The Uniqueness of Maternity Work
Let me first say that lots and lots has been going on lately, taking me out to villages and back to the hospital and all around. Since September, I've been to Dodoma, Iringa, Dar es Salaam, Wampembe village, Sumbawanga, and all around the Nkasi District. In between, I've been filling out loads of paperwork for my two(!!) grants that I've now be awarded for my research and trying to pin down people for interviews (a bit like herding cats), as well as thinking ahead to residency permit renewal time, research clearance renewal (anyone thinking of doing research in Tanzania, I have lots of tips on these topics if you're interested…), and the holidays. When I'm not doing all of that, I will be either passed out on my bed or training for the Kilimanjaro Half Marathon in Moshi on March 1st. Wow. Now, onto the research.
The hospital has recently implemented a new accounting system, which now involves computers and printed receipts for medications and services provided. As with any big change, this one has been accompanied by a number of growing pains all around. I think there seem to be a number of new benefits of the system, including more accurate accounting and an increase in hospital revenue, always a good thing when government support is sometimes unpredictable, more predictable patient flow, and better record keeping. However, the nurses, in particular, have raised a number of concerns about the new system. These concerns have come from all sides, all wards, and a number of different nurses. However, the maternity ward staff have arguably had more changes to deal with than most of the rest of the hospital.
Only one month into this new system, there have already been reversals of policy and more changes. Maternity seems to be considered the problem child these days. First, we were problematic because we weren't using patient files, women just reported directly to the ward, bypassing the records department and payment window because all care for pregnant women is subsidized by the government. Then, we were a problem because we effectively used up the entire hospital's store of paper files for starting new patient records. Think about it. The maternity ward sees between three and six hundred deliveries each month, EACH MONTH! Of course we're using a lot of files. Personally, I thought the files were nice and were helping keep women's paperwork together and more organized. However, now, we have gone back to no files or charts. As another consequence of this new system, the nurses have to record the exact number of each supply used in the care of a patient. That means writing down the number of pairs of gloves you use, the number of syringes, IV fluids, uterotonics, etc. Now, this wouldn't be too terrible (though still onerous) if there was a systematic way in which to do it and then compile the info for the end of the day report. However, no such system exists and the nurses have been complaining loudly and often that this has drastically increased their workload on a ward where they are already overburdened and frequently extremely busy. The hospital, particularly the pharmacy and main store, will now no longer disperse supplies without the specific names of patients and a daily head count. This means that we did not have any gauze on the maternity ward, not a single piece, for nearly two weeks. It would be impossible to take the name of every woman who comes to give birth to the pharmacy in order to beg for some gauze. The baby would be out already before you even found the pharmacy person to talk to about the issue!
I see one of the major problems here as being located firmly with some of the hospital administration. There are several among them who have never worked on a maternity ward and therefore are unfamiliar with what it's like in the trenches, so to speak. They makes these plans with a broad brush and then expect maternity to adhere to the same protocols as the medical medical ward, which as one of my interviewees once said, "doesn't have any emergencies. What kind of emergency does medical medical have? Maybe someone is having diarrhea but it's not an emergency like on the maternity ward." We can't be running back and forth to the pharmacy to ask for gauze every time a baby is born. How is that supposed to work? Even the opening of a new file for every woman was drastically different for maternity than the rest of the hospital, not just because of the high volume of patients. It's time that the administration get it firmly in their heads that maternity will not be able to fall in line behind all the other wards, it is a uniquely complicated ward that should be treated differently and probably with more flexibility and inventiveness in order to address its unique issues. It's a daily struggle. I think these recent developments will probably be reflected in the questionnaire about to give to all of them. We'll see if it shows in how they rate their levels of satisfaction and empowerment...