The two study hospitals presented two diverse contexts where there were stark differences in the experiences of the mothers during the first 24 hours of their baby’s admissions.
Kijani
In Kijani hospital, mothers were involved in caring for their newborns within the first 24 hours of delivery. While some mothers had experienced a trouble-free delivery, others had had some kind of complication, such as extremely high blood pressure, prolonged labour or other conditions that necessitated delivery via caesarean section. The mothers who had a trouble-free birth were well enough to walk up to the NBU either on their own or accompanied by a nurse and become immediately involved in providing care for their babies. For mothers who had complications (who had undergone surgery or were still themselves
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receiving treatment in the maternity ward), their arrival in the NBU was delayed. The focus for subsequent descriptions in this chapter is on those mothers who were well enough to start caring for their babies within 24 hours of delivery.
The level of care that these mothers were able to provide in the first 24 hours was influenced by how well or sick their newborn was. An example of the experience for mothers with very sick babies that required medical oxygen during the first 24 hours of admission is provided in box A. The observed experience of a mother with a premature baby that didn't require oxygen is described in box B.
As is described in the boxes, within the first 24 hours of their baby’s admission, mothers, even of babies that needed to be placed in a resuscitator, would become involved in providing some level of care. For all babies, the main task performed by the mothers during the first 24 hours of admission in Kijani was diaper changing and for those who were not on the resuscitator, feeding. Though there were a few who breastfed term babies with jaundice or an infection, mothers of premature babies who were not on oxygen therapy expressed milk and NG tube fed their babies. In very rare instances, the mothers would also top tail (clean) their baby but this would depend on the timing of admission. As described in chapter 5, hot water for top tailing was provided once a day at 6.30 in the morning, therefore babies admitted after 7 am or at night were not top tailed until the following day. Throughout the first 24 hours of admission, the nurses on the ward concentrated on giving medication while the mothers took up the bedside monitoring and care of their babies. As described in boxes A and B at admission, I observed that after receiving the baby and the baby’s notes from the maternity, the nurses admitted the babies and directed the mother on where to place their baby. After admission, the nurse would fix the IV lines and NG tube as required, and then instruct the mothers on what to do. This brief exchange of information often involved the mother being directed to change diapers, express milk, and feed the babies. Following these initial actions and in between their busy routine of medication and paperwork, the nurses then conducted regular formal observation of the critical babies in the radiant warmer.
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Box A: First 24hrs in Kijani – room A
Multiparous mother with a very sick baby
It’s just a few minutes past eleven o’clock and the doctors and clinical officer interns have just finished conducting the morning ward rounds in room A. On duty this morning is nurse Mwajuma. Mwajuma is so engrossed with calculating the fluids and fixing the IV fluids for the 14 babies in room A she barely talks to the mothers who are expressing breast milk by their baby’s incubators. As I had observed that some of these mothers struggled with expressing milk, I expected her to once in a while check on what the mothers were doing and offer assistance. Once in a while some of the mothers needing help with feeding try to catch her attention, “let me finish with this I will come”, she responds. She moves from one baby to the next. The room is very calm, with the mothers each sitting on a plastic chair by their baby’s incubator. As they express milk, they sometimes pause and take a moment to catch a breath. Apart from complaining about the pain, some of the mothers talk amongst themselves about how difficult and tiring expressing milk is. Once in a while they look at each other and smile, a few compare how much they are able to express. Tough as it is, they carry on till they attain the ‘required’ amount. During these activities, a nurse carrying a baby from the maternity ward walks in and tells Mwajuma “this is your baby where do I place her?”. The nurse from maternity is accompanied by the baby’s mother who had delivered just within the past 30 minutes. They are followed by three other mothers, each carrying their baby. These three mothers each have a baby that is premature but stable and they are shown by Mwajuma where to place their babies. All are placed in shared incubators. For the very sick baby carried by the nurse, a brief hand over lasting about 5 minutes follows with the baby placed in a radiant warmer. Both nurses stand by the radiant warmer they hold a brief discussion with the maternity nurse briefing Mwajuma about the baby’s problem. After the process of handover is complete, Mwajuma proceeds to set up the oxygen and fluids for the new admission. All this while, the baby’s mother sits quietly on a plastic chair next to the table. Mwajuma had pointed to her where to sit. She is dressed in a blue hospital gown, tied around her waist is a leso, her hair looks unkempt. Her eyes fixed on the radiant warmer where her baby is lying; she doesn’t talk at all. Once the new baby is linked up to the oxygen and fluids Mwajuma briefly turns to the new mother and offers her some information, explaining: “we will not feed her for now, she has problems breathing so for
now we will put her on oxygen, we will tell you when you can start feeding”. Mwajuma then moves on to attend to the
