Bump to Babe goes to Ethiopia
Carene Many of you might know that I visited Ethiopia in November 2023. If you missed it, well then you are in the right place as I hope to capture my experiences in this blog.
I was fortunate to be nominated by my previous employer, Jenny Wright the CEO of Milk Matters Breast Milk bank, to join a team of extraordinary health professionals to visit the health facilities in Hawassa, Ethiopia. Why Ethiopia you may ask?
Dr. Fitsum Belay, from Hawassa University Hospital, completed her training as a Neonatologist in Cape Town a year ago as part of the African Paediatric Fellowship Program. The program offers a support visit to all fellows with a team of their choosing. Dr. Fitsum requested a team consisting of a consultant Neonatologist, Speech Therapist, Clinical Technologist, and a Dietitian with milk banking experience. Her goal for us was to share experiences on collaborative efforts on advancing neonatal care and aid in establishing subspeciality training in neonatology at Hawassa University.
And so, the pressure was on. I worked hard in the weeks leading up to our departure to prepare a lecture on neonatal nutrition and training materials for the nurses and doctors. At this point I felt confident that I had compiled a very comprehensive lecture for the broad topic I was given, little did I know what lies ahead.
“It was clear to me that my focus needed to be on the treatment of the mothers as part of the infant’s treatment…”
We started traveling on Saturday the 18th of November and arrived in Hawassa over 24 hours later. We were welcomed by Dr. Fitsum and Dr. Salome (paediatrician) with open arms. They took us to our beautiful accommodation at Haile Resort and advised to rest well, as for Monday morning we will talk business.
Figure 1: View from our rooms at Haile Resort
I started the day off with a cold swim, steam, lovely breakfast and coffee ceremony as they call it. Off we went to Hawassa University hospital, peeping through the car’s windows like tourists and full of excitement. Thank goodness we did not need to drive ourselves as the roads seemed to be a display of beautiful chaos, where frequent hooting means “please take note, I am heading your way” and not the much ruder version we are used to. On our route we were able to see some of the beauty of the town, coffee ceremonies under trees, a bunch of children in a small bajaj (tuk tuk) being dropped off at school, donkey cars, a variety of large birds and right opposite the hospital gates we saw a very opportunistic entrepreneur selling coffins. Little did we know…
We arrived at the hospital to Dr Fitsum and Dr Salome welcoming us, from where they took us on a tour of the hospital. She explained that Ethiopia has the 2nd highest number of neonatal deaths in Africa and a 50% home birth rate. The neonatal mortality rate has risen since the unrest in the North of the country from 29 to 33/ 1000 live births. Hawassa Referral hospital serves a population of 18 million and was designed with 400 hospital beds, however only 250 are currently operational.
“My first thought to myself was, how on earth am I supposed to help them if they don’t even have running water?”
The neonatal unit consists of 2 rooms with 10 beds each – for term and preterm babies respectively. The 10 Kangaroo Mother Care beds are on side wards off the paediatric department. Dr Fitsum is the only neonatologist for the region.
All of what we heard, and saw was shocking to say the least. The building is falling apart, with open wires, broken windows, and wood scaffolding as far as the eye can see. The stench of infection filled the hallways, corners filled with dirt, trash and broken equipment laying around taking up space. It was heart breaking to see the conditions that the babies and mothers are subject to. I think the one thing that shocked me the most was the fact that there was no running water in the entire hospital. They have buckets of water on the floor to wash equipment and a tank of water with soap at the entrance of the neonatal unit. I quickly learned why no one seems to drink water while they are there, visiting the bathroom is not a fun task.
My first thought to myself was, how on earth am I supposed to help them if they don’t even have running water? There is no way a breast milk bank can even be considered if there is no water or infrastructure.
I was quickly paired up with a nurse who was delegated by Dr Fitsum to take the lead on breastfeeding practices. Language was a bit of a barrier between us at first, but I tried to assess their current practices and equipment as best I could. These are a few of the aspects of breastfeeding related care that was of concern to me:
- The mothers are not at the baby’s bedside to practice skin to skin, reportedly due to hygiene concerns and an infection outbreak.
- Privacy and comfort for breast milk expression or breastfeeding is out of the question with hard, broken seating in the walkway of the ward allocated for this purpose. This was an upgrade from mothers having to sit on the dirty floors to express milk.
