Midwives are trained to wait.
We wait for our patients to go into labor, and once they do, we wait for a baby to arrive. It requires patience and an ability to be with women in a way that is comforting to them and helpful to their birthing. In the end, with our patience and their labor, we usually have a success story. A new life has come into the world. Sighs of relief and exclamations of joy greet the new being.
At this time, during the worldwide spread of Coronavirus, midwives are being asked to be patient in a whole new way. We must prepare for the inevitable presence of this new virus in our midst as we do our job of caring for women. Labor and birth cannot be put off until a more favorable time.
As almost everyone now knows, the pandemic started in Wuhan, China 6 months ago. It spread quickly to Italy and then Europe as a whole. The United States soon followed. Even though we had been bombarded daily with information about the disaster that COVID-19 was causing in other parts of the world, we did not prepare well. Consequently, we have been in the position of constantly trying to catch up, even as we are dealing with the day-to-day anxiety that goes along with a pandemic that has more questions than answers.
What does this mean for my colleagues and friends in Malawi? We are all hoping that Malawi will be spared the disaster that has unfolded in the US since early March. In certain ways, Malawi seems more prepared for the Coronavirus than we were in the US. This gives me some hope. And yet, are Malawi’s official numbers the real story? Have all the deaths due to this virus been counted? Have all the cases been documented?
My work as a Seed Educator in Malawi since July 2019 has been to help launch a Midwifery Led Ward at Queen Elizabeth Central Hospital (QECH) in Blantyre. We want midwives to be able to work to the full extent of their licensure and to practice within their professional scope of practice, with collaboration from other members of the healthcare team, as needed. The Midwifery Led Ward we envision will be a model for midwifery students to learn from faculty mentors and to see true midwifery practiced by the midwives on the ward.
The pandemic has, unfortunately, put a halt to many of our plans. Ward 1A, our future Midwifery Led Ward at QECH, has now been designated as the COVID-19 ward for pregnant patients who test positive for COVID-19. Now all are waiting for the first patient to arrive. There are 443 documented cases of COVID-19 in Malawi as of June 8, 2020, and none of these cases appear to involve a pregnant woman. As midwives and nurses, we are good at getting down to work once we know what the protocols are, and how to follow them safely, for both ourselves and our patients. But these days the protocols are moving targets. The scene we come into each day is different. What testing is available? Who should be tested? Is universal testing ideal? If so, how could that ever be implemented in Malawi? Are the criteria for testing uniform across the country? Should they be? What works for one hospital or health care facility may not work at another. How about antibody testing? How should this be prioritized and what do the results mean?
Midwives in Malawi are absorbing new information each day, all while waiting to see how their tasks will change if and when the virus is detected in one of their pregnant patients. While Malawi is still more in the waiting stage, the intensity of the pandemic is diminishing in other parts of the world. The adrenalin level is decreasing for midwives in the US as they now know what their responsibilities are and can focus on the work that is required to give the best care possible. What is left are the emotions of dealing with the trauma and stress of the many patients who have been cared for. As the Coronavirus curves flatten around the world, a sense of shared experience and being as one in this time of crisis is quite prevalent. Our societies work well when we think of not just ourselves, but also about each other. More than ever, I (now in Maine) feel connected to the midwives of Malawi as they wait to see what the pandemic experience will be for them.
The act of waiting has been difficult, to say the least. Being one of the last places on the planet to experience COVID-19 has its advantages, but also its disadvantages. There will likely never be enough Personal Protective Equipment (PPE) for everyone who needs it, and the close living quarters of many Malawians and their very close daily social customs make the spread of COVID-19 more likely. What lessons can Malawi take from the US and other parts of the world that will be helpful for their unique set of circumstances?
Some of the anxieties that a pregnant Malawian mother may have include fear of not being able to be with her guardian during labor; fear of her baby contracting COVID-19; paralyzing fear of entering a hospital where there are cases of COVID-19; and the usual fear and anxiety about how the labor and delivery will go.
Amongst midwives and nurses, anxieties and fears are present as well – though take different forms. For these health workers, concerns can include the most basic fear for their lives; concern about contracting COVID-19 from a patient and therefore not being able to work any longer; fear bringing the virus home to family members; anxiety about not being able to give the care that would have been possible before the pandemic; and concerns around the inability to see the whole of anyone’s face as everyone wears masks. How much emotion and sympathy can the eyes alone show? Can respectful maternity care be given when all the patient can see is a pair of eyes surrounded by PPE?
Another source of anxiety is the fear of Post-Traumatic Stress Disorder (PTSD) for health care workers. The mental and physical health of nurses and midwives is in jeopardy. There is and will be PTSD for both the seriously ill patients who have recovered and for the health care workers, whether the illness is COVID-19 or something else. In the US and Europe, mental health services are available, but they are sorely lacking in Malawi. Health care workers in Malawi will be mostly on their own as they grapple with this new reality.
An additional concern is regarding Intensive Care Units. The ideal nurse-to-patient ratio is 1:1, but now it is 1:8 in well-staffed hospitals, 1:14 in smaller hospitals, and as much as 1:100 in low-resource areas of the world. This fact causes grief and loss for both patients and caregivers, as the quality of care that is needed cannot be delivered. The nurse-to-patient ratio in Malawi is quite high, and the best model for caring for COVID-19 patients is still being worked out. It is not easy to plan for something whose scale is unknown until it arrives.
I take hope in the fact that many nearby African countries survived the Ebola crisis and are stronger and more resilient. I hope this experience will enable Malawians to be better prepared than we have been in the US. Their learning curve may not be as steep, but they have fewer resources to draw on.
I ask myself how this pandemic might turn adversity into something positive so that we can become stronger and more resourceful, both here in the US and in Malawi? The coronavirus is an unseen enemy. But people are coming together in a way that is not often seen. There is the sense that we are all in this together.
Kathy Beach, DNP served as a Seed Global Health Midwifery Educator in Malawi. In Malawi, Kathy worked with faculty at Kamuzu College of Nursing and Queen Elizabeth Central Hospital to launch a midwifery model ward to strengthen midwifery practice and education Malawi. Kathy began her teaching career in 1975 in Siaya, Kenya where she helped develop a secondary school. Her interest in midwifery began when she met Pauline Obara—the then head nurse of Siaya District Hospital. After assisting Pauline for a year, Kathy returned to the U.S. and earned BSN and MS degrees at Columbia University. Her doctoral work at MGH Institute of Health Professions focused on pelvic organ prolapse; she created a classification system for grading vaginal lesions caused by pessaries. Her subsequent clinical work involved protocols for consistent and effective treatment of pessary-caused vaginal lesions, particularly in women unable to self-manage their pessaries. Most of Kathy’s 35-year midwifery career has been in Portland, Maine. She continues to teach, lecturing and precepting medical and nurse-midwifery students, residents, and nurse practitioners.