Week 4

My main day at the health center was Wednesday to attend the child welfare clinic and attempt to interview postpartum women. However, no patients in this phase of care came for their visit. As a result of it being my last opportunity to conduct direct interviews, I decided to bring my total number of patients to 50, disregarding which service they were seeking. Therefore, I added the final eight interviews from the reproductive and child health center. In all, my research included 20 antenatal women, 25 patients from the child welfare clinic who have children ranging in age from newborn to 2 years, and 5 deliveries (none of which I was able to directly observe). Although I was unable to obtain my original goal of 15 women from each category, it seems like all women were able to answer the questions related to their most recent pregnancy and contribute to my research process. There also did not seem to be any different patterns dependent on which service they were attending, thus the results were not adversely affected.

Waiting area at the outpatient department

An additional opportunity I took advantage of was to follow the community health nurses on a home visit outreach into the sub-areas of Kpando. They supposedly do this on a weekly basis, changing their desired location each time. The intentional service is really good but I saw the actual process as a priority for future investment and commitment. The objective is to identify children who are not attending child welfare regularly and are not up to date on the recommended immunizations by requesting to see their health record, as well as to assess for any immediate health concerns through direct observation. Additionally, the nurses provide health education and counseling as appropriate to individual needs. If the child qualifies and has not yet received the vitamin A capsule, they will also give it in the home. However, no immunizations are given nor are the children weighed because it would require carrying the small cooler, supplies, and an appropriate scale. For this, they are referred back to Kpando Health Center (the same place they have not been attending). If a child is identified but has no health card, the nurses just write down their name and contact information to follow up rather than register them and provide the necessary care at once. I was expecting to be gone the majority of the day conducting home visits but it turned out to be a complete failure and almost even a waste of time. The team seemed to walk aimlessly just looking for people with children under age 5. We literally saw 5 mothers and her child(ren) before the nurses said they have closed for the day because the weather was too hot. They even admitted they prefer to only do home visits only for about 1-1 ½ hours then return to the health center for the remainder of the day, although a nurse stays there as well in case anybody comes for care. This adds to the opposite problem which I actually encountered earlier in the week when it was raining. They postponed the clinic then as well because nobody would show for care (staff and patients alike). Additionally, it becomes nearly impossible to pass between the houses as the paths are all uneven dirt trails that become a muddy mess. Although I understand the complications, it is very unfortunate that the weather acts as such an impediment to reaching the vulnerable populations and providing essential services. In my opinion, it definitely represented a missed opportunity to invest in maternal, newborn, and child health.

I gained access to a maternal health workshop manual which was designed by a previous group of volunteers with the organization but has not yet been fully implemented due to a lack of volunteers. It is directed toward encouraging self-efficacy of pregnant women by preparing them for the normal delivery and postnatal period as well as educating them on unexpected complications during childbirth or the postnatal phase. It also encourages the presence of a birth partner whether it is the spouse or a family member. I feel the manual is very well organized and culturally appropriate, including small posters with English and Ewe translation. I was unaware of this project prior to my arrival, and actually would have preferred my practicum experience to focus more on the implementation and evaluation of the workshops within rural communities, as it is very similar to my topic. I also think this project would have made me feel more beneficial to the community and given me that greater sense of fulfillment I was looking for. Maybe it just means I will have to take over the program on my next trip to Ghana

Since outreach was so quick, this is the only picture I got of the community health nurses at work

I am getting the sense that some of the wound care patients are not adhering to our own recommendations thus are not helping in the healing process. This is only working against all of our own efforts. Many refuse the Vaseline. Some do not soak the foot regularly to get rid of the buildup of dirt. One was referred to the hospital but failed to show with her insurance card and health record. The next time we went to visit we were told she had gone to the bathroom when in reality, she was actually running to hide from us because she knew what we were going to say. This is really disappointing to me as it is abusing our resources when they could be invested into something else. On the positive, some are in fact kept very clean and one man has taken over all of his own wound care, we only stop by to assess and give additional tips. A 1 ½ year old girl fell into a pot of boiling water in January and suffered severe burns to both hands/ arms. It also somehow deformed the bones in her hands, where she now has very limited function. To me, it appears as a crush injury. The skin has healed very well but unfortunately the hands will probably never be fixed. Even back home a case like this would require several plastic surgeries. The funds that people back home helped me raise were meant for wound care supplies. Some of the money will go to basic needs but a larger portion is probably going to start investing in intensive care one at a time in the regional hospital so the patients can graduate out of our program. Although this was not the original intention, I agree that it is the best option for now as what volunteers have been able to accomplish is very little over the past 3 years. Getting local advice may prove to be very beneficial so those who are committed can move on and become productive members of society. On the walk back, I noticed two signposts significant for public health. The first was to promote hand washing as a means to prevent illness. The second was to use latrines rather than open defecation. I don’t know how effective they are, but it was at least encouraging to see an effort.

