Report on visit to Lumley Government Hospital (LGH) by The African Maternity Health Link Team.
22nd to 31st of January 2013
Visiting Team of 2013
Helena White – midwife, hospital based
Karen Cauvin – midwife, hospital based
Kathy Humpherson – midwife, community based
Pat Rogers – midwife, community based (recently retired)
Objectives for visit
1 To provide training sessions on topics requested by LGH midwives
2 To assess any changes in practice implemented since last visit
3 To visit new midwifery school in Makeni,
4 To visit Princess Christian Maternity Hospital as the main referral unit for LGH
5 To strengthen professional relationships between Redditch and Lumley midwives
6 Networking with other charities and NGO’s currently working in Sierra Leone to pool resources and make effective use of time.
The outward journey was surprisingly smooth considering the adverse snowy weather conditions and many flights being cancelled. Flight time was approximately 6hrs arriving to wonderful morning sunshine in Freetown.
Arriving in the early hours was an advantage in that we had the whole day to use rather than using a day for travelling so after dropping our many and very heavy suitcases we went straight to LGH to see our colleagues.
Our first obstacle was actually reaching the hospital as the road was closed due to improvement works so the taxi driver went the ‘alternative route’ which was something akin to an off road track enjoyed by 4×4 drivers at the weekend in the U.K! Not so enjoyable in a very elderly Nissan Sunny. On future visits to the hospital we took transport to the junction and then walked. This took about 20 minutes and was always interesting with either construction traffic working 2 feet away, funeral processions or cars pushing through and losing their entire exhausts on the road. The hospital itself looked the same, quite shabby, dirty and crowded. However we received a wonderful welcome from our colleagues and gave them the first consignment of bras to distribute at antenatal clinics. Many people bring baby clothes that are then made into bundles and given to the women as they are discharged with their babies but we felt, giving something in the antenatal period may also encourage increased attendance. It was also great fun that needed no language.
We discussed our itinerary with Matron Bah and the team of midwives to ensure that our time was used to its full potential.
A visit to Princess Christian Maternity Hospital (PCMH) was arranged for today. As facilitators of practice change it is essential for us to have an understanding of how things work, or otherwise, in Sierra Leone.
If the midwives need to transfer a patient urgently and require an ambulance they need to contact the doctor who then needs to contact the ambulance driver and authorise the transfer. The transfer can only go ahead with the doctors’ authority and payment for fuel to the driver. The journey from LGH to PCMH can vary from 30 to 60 minutes which is something to be considered when caring for a high risk patient in a resource poor setting. Our journey took approximately 40 minutes through the jammed streets of Freetown giving us a feeling of how a pregnant woman would feel on transfer.
The team met with the Matron of the hospital –Margaret Mannah, an inspirational woman who continued her work at the hospital during the war stating –‘how could I leave, only to come back and face my neighbours?’
She took us on an extensive tour of the hospital and all its facilities, introducing all her hard working staff in each area. PCMH is a considerable improvement on services that are available at LGH but still grossly inadequate in many areas for the 4380 deliveries in 2012 – 84 resulted in a maternal death. Neonatal mortality statistics were not available.
The large room appeared to be full of women who had been waiting a long time, some lying on benches some sitting. The system apparently was that on arrival they were assessed and given a card according to how urgent the case. Unfortunately women seemed to come in and jump the queue continually and the cards were running out (taken home or lost) with no facilities to replace them. We suggested simply, a marker pen on the back of the hand and a numbering system!!!Each woman apparently had an appointment card, that she kept and a large record card retained at the hospital.
A great emphasis was put on the fact that they had no scanning facilities or indeed anyone that could operate one, something that is considered essential in the U.K.
We visited a variety of wards antenatal, eclamptic (which included ante and post natal and anything resembling hypertension to eclampsia) post-section, post normal delivery.
There was no separate facility for women who had lost babies; we encountered women who had experienced a still birth, NN Death and those that awaited delivery of their dead baby amongst women who had their babies next to them. However it appeared to be what they expected and on discussion with a couple of women, both seemed accepting of the outcome and matter a fact about the loss, almost a shrug and comment that there would be others. What a contrast to expectations in the UK.
The Ward Sisters had a pride about their ward and although impoverished appeared clean, tidy and well presented. All beds had a sheet, pillow and mosquito net. Most women had pots or bowels by the bed side with food from home, which they seemed to prefer than hospital food (no change there).
Ironically one of the things that struck us, was that each ward had a large flat screen TV on the wall, we didn’t observe any of them working, which is of no surprise given that the shortage of electricity meant it wasn’t available for urgent supplies all of the time. The Matron informed us that they were donated by UNFPA, and her intention was to use them for educational material such as documentaries and teaching.
The delivery suite had between 6-8 delivery cubicles, with no doors, containing just a delivery bed which resembled a trolley and a Macintosh (black plastic sheet). They had one modern resuscitator, which we observed operational, (housing a new born whose mother had fitted postnatally). The midwife in charge was on duty on her day off and appeared the only member of staff present. They had 2 women present during our visit, one lady awaiting a decision for section, with failure to progress after 24hours?? The other was the lady that had the seizure. The delivery suite had its own autoclave which they used to sterilise the delivery instruments, of which they had 4 sets. Overall a serviceable environment but not one any European mother would entertain having her own delivery in. Not least because of the absence of any pain relief other than paracetamol, clicking ones fingers is a common coping practise. Fortunately lidocaine is available for suturing, although lighting very poor.
