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!

Pediatrics Department

Every Monday at 8am, the staff at the hospital here in Boko gather in the inner courtyard to raise the flag, sing the national anthem, and listen to any announcements from the director of the hospital. It being our first day, we were unexpectedly pulled in front of the crowd to introduce ourselves as the newest interns to the pediatrics and maternity wards. No pressure!

The actual beginning to our day was a bit less ceremonial. We were brought to the pediatrics department where we will spend the first two weeks and were introduced to the nurses who were on shift at the time. We trailed along after them for some time as they did their morning check-in with all the current patients, making sure the files were up to date.

There wasn’t much time for them to give explanations to us as they went, as not soon after a very glamourous woman entered the ward, who we quickly learned was the pediatrics doctor. On her arrival, the staff filed into her office for the morning staff meeting. As we would quickly learn, this was the morning routine in the ward. The head nurses on shift for pediatrics and the neo-natal wards would read through the files of any new arrivals, with the doctor asking questions, and often they would discuss some points, or the doctor would give directions on how certain things should be done.

Sometimes nurses would even be reprimanded during the meeting in front of the group; everyone was expected to just take in on the chin and move on with things without showing any emotion. Most of the time, it turned into a small explanation of how the procedure was meant to be done.

After the staff meeting, the social assistant / nutritionist arrived, whom we are shadowing for our two weeks in pediatrics. It was a bit chaotic for getting started and getting to know how things run in the ward. But we soon learned that in terms of food and nutrition, she is only responsible for the children who are malnourished. In these cases, she is determining how much of what type of food the children will receive and how often, following up daily with their weight evolution and (hopefully) moving them from one phase of nutritional therapy to another.

To determine the severity of malnutrition, they use what is called the “z-score” based off the standard deviation of the weight for height. If the child has a score of -3 or more (so 3 or more standard deviations less than the average) then they are considered severely malnourished. If this is combined with “complications”, like oedema, vomiting, or diarrhea then they are referred to the hospital.

The hospital receives from UNICEF powdered therapeutic milk for free – F75 and F100. The children usually start with the F75, which is slightly lower in calories. This is because due to malnourishment, the body isn’t used to digesting food anymore. Starting immediately with too many calories or too high a quantity can result in refeeding syndrome, which generally is a disruption of the electrolyte and fluid balance in the body. In cases of very young children and/or extremely severe malnourishment (younger than 6 months or less than 3kg in weight), they instead use a diluted solution when beginning treatment.

As the child makes progress, such as complications clearing up, ideally within 3-4 days, they are moved from the F75 to the F100 formula. As progress continues, they will then move on to a porridge, called “bouillie” which has been enriched. When they are eventually discharged, the parents are sent home with some packages of the powder to make this broth, as well as packages of “plumpy nut” a high calorie, peanut butter-based product that is also distributed for free via UNICEF.

Health promotion in rural schools

As the larger group of students arrived in Parakou in the run of our first week, we were able to join them for a couple of their activities that aligned well with our internship goals and were also coordinated by our internship mentor, Eric. On Wednesday we joined them to a local school, where the Odisee students had prepared a morning of educational games for the children to teach on topics like proper handwashing, brushing their teeth, and fruit. Femke and I helped with the station on fruit.

The first game was to guess which fruit was in the bag, without looking. Each child in turn closed their eyes and put their hand in the bag to try and identify the fruit. With some of the groups it was pretty easy, and with others less so. The papaya fruit seemed to be especially challenging. The second game they played was the card game, memory. Each child in turn flipped over two cards and the group had to try and find all the matching fruit. It was challenging to coordinate with so many enthusiastic children, but in the end, it was a success. The fruit station finished off by giving each child a skewer with fresh fruit on it – pineapple, banana, and watermelon. We wanted to use the papaya as well, but sadly they weren’t ripe enough yet to eat.

