Obstetrics in Dr Gray's and in Kambia...

The last four months have flown by and I have now rotated to obs and gynae, and am now nearly half way through my placement...I'm really enjoying it so far, it’s a pleasant change to be working on a ward run, in my opinion, very efficiently by excellent midwives and obstetricians.

Just before I started on this rotation a friend sent me this link to a video about giving birth in Sierra Leone, with the warning ‘horrible but important’. It is quite shocking and distressing, but happening. The girls dressed in blue are volunteer nursing aides, untrained and unpaid.

Dying to give birth: One woman's tale of maternal mortality

http://content.time.com/time/video/player/0%2c32068%2c89844377001_1994479%2c00.html

Although I didn’t spend much time on the maternity ward in Kambia, I was aware of some of the struggles that were faced there; I heard stories of unconscious and fitting pregnant women; I would hear the singing when a mother died; I would see the babies that had suffered the consequences of a complicated labour or lack of antenatal care; and I would see the malnourished infants who didn’t get enough food after their mothers had died in childbirth.

The next few months will hopefully teach me how things can be done with more resources and more training.

Dr Gray’s is a small DGH. The maternity unit was developed around 15 years ago, after a campaign to improve local maternity services. The unit sees just over 1000 deliveries per year, and high risk deliveries are sent to Aberdeen for more specialist care. The service is run by midwives, supported by four consultant obstetricians, and four of us junior doctors. We cross-cover the paediatric ward after 5pm and overnight. This works well for me as I enjoy getting some paediatric experience, and my experience so far is that we are very well supported by the consultants. There is always a 2nd junior doctor on call if it gets really busy, or someone needs to go to theatre.

During the days we are either on call or covering theatre and clinics. On the wards we cannulate women (cannulas are free and in abundance!), see new admissions and any emergency gynae patients, and review (with the midwives) pregnant women who present to the obstetric ward during their pregnancy. In theatre we assist the consultants doing c-sections and gynae procedures – useful for brushing up anatomy skills and seeing what these operations involve. The staff are all extremely friendly and have a wealth of knowledge to share with us. There are extensive labour ward guidelines to follow, and a helpful consultant around or at the end of the phone if we're not sure what to do.

I had thought to compare a few aspects of care in Dr Gray’s and Kambia, but I’ve sat here for over an hour trying think how to do this and I’m struggling. It’s maybe not fair to compare two health systems at such different stages of development. I can say that I am in constant awe of the services provided free of charge by the NHS. It’s amazing. Yes we pay tax, but it’s worth it.

I will try to give a brief description of the maternity ward in Kambia District Hospital (KGH) and you can make your own comparisons. Kambia District has over 12,000 deliveries per year. I’m not sure how many of these happen in KGH, but at least as many as in Dr Gray’s. When I was in Kambia there were 2 midwives, a trained nurse and one doctor, covering the ward 24/7. They are supported by volunteer nurses, who have no training before starting on the ward. Electricity was provided by a generator between 7pm-11pm and for emergencies. There was one tap with running water. There was no ‘gas and air’ and no morphine. They would have to pay for a cannula, and often IV fluids and drugs, although these were sometimes available on the 'free health'. C-sections were free. I never saw a CTG being used, I think there was a machine but no paper and no power, pinna were used to assess fetal heartbeat. There was an ultrasound machine kept under lock and key, not usually available when needed. There was some blood stored in the lab, but often not enough and the wrong blood type; patient’s relatives were always required to donate blood, to replenish any blood used up. Blood tests were limited to Hb (using a colorimiter) and blood films for malaria, and rapid tests for HIV. There is no rescuscutaire and no incubators for neonates.

Kambia Appeal midwife Noemi teaching student nurses about partographs

It paints a very bleak picture and maybe doesn't covey some of the lifesaving treatment that is being provided by staff at KGH. But there is a long way to go. Many of the interventions needed to reduce maternal mortality and help these women further do not need fancy equipment and specialist skills. Much of what we were doing in Kambia was not rocket science but I think it was helping. Encouraging nurses to do a drug round and give a mother her IV antibiotics regularly so they have a chance to work. Teaching the VNAs to check vital signs, and to check the babys vital signs and then treat for infection before it’s too late. Finding a cannula for a woman so she can have her blood transfusion and receive IV antibiotics. Treating high blood pressure to prevent an eclamptic fit. Experiencing first hand the problems that are being faced and trying to find workable solutions. Being there. Supporting local staff. Teaching. Sharing knowledge and skills. Learning from each other. It can be hard but also hugely rewarding. I’m sure things are a lot better now than they were three years ago. Steps are being made to ensure free healthcare to these women. There were lots of government training and initiatives aimed at 'primary care' at peripheral health clinics, aiming to prevent adverse outcomes. Roads are being built. Things are moving forward.

 

Outside the maternity ward in a Kambia  Appeal ‘motorbike ambulance’. With a shortage of vehicles, poor roads and the high cost of fuel, these motorbike ambulances have been donated to rural communitieis in Kambia District to try and tackle the ‘second delay’ in receiving life saving interventions (delay in getting to hospital) and reduce maternal deaths.

Other exciting news is that Mary Keniger, a friend and colleage of mine out in Sierra Leone is leading the next short term teaching trip to Kambia in April, and I will be going out as part of the team. It will be a maternity teaching trip, so I’ll have the chance to consolidate skills learnt during this placement! I will post more about the trip as it progresses.

This video made by amnesty international in 2009 is worth watching:

No woman should die giving birth: Maternal Mortality in Sierra Leone

http://www.youtube.com/watch?v=oHjwc4a57Vo&feature=c4-overview-vl&list=PL8A9A633294FED554