but when they fail to complete the documentation it undermines our processes.

This is where training is especially helpful. I felt privileged to be among the people who attended training in which a team came and showed us how to use the minimal resources that we have to carry out clinical audit processes. I thoroughly enjoyed the opportunity to gain knowledge and skills about the continual clinical audit process.

Our first task was to gather the data and it was tough to convince people of the need to do this. When we approached clinical teams to ask them for figures, we were met with questions about why we wanted such figures and what we intended to do with them. When we did get the figures, the heads of departments didn’t accept them at first. Following our training we were able to go back to them and demonstrate that the figures were correct.

Carrying out the audit helped us to analyse our work clearly and gave us evidence of the challenges we face which we flagged to our managers, who were then able to see them in reality when they went on their rounds. For example, through the audit we discovered that we had only one or two thermometers, and this knowledge gave us the confidence to ask our managers to provide more. All in all, it made us better informed, which in turn gave us the courage to make our voices heard.

We realised that by continuing with the audit, there would be benefits all around. Gathering data made people aware of the bigger picture. Previously audits were only carried out by managers, but this one involved our whole team; the midwives, nurses and even the cleaners. Not only was it effective, but it also helped with relationship building. It was a great advantage to include everyone because, looking at infection prevention control alone, it is imperative to involve cleaners as they are the ones who carry the waste and are therefore key in the process. Before the audit we weren’t aware that we had such a huge range of infection, that for example sepsis was a real challenge for our ward. Following the audit, when babies returned to the hospital having been well just hours before, we now knew to check for sepsis, which was something we may have missed before.

It was great to have the team from Mulago come, and to see how, despite their challenges, they have seen great improvements, the sort of which we hope to see in our hospital too.

We now use checklists to make sure we follow the correct procedures. We have a routine for recording our work so we can see from the files what was wrong, what we did and what we missed. We can get a map of what a mother presents us with – for example high temperatures, signs of ruptured membranes – and then we can look and see whether she given an antibiotic, how she was cared for, how she delivered, whether she was operated on and how well the baby is doing.

The work we put into following these procedures is hugely important. When we were first using the checklists we would ask someone from the Mulago team or the UK team to double check them, to keep the records accurate and unbiased.

I enjoy passing on my knowledge to other people who were not able to be on the training.

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