I had my first episode of not feeling so great but luckily it only lasted a few hours in the evening. I had an awful headache and was nauseous. Probably a combination of dehydration, heat, and the dinner I was served. I remember this dish from the last time I was in Ghana and it definitely is not one of my favorites. Unfortunately, as a practicing nurse now, I had the special honor of relating the color and consistency to NG tube canisters which is never a pleasant thing to think about when you are trying to eat. The dough is called Akpele which actually doesn’t taste too bad in small amounts. It has a wheat/oat taste. It is made of corn flour and cassava. The bad part however is the stew, which is made of okra and goat meat. This gives it a very green and slimy texture. I try my best though as I don’t want to offend the cook and most of the time the food is quite good. I have actually been quite blessed though to stay healthy. All of the other volunteers have been sick at some point throughout their stay and all have taken oral rehydration salt to help with their diarrhea. 

I was able to meet a new referral case from another community and see the intake process at the children’s home. She was brought in by the social worker and her mother. Vanessa is a five year old girl who has multiple open sores on her face. These were acute. The real problem was her eye sight. Since 6 months of age, the mother realized her daughter could not see well. Just from observation and a quick assessment, both eyes had a white center and were constantly moving from side to side with no focus. If you held a pen in front of her and asked to reach for it, she would do a swiping motion to feel for it rather that reach out and grab it directly. Her brother also has the problem but he is older and attends a school for the blind. The plan is to get her registered with health insurance and attend an eye clinic to get more specialized assessment and see if she is a candidate for any surgery. They do not know if it is cataracts, neurological disorder, tumor, hereditary, etc. I also sat in on the doctor rounds at HardtHaven. A family medicine resident comes from Accra every month to work with the sick kids (those who are HIV positive, are on medication, or have health concerns). It was nice to see his process of providing more focused therapy and giving recommendations for treatment. Also that he is familiar with each case so can know baseline and track progress.

I have been trying to spend as much time in the children’s home as possible as my time is flying by so fast and I just love being part of the group. I continued with movie night both Friday and Saturday, playing the film of their choice on my laptop (even if it happens to be a Japanese film with French subtitles that nobody can understand- for whatever reason they love the movie and laugh the entire time insisting we watch the subsequent parts the next time haha). They all crowd around and look at the small screen. I also joined in on sports day but can never live up to their soccer skills. They are really happy I have gone to church and lasted through the entire service, as many volunteers try to go once and leave partially through because it is so long (one week I was there for 4 hours!). One child came up to me and gave me a big hug saying, “Auntie, thank you for coming today!” I was the only person to show and it is obvious they keep track of what each volunteer is doing. It made my heart melt.

Selase

One introduction I will make is of an 11 year old boy named Selase. I remember prior to arriving in Ghana when I heard of him. He is extremely stunted and malnourished but is now thriving under the care at the children’s home. He is smaller than many of the 7-8 year olds. Initially, he weighed just 13 kg (<30 lbs) but now is up to 18 kg (nearly 40 lbs). He has never attended school so is being prepared for a short amount of time in the home so he doesn’t have to begin in pre-K. It is normal here to have older children mixed in the same class as a child of normal age for that class. So he will likely be started in class 1 and sit with 6-7 year olds. He is very lively in the home and always is full of smiles and laughter.      

My days are already limited so I am beginning to have very mixed feelings about coming home. I knew this would be a quick trip compared to my previous adventures but I didn’t realize how fast 5 weeks would go by. I plan to spend my final days completing documents, making a health education poster, and preparing for my presentation that will be given to the maternal and child welfare staff, director of Kpando Health Center, and Ghana Health Services director. Additionally, there are several small errands which always turn into big tasks for whatever reason. So wish me luck, keep me in your prayers, and hope for a safe travel back to the U.S. Quick side note: I have worn a bead anklet for nearly 3 years without it ever coming off and this week as I was walking home, it finally fell apart. I thought it must have a significant meaning as I bought it in Ghana and it lasted until I returned. Kind of cool!

