A well-deserved rest day

At the end of last week it was Femke’s birthday. To celebrate this, the two of us went to hotel Les Routiers to take a dip in the swimming pool, enjoy the tranquility, and escape the heat for an afternoon. Since there is not much to do in the hospital in Boko, where we are also staying, we both worked every day for school. If we do an internship in the hospital during the day, we will be busy in the evening with either the necessary household tasks or with our bachelor’s theses or assignments for the internship. We also kept ourselves busy with schoolwork during the weekends, so that a day of rest and doing nothing for school was sometimes allowed and we enjoyed it immensely. You may be surprised, but even though we’ve been here in West Africa for a month, we haven’t been able to enjoy the sun and get a lot of color yet. 😉

Hotel Les Routiers is a well-known hotel in Parakou where many Westerners stay and where various ambassadors meet regularly. It was a pleasant visit, and we are thinking of visiting the swimming pool again during one of the upcoming weeks. Once we are finished at the hospital, we will need to commute into Parakou each day for our internship. Apparently, the hotel has tasty European dishes such as stew with fries, which we will definitely need to order! There is also a souvenir shop outside, which is very nice since Parakou is anything but touristy and we haven’t been able to buy any souvenirs yet.

Back to work

After a pleasant Saturday, we ended our weekend with a quiet day of work for school and then we could start our second week in the maternity department.

This week it was Femke’s turn to follow the prenatal consultations and Heather got the chance to give some nutritional tips to the women who were healing from their caesarean section operations. On Tuesday we were about to follow another woman in the delivery room. This time the experience was a bit more eye-opening compared to the last. Given that a normal, natural childbirth here always takes place without anesthesia, this is already a painful experience. But when it was noticed that the opening of the vagina was about to tear through, it was decided to cut the opening to prevent this tearing. This was also done without anesthesia. After the delivery had gone off without a hitch, the woman had to be sewn up again, of course, and this is again done here without anesthesia. Throughout the procedure, the woman cried out in pain and was told/called to her to stop yelling and to be quieter by the midwife.

This experience was yet another example of one of the most striking cultural differences between Belgium and Benin. There is no place here in Benin for sympathy for those who are in pain. When a 15-year-old girl who was about to give birth wanted to sit on a step last week because she was having a hard time, she was yelled at not to sit there and that she should just stand up or find another place somewhere else. It feels often like you’re not allowed to show any signs of weakness here.

It also sometimes happens that one of the new mothers speaks little or no French and if the midwife does not speak the same language as the mother, the midwife often gets angry with the woman because she does not understand her. Shouting at the patients and even hitting them with a book if they do something wrong, for example, is a regular occurrence here. The way of communicating is generally more aggressive than in Belgium, which took some getting used to.

It is also striking that everything is very focused on the parenting and domestic role of the women and that the partner is never involved in, for example, giving nutritional advice to the pregnant woman. Only if the woman seems to have misunderstood, the partner will also be informed. Even at the birth, the partners were not allowed to be present. The women are often three next to each other (ready to) give birth without anyone they know being present. After giving birth, they have to lie naked for a few hours without visitors being allowed to come or getting dressed (in order to be able to properly monitor the mother’s recovery and the afterbirth).

In the O.R.

Later in the week, Femke got an opportunity she wouldn’t pass up. She was allowed to follow the operation of an ovarian cyst. When she entered the operating room, she thought she was wrong at first, as the woman who was ready for the operation seemed to be heavily pregnant. In the end it turned out to be a cyst of 10 kilograms – the size of twins. The cyst was therefore completely removed together with the uterus. We won’t go into the gory details, but let’s just say it was an experience to remember. For the patient, it was literally and figuratively a great weight lifted from her shoulders.

Other than that, the working week was fairly quiet. We were able to arrange that we were given Friday afternoon off to go away for the first time for a weekend and to further explore the country. We opted for a weekend trip to Kossoucoingou, near Natitingou, close to the border with Togo. Exciting!

