No, the ship does not have a maternity ward. However, the local hospital, Hopital Be, does.
There is one large hospital in Tamatave - Hopital Be. Even its name means Big Hospital. This is one of only four teaching hospitals in the country. There is another smaller hospital in the area, but it offers very few services. The majority of people needing a hospital go to Hopital Be. As part of our capacity building programs, we partner with local doctors and nurses offering mentoring programs, education, evaluation of medical practices, and more.
We never go in and tell hospitals how they should run. Instead, we let it be known that we are willing to partner with local facilities. Hopital Be invited us into their hospital. Medical teams went into the hospital, spending time in each ward, learning what resources are available and what practices are being followed. In addition, our local nurse educator, Amy, surveys the nurses to find out what areas they feel could use improvement/education.
In Hopital Be, we have being focusing on one ward at a time. Right now, I am working with the maternity ward. There are about six nurses onboard with labor and delivery experience. There are four local midwives involved in the exchange program this year. The midwives here, or Sage Femmes, do everything. There are no maternity nurses. The Sage Femme admits a patient (though their history and physical is practically nonexistent), starts an IV, determines which medications are given, gives the medication, delivers the baby, performs newborn resuscitation, and makes any repairs to the mother. There is a gynecologist that is consulted only for emergencies.
So, how can we have an exchange program when we have no maternity ward? Well, the midwives spend time on the VVF/Gyn Ward. In this ward, about 90% of our surgeries are vesicovaginal fistula repairs. The other 10% are rectovaginal fistula repairs and gynecological surgeries, such as a hysterectomy or repair of prolapsed uterus.
Almost all VVFs and RVFs are a result of obstructed and prolonged birth. The midwives see firsthand the damage that can occur. I worked with a midwife, Evelyne, this past Tuesday. She was surprised at how many ladies were on our ward - about twenty at the time. She was even more shocked to learn that there are about 50,000 women living with VVFs in Madagascar. She witnessed the beginning of the long process of healing.
Each Sage Femme will spend two days on our ward and another day following a single patient on the day of surgery, including observing the surgery. Each Mercy Ship nurse will spend two days in the maternity ward at Hopital Be. Yesterday, Thursday, I spent the day there. I witnessed three births and observed one hysterectomy in the OR.
The health care system is so very different than any first world system. The patient or their family must provide all the basic medical equipment and medication. Women are given a list of recommended items to be purchased. This list includes the following items: IV cannula, medical tape, IV tubing, IV fluids, several syringes and needles, Oxytocin (uterine stimulant), corticoid steroid, dexamethasone (anti-emetic), latex gloves (for the nurses to wear), alcohol (to swab areas of IV site and injections), cotton balls, linens (for the patient's bed), towels, laundry soap (for the nurses to wash their hands)...and it is possible that I have forgotten something from the list. The equipment that the hospital has includes a baby scale, a suction machine (for vacuum and nasal suction), and a cardiotocograph machine. The cardiotocograph machine measures fetal heart rate and contractions, though they do not have the paper to monitor contractions. For an additional fee, the Sage Femme will listen to the baby's fetal heart rate with the machine. If you do not have the money, which most patients do not, the Sage Femme will use a fetal scope. This is a fetal scope:
I found this picture online of a suction machine. The one on the left is very similar to what is on the maternity ward here.
Another example...The nurses expressed a lot of interest in learning neonatal resuscitation. Twenty to twenty-five Sage Femmes, OR nurses, and pediatric nurses have attended our neonatal resuscitation class. We will be holding another one or two classes in the next few weeks. In the class, the Sage Femmes stated that they did not have a neonatal resuscitation mask or bag. Mercy Ships was able to donate two bags and masks. After one delivery, the baby was not breathing, and Franz, a Sage Femme who attended our class, used the bag and mask to revive the newborn. It was awesome to see that she was putting into practice what she learned.
I look forward to continue working with the Sage Femmes and, hopefully, helping to provide education that will improve their practices within their resources.
I must say that the Malagasy women are amazing. They have no epidural, no pain medication at all, yet they do not utter a sound during delivery. I do not know if it is culturally inappropriate to do so or if it is because the Malagasy are a stoic people. Even when the Sage Femme performed an episiotomy (cut the perineum), no sound was made. When the Sage Femme was stitching a torn cervix, the mom grunted a single time. They are so amazing!
To close, I want to share an interesting Malagasy custom I learned about yesterday...if a man sleeps with another while his wife is pregnant, it is believed that she will likely have a complicated labor. However, if the husband wraps his clothes around his wife's belly during labor, it is said to ward off complications!