 

Michael relaxing after his bath (HardtHaven)

God is able to do immeasurably more than all we ask or imagine, according to his power that is at work within us. Ephesians 3:20

Week 3

In relation to my practicum, activities this week shifted from patient interviews more toward office work, as I met my total number of antenatal women and the postnatal/newborn patients only seek care on Wednesdays. Unfortunately, not many showed up this week so I only added an additional six interviews bringing my total to 42 patients. My contact information was left for the midwives to call if any labor cases come in so my time is not wasted sitting in hopes of a patient arriving to deliver. It has been well established that any complicated or high risk case gets referred out; therefore the actual amount of births that occur at Kpando Health Center is limited. My timing has been really bad trying to be present at the health center for a delivery. Both times I have missed the birth by only a few minutes. I am still hopeful however that I will get this experience before my time is up. Nonetheless, I have been extremely productive when it comes to starting my reports and making conclusions. I have made a document on the summary of services through each phase of care including antenatal, delivery, postnatal/ newborn, and child welfare. This was made based on observation as well as drawing information from the health records as far as what is supposed to be documented. Supposed to be is the key… I find much of the information is missing. My cumulative interview results will be a working document until all of my patient data is collected. It has been very interesting to identify trends in data thus far, which has helped me establish focus areas and reasonable recommendations. I have interviewed a wide representation of patients, gaining the perspective of recipients from several backgrounds. Additionally, I have five staff interviews and have informally questioned others about maternal and newborn health services provided within the municipality. All seem to have similar opinions. My summary of statistics has turned out to be challenging to analyze in some parts as there are discrepancies in the numbers. It is only from the health information unit at the clinic that I am able to obtain the necessary information so I have to make do with what I have. The most important sections on maternal and neonatal mortality rate and the proportion of causes of each are accurate though which is a relief. I have slowly began developing a PowerPoint, which will be presented as an overview of my project, results, and recommendations for future opportunities to improve the maternal and newborn health services. I even had the opportunity to speak with the director of Ghana Health Services for the District of Kpando to learn more about the general health system as well as what he envisions at the health center. Finally, I am planning to make poster(s) that will serve as a means of education within the community on those topics which I feel are inadequate. A lot of work to finish in a short amount of time…

Muslim family a few hours after delivery

Although I feel that public health research is important in order to assess the condition and needs of a community, I have learned that it really is not my forte. I much rather be in the field actually serving people rather than just talking with them. For this reason, I unfortunately am not finding the same fulfillment as I had during my previous volunteer work in Ghana. I am the type that wants to be busy all the time providing intensive treatment, education etc. to people who are really in need. I want to feel like my time and energy is worthwhile and at this point I am not so sure what will come of my project. Maybe some kind of transformation will take place over the next week but it doesn’t look promising. So I have decided to spare time in the mornings twice a week to participate in my old wound care outreach program and enjoy afternoons with the children at HardtHaven, which are both full of feeling accomplished.

Wound care is always a nice way to start the day as I am up at 530 to begin my walk into the three small communities following my subdivision of Kpando-Konda. It is important to go early to try to catch the patients before they leave for work either in the market or on the farm. I love conducting home visits to really get a glimpse at the daily life, see inside their homes, and feel that sense of emerging deep into their lives. It helps you to relate more on a personal level as well as understand some of the health concerns based on their immediate environmental conditions. They are all very welcoming, sending children for plastic chairs for volunteers to be comfortable. A basic cleansing of the wound with pure water, followed by placing Vaseline on the edges to keep the tissue soft, and covering with a piece of gauze is so much appreciated. However, in my opinion there is a clear need to change the treatment plan for those with chronic ulcers. It is disappointing in a sense as some are the same patients I met 2 ½ years ago when the outreach program was initiated and the wounds all appear the same as I remember. Yes, they have not gotten any worse but they certainly are not healed nor do I see any substantial progress. It is almost a waste of supplies when nothing good other than prevention is coming out of it. I do not even know the course of treatment that would be provided if they were fully funded to seek regular hospital care. The only option for some might even be amputation, which has an entirely different impact on their ability to be productive members of society and get around town. The other problem is that the design of the program is not daily anymore so there is no monitoring of how the patients are treating their wounds in between volunteer visits. Some refuse application of medication and rather soak their foot in herb infused water or open capsules of medication and place the powder directly on the open sore. The outreach is still very much needed within the communities but would preferably be lead by qualified and committed medical professionals in the long term. Additionally, it requires attention on confounding factors to promote healing such as nutritional support, appropriate activity, and managing co-morbidities such as diabetes and hypertension. I always automatically think of all the resources, medications, specialized supplies/ equipment, and procedures available in the Western world and what it would be like to take one person from here and show them what could be done with these things. However, I know this is not feasible and rather there is an indication to adapt to their local context. It amazes me the patients still have hope and are usually accepting of care after suffering with wounds that are unchanging. To top it off, they all have an incredible amount of pain tolerance.