This week began our first week in the maternity ward at the hospital. After a relatively quiet couple of weeks in pediatrics (good for the kids, but less interesting for us), we were hoping there would be more going on in maternity, considering the courtyard in front of the ward is always full of people.

Like in pediatrics, the day always starts with a general staff meeting, in this case lead by the gynecologist. We were able to talk to her a bit beforehand, discussing our objectives for our time in the maternity department and how we could best spend our time as well as bring some of our expertise to the ward.

During the daily staff meetings, the doctor and midwives are always going through all the births from the previous day (and night) as well any important status updates from hospitalised patients. Especially on a Monday, this meeting takes quite some time, often with 20-30 (or more) births having taken place.

Our schedule in the maternity ward

Over the two weeks of our time in maternity Femke and I would be splitting up for the start of the day. I would follow the midwife conducting pre- and post-natal consultations, and Femke would follow the midwife doing the morning check-up with the hospitalized patients (generally the patients who gave birth via c-section). Next week, our second week in maternity, we will switch places. Once we are done with our respective midwives, we are free to follow whatever is happening in the reception as well as any births that are taking place.

On Tuesday, during our time after following the midwives, we were able to observe our first birth! We just lucked out with timing, going to the delivery room minutes before the woman gave birth. After birth, the baby receive an injection of vitamin K and they determine whether it needs to be taken to the neonatal ward. Tuesday and Thursdays are the days when c-sections are scheduled, although we haven’t (yet) gotten a chance to observe one. 

We were also tasked with preparing a small presentation to give to the women post-birth about proper nutrition during breastfeeding, with a special focus on anemia (iron deficiency) – a very prevalent issue here. For this week we mainly focused on fact-gathering. Rather than giving a textbook answer to the question we needed to learn from the midwives what nutrition advice would also be practical, considering the local diet and access to certain foods. For example, we learned that for the average woman, meat or fish is often only a once weekly occurrence due to budget.

Pre- and Post-Natal Consultations

Following the midwife for the pre- and post-natal consultations was very interesting. They don’t really give people formal appointments here, although they are often told a date on which they should come. (That being said, people tend to show up randomly regardless of the date they received.) They are expected to arrive first thing in the morning, register themselves for a consultation, and pay at the cash desk in advance. Then their files are gathered in order of arrival and the patients just need to sit on the benches outside the consultation room until they are called – sometimes for 2-3 hours! While it seemed for these consults that most people tended to arrive around 9am or so (based on their payment receipt), consultations with the gynaecologist had people queuing outside her office already from 8am.

The patients coming to appointments at the hospital are usually doing so because there is some complicating factor and they have been referred from their local clinic. But others just come as they prefer to be seen at the hospital and to give birth there as well. The midwife really takes her time with each patient, sometimes the consults would take up to an hour. In addition to going through the file, she does a check for anemia (iron deficiency), a physical exam of the belly and uterus, and listens to the heartbeat (with the metal cone shown in the photo). 

Depending on the patient’s needs, I was also sometimes called upon to give some nutritional advice, for example on general nutrition during pregnancy, on sufficient calcium/magnesium intake, or nutrition during times of morning sickness.

Heading to the market

This week we were also on a mission to finally make it to a local market to buy fresh produce, as this is not stocked in the grocery stores. After asking around to different people, we heard pretty unanimously that Marché Depôt, in Parakou, was the best place to go. And we got even luckier, when our friend Perpétue, who runs one of the restaurants at the hospital, offered to take us and help us navigate the market for the first time.

The market covered a couple of blocks along the ring road of Parakou in the west. Many of the vendors had a lot of the same things; tomatoes, onions, leafy greens, spicy peppers, with a few selling some extras like avocados, carrots, cabbage, potatoes, etc. There were a few fruit stands, a few selling canned goods, and a whole section just with live chickens. It was a great experience to have a local with us, who also helped negotiating the prices for everything.

