Notes from the Field: Malawi #3 (Teaching/Learning)

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This column is the third of four from Malawi and illustrates one of the ACNM Global Health Competencies. If you are interested in submitting a Notes from the Field column, please read the instructions for submission to be considered.

Addressing ACNM Global Health Competency #7 – Teaching/Learning Competency

What in my life, work, and education led to my recent position of teaching midwifery and helping to start a Midwifery Led Ward at Queen Elizabeth Central Hospital in Blantyre, Malawi?

Well, as the oldest of six siblings, teaching was part of my upbringing. For example, my sister and I ran a day care for our younger siblings and neighborhood children the summer before I entered 4th grade. I also became one of the neighborhood babysitters at age 12, often helping the children with their homework.

In college, I was one of ten organizers of the Johns Hopkins Tutoring Program, which paired inner city children from Baltimore with undergraduate tutors from Hopkins. This provided me with extensive teaching experience with the children at their homes and at Hopkins, as well as with the other tutors. The last I checked, that program had just celebrated its 50th anniversary and was continuing to serve as a model for helping young children while allowing undergraduates to gain an understanding of the broader community in which they live.

Immediately after college graduation, my husband, Chris, and I spent a year observing and studying school systems in Finland, Sweden, Norway, Denmark, West Germany, Poland, France, and England as part of a Watson Fellowship that he was awarded. We spent four months in Finland, teaching swimming and sailing at a summer camp for Helsinki children from broken families. We learned some Finnish from two gifted children who attended the camp.

Wanting to apply some of the ideas we had learned from our Baltimore and European experiences, we then traveled to Kenya, East Africa. Due to chance, good luck, and some ingenuity, we made contact with key people who wanted to see a secondary school develop in the Siaya District of Nyanza Province, not far from Uganda. We had money left from the Watson Fellowship, so we were true volunteers, requiring only housing and two bicycles for the four-mile ride from our house to the school each day. Once we established ourselves at the school and in the community, we decided to join the Peace Corps as this would allow us to have a monthly allowance and health insurance coverage. We became “field enrollees” and continued to develop Barding Secondary School. We ended up teaching at and developing that school for four years.

One of our unusual teaching ideas that worked well was the concept of having the students not only study the subjects outlined in the national curriculum, but also learn practical skills such as building a latrine, a water tank, and classrooms. We worked side by side with the students, having each Form I class build one structure for the school. We and the students continually improved our skills, and our final year saw the completion of a teacher’s house and water tank on the school compound. These physical structures gave us all a sense of accomplishment and pride in our work; they are still standing and serving the school today! I also taught basic sewing skills to the few girls who attended the school. 

At the same time, I taught biology, chemistry, math, English, history and religious knowledge in the classroom. Academic excellence was our number one goal. The school soon gained recognition for good academic performance. When we started, we had only four students; when we left in 1979, there were 120 students. Today, there are 1,200.

From rural Kenya, Chris and I moved to New York City, where I attended Columbia University for my BSN and MS degrees. I worked at Columbia Presbyterian Hospital, first as a CNA in 1979 while earning the BSN, then as an RN in labor and delivery from 1981 to 1983 while earning the MS, and finally as a CNM.

In 1984, we moved to Portland, Maine. There, in my full scope midwifery practice, I began teaching medical students and junior residents who were doing their Ob/Gyn training. As most CNMs do, I also precepted midwifery students and was invited to give lectures at the local nursing and medical schools.

Simulation training was introduced at Maine Medical Center about 20 years ago, and I was able to take advantage of this learning platform to teach obstetrical emergencies and newborn resuscitation.

The evaluation of students and residents has evolved over the years. When I began as a CNM, it was rather general. We asked the basic question, “Did the student show ability and compassion?” Students would get either a passing or failing grade, with very little commentary or feedback. The goal of performance evaluation has always been to have a system that is fair and equitable. Thankfully, this goal has become more and more sophisticated over the years, and usually students are given a very thorough assessment of what has gone well for them and where improvements could be made. However, I find the current system of monitoring, evaluation, and assessment to be over the top. Midwifery is an art as well as a science, and when we break the components down into micro-bits, something is lost. I try to let my students know early on if there is a problem, and if communication is open and honest, most students will alter their course and be successful in the end.

My project partner and coordinator for the Midwifery Led Ward, Dr. Ursula Kafulafula. She and the faculty of Kamuzu College of Nursing presented me with a beautiful piece of Malawi cloth that will look awesome on my dining room table when I have a big crowd for dinner!

Midwifery student evaluation in Malawi follows the British system, with a huge emphasis on the end-of-semester exam. There is ongoing evaluation of clinical work and group projects during the semester, but the final grade is weighted too heavily, in my opinion. I was in active discussion with my Malawi colleagues regarding this issue when we were, in the last three weeks, suddenly evacuated from Malawi due to the COVID-19 pandemic. We had just finished writing the end-of-semester exams when colleges and universities country-wide made the decision to close and send the students home to reduce the spread of the virus. Result: no final exam for the students this year!

A few of my students presented me with a gift of a beautiful chitenje with the colors of Malawi: red, green, and black. With email and WhatsApp it will be easy to stay in touch with these eager learners.

I was very sad to leave Malawi early, before my one-year contract was completed. I had three months left to finish the projects I had started. There was a scramble to finish what I could and leave notes for anyone who might be able to complete certain tasks if I cannot return to Malawi.

Chris and I enjoying our last breakfast in Malawi before being evacuated. We’re smiling for the camera, but we were sad to leave this beautiful country.

I do have the opportunity to work remotely to see if I can help make the Midwifery Led Ward a reality even from 9,000 miles away. I have a good relationship with my partners in Blantyre, and communication via email and WhatsApp is wonderful, so there’s still hope!