Diabetic patient

I had the pleasure of attending Lovia’s funeral. It was a very interesting cultural experience to learn the tradition specific to that community. It began with an introduction to the chief and greeting with the community elders while the younger individuals went to prepare the grave site. They are said to be called into the position by the spirits. They returned and carried the coffin open on their heads, with only a piece of fabric covering the body. This was a very long process as they carry the coffin all over the community being lead by the spirits to places where Lovia supposedly needs to depart. Finally, they returned to the tent in which the elders were sitting and present for questioning. It is said that the coffin answers. If the spirit accepts, they bow down and move forward in a knocking motion but if she is not happy, they abruptly back up and spin the coffin around nearly dropping it off their heads and return to resolve any problems. I never actually saw the burial as we paid respects to the mother and had been there nearly half the day. Not many were in attendance as would be the normal for funerals in Ghana but it was nice to have some showing seeing as it seems the stigma of the AIDS takes over from the person being human.

I have really taken to baby Emmanuella. She is just six months old and came into the care of HardtHaven because she was found abandoned in a drain. I learned how to carry her the African woman’s way on my back with just a piece of cloth and love just holding her in the afternoon. I teased with the children that I was going to take her home with me which they got a quick out of. Another girl is Precious. She is two years old and is the younger sister of another child in the home called Bless. She doesn’t know any English yet but always comes to me when I arrive at the home. One day she was really amused by a book with a butterfly on it. She kept grabbing my hand and pointing to it. Later I found her carrying the book on her back too. It’s interesting how the form of play mimics lifestyle- small kids carrying things on their head even if it’s just a sachet of water or a single book, girls with things on their back, and boys with fabric tied like the chiefs. Kids are kids no matter what country you live in. A quick introduction to Bless as well which is a very sad story- she is 14 years old but looks like maybe a 4 year old. When she was very young, she is believed to have contracted cerebral malaria, effecting her growth and development. She is now immobile in terms of walking but she can sit and roll from side to side. She is also unable to talk. She was actually locked in a room, hidden from society. See the report on her story https://youtu.be/SrHaogElFmc. Since being in the home, she has been working with physical therapy volunteers and will get an instant smile on her face, even making laughing sounds, when we interact with her. Goes to prove what good a little personal contact can bring to one’s livelihood.

Baby Emmaneuella

Bless- 14 years old

[Not in your own strength] for it is God who is all the while effectually at work in you [energizing and creating in you the power and desire], both to will and to work for His good pleasure and satisfaction and delight. Philippians 2:13

A tribute to Lovia~

My predictions were right… Yesterday afternoon Edem called me and said he received a message in the morning that Lovia’s condition had declined. He decided we should go see her, so I jumped to the opportunity as I had bothered him about going earlier in the week and we never made it. Well we didn’t make it in time today either. He dropped me by the path to her house as he was going to visit another patient and doesn’t like to see Lovia’s wound, yet she often insists. On my way to her house, a woman came running “Oburoni, oburoni. I want to talk to you! Are you going to see that girl? She DIED this morning oh and they have already taken her body.” It makes me feel very sad like I should’ve done more yet I have been reassured that I gave her plenty through my basic support over the last two weeks, showing up to clean a wound that nobody wanted anything to do with concerning its location, as well as the organization giving her a supply of nutritional supplements and medication for palliative care. I know there was no possibility of reversing the disease and more intense treatment would have possibly just prolonged her suffering. However, I feel like a failure and let her down because during my last visit she asked if I would come back and I said, “Yes of course,” but never did. Edem pays for the coffin and funeral expenses so she is buried respectfully as some AIDS patients are treated in disgust and would just be thrown into a hole due to the stigma of their condition. I can’t believe at just 19 years old her soul has been taken. Although she acquired the disease on her own and chose to stop taking the antiretrovirals, she is not all to blame. What is the missing gap to solving the burden of AIDS? How can similar cases be prevented? Obviously the current system is broken and understanding the education is not enough. Poverty has a distinct factor. The social aspect is also prevalent. I have now witnessed the reality of what AIDS looks like at its worse. I was debating whether or not to share her personal picture online but to put a face to the name, this is the condition I met her in...