It was tempting to buy and try a lot of things, but we attempted to pace ourselves considering we still have 9 weeks’ worth of shopping and cooking to do. The highlight for me was tasting new foods that we had never seen before (like a type of fruit for which they couldn’t even think of the French name), as well as finally getting our hands on some plantains to be able to fry up at home.

After a busy, but very interesting first week, we energetically started our second week of the internship in the hospital in Boko. Most days were very similar to those of the first week. Our day always starts with a kind of multidisciplinary conversation, la reunion de staff, after which the nutritionist arrives and we can start with the nutrition-related part. The children in the ward with malnutrition are weighed, any adjustments/additions to the diet are applied and the milk is prepared and distributed. In between, we also have the opportunity to view files, to make the feeding schedules of newly arrived children with malnutrition, to follow the follow-up consultations with children who are (on the way to be) cured of malnutrition, etc.

At the beginning of last week, a child with severe malnutrition was admitted to pediatrics whose case is very similar to Beauté’s. This is another 15-month-old girl with severe malnutrition who was admitted to the paediatrics. On arrival at the hospital, this girl weighed only four kilograms. The first few days her nutritional status stagnated and there was no immediate improvement. Only after a while was it noticed that she was gaining weight. Again, we noticed certain facial features suggestive of an underlying condition and were told that the staff thinks it is a trisomy (the presence of an extra chromosome). Today, a week and a half later, our little patient has gained half a kilo and improvement is on the way. After adding Plumpy Nut to the diet, she can now switch to a mixture of Plumpy Nut and Bouillie (an enriched porridge), which demonstrates the positive evolution in her nutritional status.

Malnutrition screening in Yebessi

On Wednesday we accompanied the group of students for the last time with the screening for malnutrition and malaria and the care of wounds. This time we were taken to le center de santé in Yebessi, a village about 75 km from Parakou. Again, we were responsible for screening for malnutrition in the children from six months old up to and including the age of four years. Fortunately, this time we only had one child whose UAC (upper arm circumference) was in yellow and we had to warn him about the risk of malnutrition.

Since we finished the malnutrition fairly quickly, Femke followed up with wound care afterwards. Here was a man who had been involved in an accident with his motorcycle the night before. He then went to a hospital, where they quickly sewed up his wound and he was soon sent home. When he came to us, he was still wearing the same clothes he had in the accident, the bottom of his pants had been cut off to access the wounds on his leg. However, these wounds were anything but well treated. His leg was completely inflamed and swollen, and no heartbeat could be found at the level of the knee.

There was compartment syndrome and a risk of loss of the leg if there was no rapid improvement. His wounds were then thoroughly cleaned (some of the smaller wounds had never even been looked at in the hospital as the blood was still all over them), loose skin was removed, and the necessary medication and care administered. If there was still no improvement on Thursday, the gentleman had to immediately go back to a better hospital in Papané where good follow-up could be guaranteed.

Visiting the Hubi & Vinciane foundation

Around noon we returned to Parakou, where we visited the home base of the Hubi & Vinciane foundation. Here we received a presentation about what the foundation works on as well as a small lecture from a Swiss doctor who has been working in Africa since 1975. This presentation was about how they are trying to introduce responsible family planning in Beninese families, teaching father and mother how to follow a woman’s fertility in a natural way. They then learn to use this information in order to fulfill the wish of whether or not to make a child. The importance of a simple presentation to the local population was also explained to us, given that anatomical knowledge is very limited and an approach that is too scientific would only cause confusion.

At the end of the afternoon, both we and the larger group gave all the material we had brought to donate. Scales for large and small, blood pressure monitors, baby clothes, and suitcases full of various materials were received with great gratitude.

There you go, these were our two weeks of internship in pediatrics at the hospital Saint Jean de Dieu in Boko. It was two exciting weeks alternating between very quiet and very busy, long days. Next week we will move up one building and start at the maternity ward. We are very curious about how our internship there will go and what situations we will see there. We are certainly looking forward to it!