Malnutrition screenings in rural villages

On Friday we were back with the big group again for a day of health screenings in more remote villages. There were three groups per village: one doing malnourishment screenings, one for malaria testing, and one for wound treatment. For our malnourishment screenings (which we will also spend several weeks doing later in our internship), we use special measuring tapes to measure the circumference of the upper arm of the child. The armband is marked by colour, showing an indication as to the degree of (mal)nutrition. If the child appears to be malnourished, the doctor from the local health centre will do a full evaluation and either treats the child there, or, if there are additional complications, the child is referred to the hospital. In cases of malnourishment, the Hubi & Vinciane Foundation is covering all the treatment costs.

Our village it was quite chaotic! There were so many people there to see us, and each parent wanted their child to get priority. It was challenging to keep some semblance of order and keep the line moving along at a good pace. After we measured the children for malnourishment and controlled for oedema and anemia, they were sent to get their temperature taken. Any child with a fever immediately had a malaria test taken. Of 10 children with fever, all 10 were positive for malaria – and it is not yet the high season for malaria!

Luckily, we did not find many children with risks for malnutrition. For the children I measured, I had 6 that fell into the “yellow” zone, which meant they received nutritional advice but didn’t yet need to seek treatment. Femke had one child who was in the red zone – likely malnourished – and was sent to consult the doctor from the health centre for further treatment.

Time flew by, and before we realized it, we had been there for almost 3 hours doing tests! And yet the children seemed to just keep coming… It was hard, but at a certain moment we had to announce that it was finished, and we couldn’t continue taking measurements.

It was a long, hot day doing the malnourishment controls, especially considering the time needed to get to and from the village, but it was also one of the most rewarding days thus far.

Cotonou

Our first night was spent in Cotonou staying in a group accommodation block at a convent. The rooms were as comfortable as expected, although we unfortunately didn’t have luck on our side as we ended up in one of the rooms without even a ceiling fan! It was a long, hot, humid night for our first one in Benin.

The centre cooked dinner and breakfast for us and so we got our first tastes of Beninese food. They use lots of herbs and spices which will take our stomachs some time to get use to. The heat from the first night hit me hard, so for the first couple days I struggled with some nausea and didn’t really get to enjoy the food beyond a few mouthfuls. They seem to cook a lot of rice and couscous, sometimes spicy and sometimes not, with mainly fish or chicken as a source of protein. We’ve had various vegetables from fresh salad to marinated onions, as well as a mix of veggies alongside beans. If you want to drink something here besides water, the main cold drinks are very sugary pops or else beer. Although with the heat the extra sugar from the soda is quite welcome! The main beer here is Beninoise, either in its regular version (about 4.5% alcohol), or the lemony version, the Panaché, (about 2% alcohol), which was a fast favourite for Femke.

Ganvié

Our first true day in Benin and we were able to follow along with the group of students as they visited the village of Ganvié. Ganvié is not far from Cotonou, and is a large village built almost entire on stilts above the water of the Nokoué lake. We spent about 3 hours touring around in a boat, seeing fisherman busy with making their catches and women selling food and supplies directly from their boat just like a floating market. We stopped at a hotel and restaurant/art gallery/giftshop for a cold drink and got to peek inside the rooms – it looked to be a very nice view to wake up to in the morning! All families here have a boat, usually one boat for each parent and then one for the children to share.

Ganvié is often called the Venice of Africa and was established in the 17th century when the people of the Tofinu village fled from slave traders of a neighbouring tribe. The religious beliefs of those in pursuit prevented them from engaging in conflict on this sacred lake, and thus the people of Tofinu established the new village, Ganvié, or “we survived”.

In the legend of Ganvié, after fleeing for several days across land, the Tofinu people come to the lake. The king transformed himself into a heron in order to find them a safe place to live. Then he became a giant crocodile and brought all his people to where Ganvié is now established. The slave traders reached the lake, and fearing evil spirits that lived within it, did not pursue the Tofinu further.