  

On the positive note, I was shown a picture of Happy after one week of critical treatment at Ho Regional Hospital. She looks so much better. She was alert, sitting, and is now eating. Her skin also appears almost healed. Praise God! Amazing what changes can be done by a small investment in children and educating the parents on proper care. I also had the pleasure of doing a quick home visit to one of the sponsored boys in the village. He is a 7 year old named Benjamin, suffering from chronic malnutrition. To me he appeared very malnourished and sick still but comparing it to the initial pictures, he has made great progress. You can tell just by looking at his face. It transitioned from pleading eyes of death to a bright smiling face!

This is a random boy who came running up to a car to hold my hand!

In the evenings when I wait for dinner, I have started joining in with the local kids in playing a pickup game of soccer or even shooting basketball which they seem to enjoy. It catches a lot of attention from adults and children passing by though to see a white girl running around. Actually, I really don’t run because I sweat just by standing! At HardtHaven, the children have taken more pictures than I have. I taught them the basics of point and shoot photography and how to take fast paced videos which they were really amused by. I find that giving them your trust and freedom really gives them joy and appreciation. The older children understand the one ‘trash’ button they are not allowed to press. I even transfer pictures to my computer periodically so I don’t risk them getting deleted. It has become my nightly ritual to go through images though and delete the many pictures that are blurry or insignificant. However there is that rare snap that is priceless! Within the community, I find it very difficult to capture natural images. One night it was really cute to see three small children sitting on a yellow water jug on top of a dirt pile while another child attached a string and pulled them down as if they were on a sled. As soon as I pulled my camera out, all the action stopped and I was instantly surrounded by 17 kids posing in front of me. 

Just playing "tro-tro driver" at HardtHaven

In being the rainy season, we had a ridiculous storm that came through. The rain disrupts all life here as it is a complete downpour. You cannot go outside in it because it actually hurts. I had opted out on going to the children’s home that day so I could work at home on some of my project documents. My plans quickly came to an end however. The power went out, my room became very dark even in midday, my outer screen door blew off the hinges, and rain came into my room creating a minor flood. This also meant mosquitoes could come in due to the increased moisture in the air and lack of a screen. Needless to say, my legs are now covered in annoying bites. I am completely reliant on my antimalarials to keep me healthy.

As far as my project goes, I ended up having a fairly productive week. My translator has been available everyday so I now have conducted 36 patient interviews. It has been interesting to see how the majority of the women in the antenatal clinic know very limited English whereas those seeking well child checkups are more educated and could for the most part communicate with me fairly well. Overall, patients are very satisfied with the current maternal and newborn health services but it has come to me that this is all they know. It is according to their standards. I can identify areas for improvement but it is a matter of determining whether or not recommendations are feasible within the cultural context. I enjoy learning from the locals how they think conditions may be improved though as this will be part of community engagement. There have been plenty of ideas ranging from the individual and local level of implementation to those requiring higher authority from the government or directors to change policies. I have wasted a lot of time waiting around in hopes that more patients or a delivery case will come. I missed three deliveries just by arriving late or being in the reproductive and child health center. Now I know of the busy days and time to arrive, and can plan accordingly to leave by noon and rather go to the office to begin working on final documents. One of the community health nurses invited me to accompany her on a home outreach day, so I am really hoping to gain this opportunity and perspective of an additional service. They follow up with patients to ensure children are growing healthy and receiving the recommended immunizations. Additionally, it is good to assess their living environment and direct care so that parental education can be provided. I plan to leave my contact this week so that they can notify me of labor cases and I can then travel to the health center to assist in the delivery/interview women after childbirth. Hopefully by next week’s update, I will have actually delivered my first baby rather than doing only the newborn care.

The first delivery case I interviewed

He [the benevolent person] scatters abroad; He gives to the poor; His deeds of justice and goodness and kindness and benevolence will go on and endure forever! 2 Corinthians 9:9

May 13-24: Part 2

My transition back to the Ghanaian lifestyle has happened almost instantly because I know what to expect thus few things come as a surprise. My mornings start off waking to the call of the roosters, children already playing even by 6, women sweeping, and sometimes music playing at the surrounding houses. I often get a ride to the health center from the director on our way to drop their daughter off at school, and then opt to walk home. I feel I am able to experience more of the culture and environment rather than relying on a car, plus it allows me to walk through the market and soak up some hot sun. This weekend I did my first set of laundry, which I had forgotten how long it actually takes to wash just a few items. It is obvious the locals are far more efficient and probably get the clothes cleaner too.