- Breast milk handling and storage was not hygienic or done according to guidelines as they do not have a fridge to store the milk, nor a dedicated milk preparation room.
- They must fortify breast milk with term formula as they cannot afford breast milk fortifiers.
- They have a very good breast pump which was donated but they are not using it as they cannot ensure safe and hygienic use.
- Infants in the NICU are often started on formula if the mother is post-caesarean section, as they believe the mother cannot produce milk yet.
- There were so many people in the small NICU, just standing around. It was busy, bright, and noisy. Surely, this must be contributing to the infection rate.
- Most importantly, the mothers were not used as a tool to aid in the infant’s care and growth. I felt like they were just vessels bringing their milk. I did not see a single smile, only pain, distress, and numbness. This was troubling to me.
By the end of the day Sr. Tumi showed me the new admission to the NICU. A term baby with respiratory distress, born via caesarean about 4 hours ago. The first thing I asked was, “did you get colostrum to feed this baby?”. The cold hard truth was that this baby got formula for the first feed, as they assume the mother cannot produce milk after a caesarean and no one has gone to see the mother. I immediately asked if we could go see the mother and try to collect some colostrum for the baby’s next feed. Little did I know that this was going to be my golden opportunity to make an impact. We found the mother in the obstetrics ward.
“..gloves being used as pacifiers to help soothe the sick babies..”
She seemed to be in pain but looked well enough to try and express milk. I noticed that the culture among the health workers is to do everything, and not to teach or empower the mothers to learn how they can help. Nonetheless, we got a generous amount of colostrum and I tried to encourage and empower the mother about her milk supply. My homework for Sr. Tumi was to help the mother to continue expressing colostrum for the baby’s feeds and keep record of the frequency and volume to allow us to monitor her progress the next day.
Upon our return to the resort, I felt deflated. I skipped supper with my colleagues and went for a run to try and feel a bit better. In hindsight I should have joined them for dinner to be able to vent and debrief. I worked late into the night to try and edit my lecture to better suit their needs, while trying to come up with a plan for the next day.
The next morning, we returned to the hospital, greeted by the sight of one less coffin on display at the gate. Today I had a fuller team, with three young and energetic nurses joining us from another facility called Bushulu. I went straight back to our case from the previous day to assess the progress. None, not a sign of another drop of colostrum given to this baby, only formula. The milk expression record that I provided was not completed further than my own inscriptions from the previous afternoon.
Figure 11: Assessing their progress in supporting our case.
I asked if the mother would be able to come and see the baby to attempt the first feed. Luckily, the mother was well enough and showed up in no time. She appeared to be in pain, with a numbed facial expression and what I hope to be a bit of excitement in her eyes. This was going to be her first time holding her first-born baby…
To paint the picture for you, there were about 5 or 8 people huddling around her, one trying to cut open her dress to get access to her breast, the other swaddling the baby in a thick blanket (no skin-to-skin), and one getting a injection needle ready in front of her eyes to spray the baby’s nose. I just stood to the side to observe her reactions. I felt so sorry for this mother, trauma, overstimulation and anxiety was what I imagined she was feeling. Needless to say, the baby did not want to latch on for the first breastfeed as he quickly became distressed in this environment. I tried to instruct the nurses to stop the breastfeeding attempt and just try to assist the mother to express breast milk for the baby. This also just seemed so painful for the mother to be expressed by multiple people. I tried to show her that she has a good milk supply to try and get her to feel a sense of accomplishment, but she just acknowledged with a nod of her head. On the positive side there was enough milk to feed the baby with only the mother’s milk.
“…seeing the mother’s milk drip out while she was holding the baby, she looked at me and smiled.”
It was clear to me that my focus needed to be on the treatment of the mothers as part of the infant’s treatment. I took the team aside to debrief about the session with the mother and completed a training session to include maternal care, how to practice skin to skin in the neonatal ICU, proper hand expression techniques and infant readiness to feed.
Something seemed to click with the team. They had never considered the mother as a valuable asset to the infant’s care, nor someone that can relieve many of the nursing tasks. “The mother is not a cow, she is your most valuable asset…so please use her and treat her as such”.
Figure 12: the team showing interest!
