Global Nursing Fellow Sends Update From Rwanda

Kate Sullivan, MSN, RN, CNM, who has worked for 30 years at Brookside Community Health Center and the BWH Midwifery Group in the Center for Labor and Birth, is BWH’s first Global Nursing Fellow. The fellowship was developed jointly by the Department of Nursing and the Division of Global Health Equity to identify contributions of nursing in developing countries and implement effective treatments, provide opportunities for BWH nurses to participate in clinical field rotations around the world and to develop nursing’s role in interdisciplinary care models globally. Her fellowship lasts six months. Below is Sullivan’s account of her first few weeks in Rwanda.

How to begin? Rwinkwavu is a 111-bed hospital. This is a useful description in that it hints at the level of busyness: however, there are two or three to a bed, especially in Maternity, and there are people sleeping on the floor in the halls and up against the outside walls all night waiting to be seen in Emergency. Partners In Health (PIH) rebuilt and expanded an essentially empty hospital building. Now there are three long low buildings connected by protected passageways. It is delightful to move around the hospital from building to building as you get fresh air and plenty of warm greetings as you move along the passageways. A short walk away is a large and busy health center with three buildings as well. Large outdoor shaded areas are used for group patient education. Patients have their return appointments, for instance for HIV care or chronic disease care, grouped monthly. It is quite efficient, and quite lively.

Several of the wards have large lovely murals painted on the walls; there are plenty of windows; the beds are old metal frames with sagging mattresses, most (but not all) have sheets. Many patients are bed-bound. You do see them squatting at their bedsides and peeing into large dishpans. Someone then carries the pans over their heads to the latrine area. I have learned to step lively on the rocky paths. There is an occasional screen that is moved from area to area to allow for privacy, but this is not the norm here.

Nurses wear white coats from a variety of U.S. hospitals. Usually a doctor’s name is embroidered on the coat. I am still not used to that! They carry small trays of instruments and cotton gauze, quite formal in appearance.

Maternity is not quite as airy and pleasant as the other wards, sadly. They have two beds for delivery, seven beds for postpartum and early labor combined (and any other serious gynecology pathology and/or miscarriage issues), and nine beds in a more remote post-op ward. The caseload here has tripled in the last year. It is common for women in active labor to be waiting in the tiny space in Maternity for the chance to get up onto a bed to be examined. They are quietly breathing or leaning on the walls, and it is only the frequency of their contractions that tells you they are super-active. Rwandan women do not, for the most part, vocalize during labor or even appear to complain.

I have been so impressed by their fortitude, but have also noticed that they are shamed a bit - by most but not all of the staff - if they moan, so I am guessing that there is a cultural expectation of stoicism. I have noticed that the female nurses are not any more likely to be supportive and gentle than the male nurses. It is interesting.

Needless to say, it makes me nervous to not have enough space for evaluation of laboring women. Could she be the one with the prolapsed cord or the transverse lie, I wonder. It is sad for the women themselves – they have no family members for support, no space to enjoy as their own while they get to know their babies and learn to breastfeed, no fresh air or light, etc., and I can get up on my high horse about women’s rights and dignity (why do other patients have these amenities and not the childbearing women?) and then some serious pathology requiring urgent medical care surfaces, and I forget about the less-than-perfect circumstances and stand in awe of the fact that we can produce blood products and a qualified and caring surgeon when we need them, and always give the appropriate regimen for prevention of mother-to-child HIV transmission, and have enough antibiotics to take care of infection.

I’m not saying that I don’t want to help change many, many things, especially in labor and birth care. I’m just saying that sometimes whether women get unnecessary episiotomies or even questionable Cesareans seems the least important thing at a given moment.

Postpartum women and their babies are jumbled together in postpartum beds - no particular division by acuity or infectious status. Many go home within hours of their birth, not surprising to me that they have responsibilities that do not wait for their recovery from childbirth. The babies are named on the eighth day, and that is when sexual activity typically resumes. Family planning coverage is estimated at between 7 percent and 15 percent here. Women like Depo-Provera, which is injectable and lasts for three months, because it makes them hungry and they eat more. That is a nice switch from U.S. women’s complaints about this same side effect. National standards are very, very conservative with regard to administration of hormonal methods. For instance, I have seen a mother of nine, who wanted Family Planning, turned away because she was not yet six months postpartum. Needless to say, I would not have done that in my own practice.

Prenatal care: sigh. National standards grade facilities based on whether women come for care, ideal of four visits is not often reached, and get their tetanus vaccines. PIH has, of course, added a strong emphasis on HIV detection and treatment. There is an outstanding system for prevention of mother-to-child HIV transmission: compassionate nurses, very broad community health worker coverage, daily visits for people on antiretroviral therapy, well-organized pharmacy supplies, an heroic effort to provide everything that is necessary for safe formula feeding for the babies. It is amazingly impressive.

But normal routine prenatal care beyond identifying HIV and syphilis and preventing tetanus does not really take place. The visit is a quick tetanus vaccination and routine BP, if we are not too busy, and no particular attention is paid to huge discrepancies in size and dates. A high BP does not necessarily evoke a response, staff distrust their scales and sphygomanometers. It is very, very common to have women present to Labor and Delivery complaining of being overdue by a month. This takes a huge amount of time and education to overcome, and even then, they are very likely to return two days later with the same complaint, hoping for some sort of action from us. It is also common to have women present in labor looking term and being dated at 30 weeks. Dreams of teaching ultrasound skills to interested nurses have dissolved. The basics are really more important at this point.

My major initiative at the moment is working on prenatal care: adding labs, teaching staff how to size pregnancy, trying to get Rh immune globulin on site, trying to prevent problems associated with hypertension, establishing patterns of referral. I have worked a lot on physical conditions in Labor and Delivery. We’ve tried moving the two beds around, have repaired the nonfunctional sink. Now we will work on handwashing. We’re talking about post-op infection rates and management of chronic hypertension, Fortunately, the doctor who is primarily responsible for Maternity is open-minded about ideas for change. And even more fortunately, I am working with the PIH nurse-mentor for the fellowship, Emily Hall, who has developed a quick and effective response to problems here. She basically says, “Yes, I get that this is a problem, Now what is our first step in fixing this?” This is always helpful, but still, I am stunned at how long it takes to actually get something done. I do, of course, remember how many times people had told me that very same thing. I guess I just could not imagine it.

This week has included a maternal death due to severe uncontrolled hypertension. It was a mother of three young children. My first look at a footling breech, with toes presenting at the perineum, a mother who has presented multiple times for being ‘overdue’ who explained to me in great detail via interpreter that she recently used a traditional medicine which caused her to give birth to four frogs from her vagina, a beautiful full moon, a birthday party for the Italian doctor here, a reported black mamba sighting. This is life at Rwinkwavu.