other babies leaving the new mother sitting on the chair where, after a short while, she dozes off sitting upright. The other mothers by now have finished expressing milk and carry on with feeding their babies. Some of these mothers step out of room A after feeding their babies leaving behind the new mother and others who choose to remain behind to observe their babies after feeding. While some of these mothers chat with each other, others sit quietly just looking at their babies, once in a while getting up to gently touch their newborns [opening the incubators or through the hole in the incubator]. It is now 1:30pm, the drugs round for all the babies on the unit has finished and as Mwajuma passes by, she notices the new mother sleeping on the chair. She tells her to go back down to the postnatal ward and rest. Throughout the day, the mother occasionally pops in to check on her baby, the only task she can perform on this day is change diapers. To do this she unfastens the diaper to check if it is soiled, and if it is she proceeds to change it using the new one she brought up with her from the maternity ward. When they come to deliver, mothers bring with them essential baby items such as clothes and diapers. The information about what to carry when going to deliver is normally given to pregnant mothers at their antenatal clinic. I notice that she initially attempts the diaper change with some hesitation, she removes the straps of the diapers, takes some time looking at the baby as if wondering what to do next but eventually manages to finish the process. Taking great care not to touch the IV tube and the oxygen mask, she barely lifts the baby, gently holds up the baby’s legs and lifting slightly the baby’s lower torso to remove the soiled diaper and places a new one. One of the mothers then shows her which bin to throw away the soiled diaper. She then goes back to the postnatal ward. Unlike the rest of the mothers, she is still not allowed to feed. Just as it is with most of the mothers whose babies are new in the NBU, her interaction with other mothers on this first day is very minimal, only talking to them when she
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Box B First 24hrs in Kijani – room A
Premature baby
Among the three other mothers whom nurse Mwajuma had shown where to place their babies was Hellen. Hellen is a first time mother and she was told to place her baby in an incubator that already contained another premature baby. For the first one hour, she mostly just stares at what is happening around her. Next to her are other mothers including the mother of the baby that is in the incubator with her baby, all of whom are busy either expressing milk or feeding. Nurse Mwajuma is still attending to the baby in the radiant warmer and Hellen appears to have no idea what is expected of her or what she is to do. She keenly observes what the other mothers are doing and strikes up a conversation with the mother of the baby who shares the incubator with her baby. Her neighbour had been there for a couple of weeks. Under each incubator are drawers and her neighbour informs her that she can keep her babies diapers and feeding cups in the drawer. After checking, Hellen realises that her baby needs a diaper change and goes down to the postnatal ward to bring some diapers, she had brought with her essential baby items such as clothes and diapers which she had left in the postnatal ward. Upon her return, she turns to one of the mothers next to her and asks how it is done, she asks how to open the incubator and how to change the diaper. Having been there for some days now, her neighbour knows how to open and close the incubator and Hellen observes and learns from her neighbour. She is instructed by the mothers next to her on how to go about diaper change and how to close the incubator when done.
Mwajuma passes by and tells her to express milk and feed the baby. “She doesn’t have this pipe”, she informs Mwajuma who then tells her and asks her to wait a bit. As nurse Mwajuma goes away, Hellen turns to the mother next to her and asks, “Where do I get the cup and how do I know how much I am to feed?” she asks her neighbour.
“The nurse will fix for you this pipe and tell you how much to feed”, she is told. She sits and waits for Mwajuma to
get to her baby. When the nurse gets to her, she stands behind the nurse wanting to observe what the nurse was doing. However, immediately she notices the NG tube being inserted in her baby’s nose, she moves back and looks the other way, with both hands on her cheek. She can’t bring herself to observe the procedure. One of the mothers next to her smiles and asks her what was wrong to which she responds that she can’t watch that pipe being fixed, she imagines that the baby is feeling pain.
After fixing the NG tube, the nurse provides her with feeding syringes and tells her “do you have a cup, get a cup
and express milk, then measure 5 mls and then feed the baby, I will get you the syringe, so you measure and then pour into this pipe”. She is handed the syringes which she places on the drawer on her baby’s incubator and proceeds
to get a cup. She is advised by the mother she is sharing the incubator with to go and buy a cup downstairs by the gate. Hellen leaves the NBU and after a few minutes she walks back in with a cup, sits back on the chair and begins expressing. Having seen what the other mothers were doing, she follows suit and does what she saw the other mothers do. Unsure of what to do next after expressing, she turns to her neighbour and asks how to measure. “Put
what you have expressed into this syringe, you see this lines and numbers here, pointing to the marks on the syringe, so this is one..two,…five, so you put until here and then you open here and pour the milk inside the pipe”. After
feeding her baby she is shown where to wash her cup and she then keeps her feeding cup and syringes on her drawer. After feeding she continues to sit by her baby’s incubator talking in low tones with her neighbour.
