This past week, we were able to spend a good amount of time getting to know our way around the maternity ward and the delivery suite at Queens, and in doing so, I gained a bit more insight into the intricacies of the Malawian healthcare system at large.
The nurse’s station in the Delivery Suite.
One of the technologies in development at Rice, AutoSyP, is preparing to start clinical trials in July. AutoSyP is an infusion pump that can deliver medications to a patient at a constant flow rate over an extended period of time. Infusion pumps not only improve accuracy and consistency of flow but also relieve overworked nurses from having to be available to administer a medication for the entire duration of the treatment.
One of the two infusion pumps currently available in the High Dependency Unit of the Delivery Suite.
In order to prepare the clinical trial protocol, it’s important to understand how nurses currently administer medications that must be delivered to the patient over a specific time period of several minutes or hours. One example of a procedure that fits this description is magnesium sulfate (MgSO4) delivery to pre-eclamptic or eclamptic expectant mothers in the maternity ward. Pre-eclampsia is a characterized by swelling, high blood pressure, and protein in the urine, leading to a high risk of seizures during labor and delivery and placing both mother and child in danger. However, MgSO4 acts to stabilize the mother, and it must be administered constantly from the time the condition is identified to 6 hours after delivery. The goal is therefore to understand how nurses currently manage MgSO4 administration and to create a protocol that integrates as easily as possible into the existing system.
Through these observations and conversations with nurses and physicians, I learned a few things about the Malawian healthcare system in the process:
The reality of a procedure is often different from the textbook description of a procedure. We had read about the two different types of MgSO4 administration techniques, one of which uses an IV drip and one of which uses intramuscular injections, but when we went in to observe the procedure, what we found was a mix of the two techniques. Limited supplies meant 60mL syringes were scarce and infusion pumps were often unavailable. Therefore, while the loading dose was administered by a nurse through an IV (this takes only 10-15 minutes of flow rate control), the maintenance dose had to be administered intramuscularly every four hours. An IV drip of the maintenance dose would have required constant flow control, and without a nurse continuously at the bedside, this control is not possible.
An example of some of the syringes available to nurses.
There are often variations in methods for a procedure across the nursing staff. It is often hard to locate the references for these textbook procedures, and it becomes even harder to locate a protocol when the reality of the treatment is a blend of multiple techniques. There was an official reference on the procedure that was located after about 10 minutes of flipping through a book in the main office of the delivery suite, but there were limited resources for nurses on the floor of the ward itself, so many times the procedure could look significantly different depending on which nurse was administering the treatment.
Policy decisions can sometimes prioritize ease of care over patient comfort. One of the main reasons nurses were using a mix of these two protocols was actually due to something far beyond their control, and one of the obstetricians explained this reason to us. In 2014, Malawi held its first tripartite elections to vote for local government, members of parliament, and the president in one single election. Peter Mutharika won the election over the incumbent Joyce Banda, and this shift in presidential administration was felt across government ministries – particularly the Ministry of Health. Specifically, political affiliations with pharmaceutical companies led to changes in the way that the government procured MgSO4: The concentrations changed from 1g MgSO4 diluted in 2mL to 2g MgSO4 in 10mL. Now, instead of receiving intramuscular injections of 10mL, patients must receive 2.5 times that, 25mL, in order to have a full maintenance dose. Imagine being injected with 25mL of fluid every four hours- that’s a large amount that causes patients extreme discomfort and soreness. However, because it’s easier for the government to procure and intramuscular injections are faster for nurses to administer, it becomes standard of care for MgSO4 administration.
One of the MgSO4 vials used in a maintenance dose. A full maintenance dose would be 2.5 of these vials.
It takes significant time and effort to shift a system towards a new method, but if implemented well, AutoSyP could not only simplify a day to day task for nurses but also lead to more customized, comfortably delivered care for mothers. Observing the system surrounding this aspect of maternity care allowed me to see how both hospital procedures on a micro-level and policy procedures on a macro-level can directly impact patient care. Providing nurses with a viable alternative that integrates into their routine would benefit both parties, so I’m excited to see how AutoSyP is received next month!