Today Ganvié has a population of about 30,000 inhabitants, the majority living on houses built on stilts above the water. There are about 3000 buildings including a hotel, bank, post office, school, church, mosque, and hospital. The school is built on land so that the children have space to play on solid ground.

Porto-Novo

We spent the night in Porto-Novo, the capital city of Benin and not far from Cotonou on the coast. The stay was at an agricultural project called Songhai, which was focused on sustainable living (everything at the centre was repurposed) and was home to many rescued animals. Here we finally had a room with a ceiling fan and even got to take a dip in the swimming pool to cool off from the humidity! We were, however, puzzled by our toilet that didn’t seem to flush… we kept having to fill the back of the toilet with water in order to get in running. Until we finally overheard someone talking about turning the water on for the toilet – aha! The tap that we were unsure of touching actually had a purpose. Apparently here if the washroom isn’t in use, they turn off the water to the toilet using a small tap on the side. Success! We had a working toilet. Live and learn, this knowledge would come in handy.

Enroute to Parakou

On Sunday morning we were up early and leaving the group behind as we caught a local bus north to bring us from Porto-Novo to our internship location in Parakou. As we waited for the bus to depart, there were women come on periodically to sell drinks and snacks. We had our own water with us, but not much to eat. But because we only had larger bills, we were unable to buy anything, as they couldn’t make change for us. So with only a few small things to eat, we made our way north for the 7-hour bus ride.

It was a lively bus – there was African music playing on the speakers for the whole journey, plus several times a man would board the bus and then spend over an hour regaling the passengers with tales of the healing powers of the wares he was trying to sell. Soaps, powders, oils, we saw them making good business on the bus with the locals. They were always very charismatic men, telling stories and getting the passengers laughing. The bus had no air conditioning, but the wind through the windows kept things comfortable. Although as the day went on, and we got further north, you could feel the temperature climbing!

When we stepped out of the bus in Parakou, we were absolutely swarmed by the local motorcycle taxi drivers (called zems), who were looking for business. However, we were waiting for our internship mentor to meet us there and didn’t know what sort of transport we would need. A couple of the drivers helped us move our things under a shelter to the shade and kept us company while we waited. It, of course, turned out to be good business for them, as our mentor, Eric, arrived on his own motorbike. So we needed to load up one zem with 3 of our suitcases, Femke and the 4^th suitcase went on another zem, and I was with Eric as we rode about 20 minutes to the north of Parakou to the hospital of Boko (Hôpital Saint Jean de Dieu). Finally arrived at our accommodations for the next 11 weeks!

The internship in Benin is with the Hubi & Vinciane Foundation, an organisation that has been active in the country for more than 40 years. As nutrition & dietetics students, two of us will be spending 10 weeks working locally with the foundation, learning and assisting them on their various nutrition-related projects.

The projects involved topics such as preventing, detecting, and treating malnutrition, education in villages and in schools on healthy eating, and the prevention of hypertension and diabetes. We also hope to learn more and help out with many of the other projects that the foundation is active with. (Learn more here.)

Of course, we have our own personal goals for the internship period, such as:

• Gaining experience at both the community and hospital-level
• Learning about local food, ingredients, preparation, and the role food is playing in their culture
• Learning about how accessible healthcare is and what barriers might exist for people to access health services
• See first hand the initiatives to prevent/detect/treat malnutrition
• Follow along with other projects through the foundation, like education on feminine hygiene & support, community garden projects, agricultural entrepreneurship, etc.

We will be living on the hospital campus, about 15 minutes north of the city of Parakou. Parakou is the largest city in the north of the country. We will fly into Cotonou (on the coast in the south), and spend the first days there and in the capital, Porto-Novo, before journeying by bus about 8 hours north to Parakou. 

Femke and I will be co-writing this blog, alternating each week to keep you updated on what we are doing. 

Follow along in real time via our Instagram pages: 
Heather: @healthfully.heather  
Femke: @femke_vuylsteke 

Photo via Unsplash, arial shot of Porto-Novo, Benin’s capital city.