She asks “for how long she will have to stay in here”. The other mothers almost in unison tell her that she will have to be patient as with such babies one can never tell for how long one will stay in the hospital. She becomes curious and asks the others for how long they had stayed there and one of the mothers tells her not to worry she will just find out as the days go by. “does it mean that I may stay here for very long? How will I survive the way I hate the
hospital environment?” she asks, and one mother tells her that no one likes the hospital environment, you are just forced to stay because there is nothing much one can do with a sick baby at home. “welcome to the club” another mother tells her. She spends the whole day in the NBU following the routine that she sees the other mothers
In Kijani, despite the fact that I observed considerable anxiety among all the mothers within the first 24 hours, there was a noticeable difference in the manner in which mothers tackled the expectation of immediate involvement in their baby’s care. In general, the multiparous older women appeared to cope better with these expectations. In comparison, the uncertainty of not knowing what to do appeared to complicate things for first-time mothers. The process of beginning to take on the care of their newborn was harder for the younger first-time novice mothers who did not have the practical skills acquired through previously caring for a baby. For example, diaper changing for the multiparous mothers, who already had previous experience of caring for a baby, appeared to be a straight forward compared to the first time mothers, many of whom I observed struggling with this task.
The severity of their babies’ illness dictated the experiences of mothers in involvement in providing care for their newborns within the first 24 hours of admission. Just as it was for first-time mothers, the mothers of extremely premature babies also initially struggled practically, irrespective of their parity. This was clear in the manner in which they handled their newborns while changing diapers as illustrated by the passage below from my field notes. They did this very gently, occasionally pausing as they touched their newborns, some with a grimace of pain on their faces, probably indicating their fear of hurting the baby.
“Me I have never seen something like this,” she says as she tries to change her baby’s diaper. She gently lifts the baby and places the diaper and quickly leaves it for a minute, stands back and looks at the baby with her hands placed on her cheeks. “This is my second born, the firstborn was not like this one, I have never seen a baby this small”, she says. She leaves the diaper without fixing the straps and walks away……. (Field notes_Kijani hospital). However, despite their hesitancy, the motivation to perform this task seemingly emanated from their understanding that the bedside care of their babies lays squarely with them. Learning how to undertake these tasks effectively was achieved mainly by observing what other mothers who had been in the unit longer were doing. Through these observations mothers new to the NBU were able to grasp the techniques and steps involved in providing care for their baby in this environment. When unsure, I observed mothers would often turn to their neighbours for help.
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The first 24 hours in Tausi
In Tausi the babies to be admitted to the NBU were always brought to the unit by a maternity nurse. At times the next of kin, in most cases the baby’s father, accompanied the nurse. In contrast to Kijani, it would take several hours before the new mothers started making their way into the NBU. This was the case for all mothers irrespective of the mode of delivery and their condition at delivery. Unlike the scenario in Kijani, where the mothers (when physically able) followed or took their babies from maternity to the NBU and only subsequently found their way back to the post-natal ward, the mothers in Tausi were all transferred from the maternity ward to a room in the post-natal ward for recovery. Mothers of the babies admitted in Tausi, therefore, took much longer to come to the NBU than in Kijani. For instance, I observed that the mothers whose babies were admitted in the mornings would rarely come to the NBU during the day. Exit interviews with these mothers revealed that most of them only visited the NBU for the first time more than six hours after their baby’s admission. The practical norm in Tausi had the effect of promoting mixed feeding (breastmilk and formula) among even the otherwise well but premature babies.
As discussed in chapter 5, one of the mandatory items in the list of requirements for a new parent whose baby was admitted onto the newborn unit in Tausi was formula milk. Therefore, before the mothers came to the NBU, babies were fed on formula milk and even after the mothers started visiting the NBU, babies would be given formula milk whenever a mother could not be reached or if there was no more of her expressed breast milk for her baby stored in the fridge. Babies in Tausi were bottle-fed if stable and NG tube fed if critically ill by the nurses in the absence of their mothers. I also noted that the babies’ diapers