After this eventful morning we were taken to Bushulu mother and Child Center. This was a private health facility just 30 minutes down the road from Hawassa University Hospital. The facility is funded by Austrian government with state of the art equipment. It was clean and inviting. I noticed that they already have some equipment that would be necessary to run a breast milk bank. I eagerly asked Dr Fitsum, if they considered starting the milk bank here. She then smiled and said, “this is exactly what I wanted you to notice”. We received a tour of the facility, including their laundry, uniform sewing station, power plant and water purification plant. We did a round of the wards with the team that joined us at Hawassa and trained some of the staff before heading home through the bussing city center.
Ending the day on such a positive note yielded a pleasant evening with the team. We had dinner, lots of laughs and yet another late evening working on our lectures and reports of the day.
Day 3 started with a fantastic lecture by Dr Rhoda the Neonatologist from our team, on neonatal mortality and the five stages of hand hygiene. As we all adjourned the session, the 3 young Bushulu nurses called me aside to show me photos of their implementation of my training from the previous day. They placed the infant’s skin to skin on the mother’s chest and saw marked improvement is the infant’s stability. They seemed very impressed and excited to show me their new found skills.
“…and most importantly (in my opinion) prioritize using breast milk and practice skin to skin.”
We all went eagerly to see the progress with our case. To my surprise they had used the milk expression record that I gave them to log the mothers breast milk expression volumes and times. She did a fantastic job, she expressed 9 times since we last saw her and exceeded the volume that the baby needs. We praised the mother for her hard work and abundant supply and allowed her some time to bond with her baby before assisting her with a breastfeeding attempt. As I clapped hands in excitement from seeing the mother’s milk drip out while she was holding the baby, she looked at me and smiled. This was the first time I saw her look happy, and I will never forget her face. Although we could not communicate, I felt that we had established a relationship. I can only hope that she knows how valuable she was to my impact there.
I had the rest of the afternoon to rest and work on my lecture. The team took a lovely sunset boat ride on lake Hawassa, where we encountered hippos and the local fish market.
Figure 18: Sunset cruise on Lake Hawassa.
Thursday morning was time for my lecture. I was nervous but excited to share my message. I had been working on this lecture for months, trying to tailor it to their needs. I felt like my whole career had been leading up to this point. My experiences as a Mother-Baby-Friendly Initiative assessor, peer breastfeeding counsellor at three large NICU’s, clinical manager at the breast milk bank and lactation consultant. Each of these contributed to the message and information I was about to share.
The room was packed, probably about 40 people staring at me. Mostly the resident doctors, some students, nurses and our team.
About an hour and a half later I shared my message, answered questions, and motivated the audience to prioritize breast milk as a means of reducing infant mortality. I felt so relieved that the message was well perceived and executed.
What I remember from there on was a bit of a blur. More coffee ceremonies, meetings, gifting, and photo sessions.
We had a visit to another health facility, Adare district hospital situated in the city center (less than 5 km from Hawassa Hospital). We were given a tour of their neonatal and KMC unit. Another display of very little space and equipment, but a dedicated team determined to make a difference. We saw more plastic bottles being used for oxygen administration, gloves being used as pacifiers to help soothe the sick babies, the mothers all just down the hall in a very crowded space and not with their babies. Dr Rhoda quickly worked her magic with some easy “housekeeping” tips to rearrange the NICU and KMC units to allow for more space, easier workflow, and infection prevention.
This made me realize even more that small things can make a huge difference. Even in those situations where it might seem impossible, or just too overwhelming to even try. Washing your hands before and after each patient, creating space between incubators, not using your phone in the unit, and most importantly (in my opinion) prioritize using breast milk and practice skin to skin.
It is truly difficult to put all the events and emotions into words, but it truly felt like a life-changing experience. Initially I felt like I was not worthy to join the team, then I felt hopeless and overwhelmed, but later it became clear that I was able to make an impact and inspire.
Figure 26: Meeting at Hawassa University to discuss increasing the majors to include multidisciplinary care such as Dietetics and Speech Therapy.
On the last day when we said our goodbyes and shared our experiences I realized that, “this is it”. The immature dream I had as a young student of helping the vulnerable babies in Africa. It may sound cliché, but this realization gave me a true sense of fulfillment that I will forever cherish.
Figure 27: We were gifted with beautiful local artwork and 2kg of Ethiopian coffee.
I am extremely grateful for the experience, and I do hope to travel back soon to help them kick-start their breast milk bank and see their progress in their newly upgraded units.
January 2024
By C. Joubert