I have allowed time to visit HardtHaven Children’s Home nearly every day in the afternoon once the children arrive home from school. I usually jump to the opportunity to help complete homework, although some are not motivated to learn and are searching only for answers. Play time is then a priority whether it be chasing each other, tossing a ball, reading, or just cuddling. I even enjoy just sitting back and watching their natural interactions. I have always been a baby/toddler person so of course my favorite evening was hold baby Emmanuella while little Precious held my hand and we ran around the premises. Both children are new to the home since my last visit, so I am anxious to learn about their individual stories of what brought them under the care of these very special matrons.    

The first week at Kpando Health Center was spent primarily in observation as my hired translator ended up traveling to Accra to accompany a family member with surgery. This provided a good opportunity however to get settled with the staff, learn the process in the maternity ward, and gain an introduction to the reproductive and child health welfare clinic that is put on by community health nurses. I am actually quite impressed with the care that is being provided under these conditions. I came with the expectation that gaps would be easy to identify; however, with just a few surveys completed, it seems people are satisfied with the maternal and newborn care. I have spoken with a midwife, nurse, statistician, and the health center’s director to analyze various perspectives on this topic. My favorite encounter has been with the health information unit as they have all the facts and numbers, which of course a Westerner who is doing research welcomes. I have learned that the vast majority of births are skilled deliveries although some still give birth at home with traditional birth attendants. In 2014, Kpando municipality had five cases of maternal mortality (one heart failure, two hemorrhagic shocks, one sickle cell crisis, and one acute intestinal obstruction) and 22 newborn deaths (ten asphyxia, six sepsis, three meconium aspiration, two prematurity, and one immunosuppression). All of the latter occurred under five days of age. The limitation from this data however is that it only monitors institutionalized cases thus anything that happens outside of the Ghana Health Service facilities are not accounted for. The true incidence may therefore be much greater. The entire municipal and Kpando Health Center appears to have good antenatal and postnatal care attendance with mothers coming monthly for checkups. Additionally, 71.55% of the community is active members of the National Health Insurance Scheme. The amount of qualified health workers is surprising to me. For example, there is only one OB-GYN doctor in all of Kpando and one midwife per 5,178 people. This greatly limits where specialty services are available, thus impacting accessibility to care. I found it very ironic that the week prior to my arrival was child health promotion week where the focus topic just happened to be on keeping newborns clean through caregiver hand hygiene. This is in effort to reduce newborn infections. With my primary interest area being that of the neonate, I hope to explore this topic more and identify ways to benefit newborn outcomes.

Since Kpando Health Center does not have admission wards other than accepting normal deliveries, any complicated cases or women with risk factors get immediately referred to the local hospital. Therefore the actual amount of deliveries at the health center is extremely low. I was able to speak to one lady after she had delivered during the night and learned that all are discharged within 24 hours. So far, the most common reasons for seeking maternal and newborn care has been to get a urine test to determine pregnancy, routine appointments, ensuring that the baby is healthy, seeking prescriptions for anemia such as iron supplements, and distribution of intermittent preventative treatment for malaria during pregnancy. I was taught how to assess for fetal heart tone using a fetoscope (which I found very difficult to hear from), measure the fundal height, and palpate the fetal position. It would be interesting to witness the mother’s reaction if they were able to hear the heartbeat themselves like we experience in the U.S. Also to see the baby in an ultrasound, which I learned they have available at the referral hospital.

I really enjoyed what services the community health workers are providing at the child welfare clinic (appropriate for someone studying public health!). This occurs every Wednesday, encouraging mothers to bring their children up to age five for weight monitoring, vaccination administration, and education on a maternal or child health topic of choice. There were probably a total of 20-25 women who came in my one day there so far. I was asked to provide counseling to one mother whose son has gradually been reducing weight. For those that are acutely malnourished, the government has provided the facility with nutritional supplements to distribute. All children also receive a mosquito net at their 18 month appointment. Mothers have to bring their own sling to weigh their babies in. The children are stripped down to nothing and then hung from a ceiling scale. Some cry while others look with curiosity. Many of my postnatal and newborn interviews will come from this clinic and since my reports should all be completed by the Monday before I depart, I am hoping my last day can be spent assisting throughout the entire process. 

He gives power to the faint and weary, and to him who has no might He increases strength (causing it to multiply and making it to abound). Isaiah 40:29