If you remember my first entry about the Safe Motherhood Program, then you know that the team of Duke Engage students here (10 of us, ranging from incoming sophomores to seniors) spent the first week of work assisting in the Safe Motherhood intervention that provided free antenatal care services, such as physical examinations, sonograms, and drugs, to mothers from the Mbarara municipality who were able to come to the private clinic at Mayanja Memorial Hospital during the week. The next week we began a longer leg of the program, which will not be completed until the end of July. These last few weeks we (the Duke Engage students, a few paid students from Mbarara University of Science and Technology, and Mayanja Memorial Hospital and Foundation staff) have been taking the intervention's services to government-run health centers in rural areas around Mbarara. Each week, we visit a different health center every day; on Mondays we go to Kashongi, Tuesdays to Kikyenke, Wednesdays to Rubindi, (all of which are about an hour and a half away from Mbarara town center) and on Thursdays we go to Kikagate, which is the furthest one, requiring about a 3 hour drive on very poor dirt roads (the town happens to be right next to the Tanzanian border).The health centers we visit are designated as health center III's by the Ugandan Ministry of Health. My understanding is that they are supposed to be equipped to handle common diseases such as malaria and STIs by providing free drugs and treatment by a couple of nurses, HIV counseling, family planning, antenatal care check-ups (basic minimum, not including sonograms) minor emergencies, and uncomplicated deliveries usually managed by a midwife. Anything they cannot handle they usually refer to higher level health centers or regional referral hospitals (also government-funded). The health centers are usually two buildings: one building has a large room with maybe 10 beds, a small lab room, and a wash room, then the other has a small pharmacy, an office space or two, and some more beds, maybe a labour ward.
A typical day in these health centers, "in the field" as we say, is as follows: first, pregnant mothers arrive at the clinic in the morning and wait for the team to arrive (we leave Mbarara town at around 8:45 am except on Thursdays, when we leave at 7:30). In the first weeks we got upwards of 100 women on some days, but more recently the number is about 50 per day. The women come from the area served by the health center, and while some live a 5 minute walk away, we have spoken to some who have walked 4 hours (an extraordinary feat for a pregnant woman). Then as the ultrasound tech and the rest of the team (6 students each day and frequently also one of the on-site coordinators) get the different stations set up, a team nurse or midwife will gather the women outside and deliver a health education talk, where she tells mothers about pregnancy, the possible complications they may see, the danger of not seeking healthcare if these complications arise, and the importance of delivering at a health center. I believe sometimes she also mentions family planning methods, prevention of mother to child transmission of HIV, and nutrition.
Then the mothers are registered by one of the MUST students or another staff member (actually for the most part I believe mothers have been registered prior to the talk), two students set up a station where we measure the women's blood pressure, height, and weight, two others assist the nurse in setting up a bed where she does physical exams, and two others assist the ultrasound tech in setting up a bed where a portable ultrasound machine allows the intervention to provide the mothers with a sonogram examination. Then once the health education talk is over, the mothers proceed to get in line for the services.
Once they pass through every station, they check out at the bed net table, where if they do not own a mosquito bednet to prevent them from getting malaria through mosquito bites while they sleep, they receive one for free. The nets they receive are provided by the funds raised by the Progressive Health Partnership, the student organization at Duke which began the foundation for this Duke Engage project.
Almost every mother who comes to the intervention brings with her a mother's health passport or antenatal card which the health workers give them and their formats are standarized by the ministry of health with blanks and charts to fill in about their personal health record and their antenatal care visit results. If they don't have these, they will usually have thin notebooks where we write down their results throughout the day. They will usually also bring a purse with personal items and will almost always bring a ketenge, a large piece of cloth with multiple purposes. When they go through the blood pressure/weight/height station, we record the measurements in their books or cards. Then they get in line to see the midwife/nurse. She performs palpitations (meaning she feels around on their bellies and wombs) and determines the position of the baby, estimates the gestational age, listens for the fetal heartbeat, and predicts any complications. She also prescribes antenatal drugs including iron and folic acid supplements, drugs that can both prevent and treat malaria during pregnancy, antibiotics, and deworming tablets, and examines the inside of the mother's eyelids to see if she may be anaemic. Then the mother is seen by the ultrasound tech, who determines the health of the maternal organs, liquor amii, the position and echo grade change of the placenta, the position of the fetus, the femur length, gestational age, and expected date of delivery. If the child is an embryo, slightly different information is gathered, and if it is a multiple pregnancy then she determines how many placentas and sacs are present and information for each fetus. If the mother requests it, she may be able to determine the sex of the fetus by checking to see if a scrotum is present, but unlike in the US, most of these mothers have never had an ultrasound examination, so they are not usually shown the screen so that they can see the baby, nor do they get a print out of their child. The results are recorded on a special form and given to the mother, as is done in the physical examination, and some of the information is entered into large registers for the nurses' personal records.
I mentioned that all the students help set up in the morning, but during the day in the field not
all students are always assisting in record keeping, blood pressure/weight/height measurements, and moving women along. Two students each day are responsible for conducting a focus group with a different group and type of community members each week, and two are engaged in conducting an assessment out in the community in the homes of mothers who we had seen in the prior week. One of the students who assists directly in the intervention simultaneously administrates the MUST students who conduct the survey that we developed in order to do a baseline assessment of the antenatal health and related subjects of the community, which we hope to use in the future to guide future programming. I will explain the details of these three projects more in a future entry, because they are a large component of the work the team is doing here.
When the day is done, usually because a) we have seen all the mothers who came, 2) we run out of battery power for the ultrasound and the power is out in the building, or 3) we run out of bed nets (which only happened recently). Then we pack up all our stuff and ride back to the hostel, usually arriving at around 6 pm.
The rest of the team, 4 students each day, who do not go into the field, spend the day shadowing at two hospitals. Two students will spend the morning doing rounds with the doctors at Mayanja Memorial Hospital. Two others observe the labour ward and surgery at Mbarara Referral Hospital, and after lunch the four students will work back at the hostel entering data and completing other tasks, usually on the computer, related to the project. We rotate every day, so for example I spend Mondays at MMH, Tuesdays in Kikyenke Health Center III conducting a focus group, Wednesdays in Rubindi supervising surveys, and Thursdays at Mbarara Referral. On a Friday like today, most of us go to the Mayanja Memorial Foundation Offices and have meetings to debrief on the results we gathered during the week from our three side projects, enter data from surveys into our database, compile notes from focus groups, discuss the scripts for the next week's focus groups, and work out any problems we want to discuss. On a day like today, we will work for a half day and then begin our weekend journey - this weekend we are going to a town called Jinja, which is next to the source of the Nile River. We will be lodging in Kampala, the capital of Uganda, and on Saturday morning we will be picked up and driven to Jinja (approx. an hour away) and we will spend the entire day on the Nile. I am excited about the trip to Kampala - we will be riding on a public bus.
Thanks for reading, and once again, I will write more about the project after I get back from the Nile....
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