hospitalized at mattresses on the floor in the case all beds are occupied. But on other days it might be less busy; one day there were only three patients at the ANC ward. Outside the rainy season, other events may lead to overcrowding of the ward, such as when the COM was offering free obstetric fistula repairs and were “recruiting” patients from surrounding areas. Two midwives from the Obs&Gyn ward told me this led to a very hectic and busy week at the ward. From what I observed, the AN, PN and Obs&Gyn wards were covered by two up to six midwives. It happened twice that I found one midwife covering the whole ward in a day shift, because others were “away to the bank”, “accompanying relatives in the hospital” or called in sick (at PNC ward). Of what I heard from Beatrice and Martha, it happened regularly that they had to cover the wards alone during night shifts. Especially these two older midwives (aged 54 and 67) complained about the regular basis on which they had to do nightshifts now, while before (“when they were young”) there was more staff and they only had night shifts once a month. Now it is about once a week or three times a month (Martha). For Martha from ANC ward, it is the busy night shifts that make the work heavy for her. She said there are three full-timers on the roster (to cover all shifts), and saying that with an additional three full timers it would be much better. At the Labour ward, it is a different story all together. The minimum of midwives on the roster should be 12-14, so they can rotate shifts. At the time of this study, there were only six, who have to be divided over seven day and seven night shifts a week. They need the extra part-timers who are coming on locum desperately to assist them, but the number of locum midwives had decreased during the last two months. Chisangalalo (aged 30) said the following about the staff shortage: In our ward, at the paying side, we have 14 beds. We have to be about four midwives [at the paying side], maybe each taking care of four patients, which would be better. She will be concentrating on those four patients. But we have got few midwives. One is staying on the paying side and intensive care unit [covering 18 patients if full], the other one is on admission, another one is in theatre and maybe just two midwives are on the main ward. Like one would take care of eight patients, it would be different than when one would take care for four patients only.
In total, there are 30 beds at the Labour ward. She is means that they sometimes have to cover eight patients at once, who are about to deliver a baby, suffering complications (since they are mainly referrals from other clinics and district hospitals), or have just delivered and need close monitoring for haemorrhages. Violet from the paying ward (1A) says there might be more midwives in government hospitals, but the workload is much heavier because patients are coming from all the districts around. She compared this with her experiences in a district hospital, where she had more opportunities to go for workshops because the ward coverage was better. The results of the questionnaire also point out that the staffing level is least adequate, compared to availability of equipment and even the salaries. Only three (12.1 percent) out of the 31 respondents thinks it is “not adequate”, the other 27 respondents scored the staffing level as “not adequate at all” (87.1 percent) (see Table 3). Consequences for daily practice: frustration and improvisation According to many midwives, the low staffing level is very detrimental to the quality of care. Martha (aged 67) from ANC ward says when it is busy, they only do emergency things, tasks that are really 69