Theatre was situated down stairs near the entrance, and although we had a discussion with some of the staff on duty we did not see inside. We were advised that they had no elective cases and under normal circumstances they would perform caesareans under a spinal rather than GA. It seemed surprising to me that they could not therefore site an epidural.
Overall the visit answered many of our questions, but confirmed that Lumley is indeed a poor relation. It became apparent to us that lack of leadership and accountability is a big problem at Lumley, which has resulted in poor motivation and a low morale.
We were keen to see the midwifery school that is attached to the hospital and had a brief discussion with one of the tutors as the principle was unavailable.
The training school;
Entrance requirement is 2yrs RN experience.
18mths course of 28-50 students
Training comprises of class teaching and clinical placement. Students are expected to complete presentations and research covering various topics. Students attend 12weeks in school training prior to going on placement.
Assessment is via 3 exams, the final being externally set. Students are allowed 2 attempts within a 6mth period.
Unfortunately no syllabus was available to view and no lecturers free to discuss the process in more detail. The assistant we met had only recently started working there. We were unable to view any of the facilities, unfortunately, as it would have been beneficial to compare the 2 training schools, Makeni& PCMH, in terms of facilities and syllabus.
From discussions with staff at differing levels the common problem seemed to be having adequate staff and time to mentor students effectively. The Matron felt newly qualified midwives lacked basic understanding and routine taking of observations.
One of the exciting things about working on this Link is meeting such a diverse and interesting number of people. We met up with two U.K. midwives who were working on behalf of ‘Life For African Mothers’ (a charity set up by Angela Gorman, in Cardiff S. Wales, distributing life saving drugs to sub Saharan Africa) and had recently visited Bo, in the south of Sierra Leone, to deliver a consignment of drugs and much needed education updates to the midwives working there. They had also spent time at LGH with the midwives and we encouraged them to return to support the work that we had already begun.
We also met representatives of a Canadian solar energy company who were very interested in looking at LGH with a view to extending the system already in place there. By working in collaboration with other charities already established in Sierra Leone the improvements will develop more rapidly.
We spent today confirming the midwives knowledge of ‘normal’ midwifery care so the ‘abnormal’ is more easily detected. Their level of knowledge was encouraging and we had great fun doing the role plays of different ladies in labour, deciding in the best care plan and what to offer them. We also discussed our use of the Cardio Toco Graph which, while not available at LGH, gave the midwives an insight into the normal pattern of a baby’s heart rate during labour. They had expressed concern that if the baby was tachycardic then a caesarean section was required but we discussed many clinical reasons and treatment for tachycardia without surgical intervention.Use of the partogram in labour was emphasised as an invaluable tool to recognise the danger signs of the abnormal before they became emergencies. We tried to fix the only sonicaid available but as usual it was the batteries that were the problem!
Met with Dr SasKargbo, Director of the Reproductive and Child Health Programme at the Ministry of Health and Sanitation. He kindly agreed to sign our Memorandum of Understanding and was pleased to receive a small amount of Misoprostal from ‘Life For African Mothers’ that we had brought with us. We discussed our plans for this trip at LGH and our hopes to support them into the future. He explained the system of equipment supplies to the hospitals and they could only supply what was available in stores. Any supplies or equipment needed was to be applied for by the Chief Medical officer at the hospital directly to the Ministry and then released by stores once authorised. This process can take some time.
Further training sessions on normal midwifery care and dealing with a cord prolapse was taught in the afternoon at LGH.
On our last visit we had instigated the use of three small emergency boxes to be stocked and kept in the labour room; one for PPH, one for cord prolapse and one for pre-eclampsia. We eventually located the boxes but struggled to find the appropriate supplies to fill them. In Africa you just have to work with what you do have and quite often you just have to improvise! This emphasised to us how lucky we are that our supplies are automatic and emergency equipment is always available.
The team had an R&R day today in preparation for a heavy schedule next week.
As it was Sunday most of the staff were at church and so LGH was staffed with just one midwife and a pharmacist. There were no ladies in labour which was fortunate so we decided to do some cleaning and tidying to try and encourage the midwives to have a more systematic approach to their working environment. There was no running water at the hospital due to the road works so we asked for some to be brought from the standpipe down the road. It was difficult to do an effective job as basic cleaning materials did not seem to be available and the equipment is so old and worn it was difficult to see what you had cleaned and what you hadn’t but the overall impression was positive and the staff were grateful that we were happy to do all tasks required to improve things for them.
We travelled approximately 130 miles up country to a town called Makeni to visit the new midwifery school and find out what level of education the midwives receive during their training. We met up with the principle –
FrancessFornah – and were very impressed by the tutors and facilities available at the school.
The current training scheme started in 2010 and is a 2yr programme. It is supported by the Ministry of Health & Sanitation with the aim to improve maternal mortality statistics.
Applicants need 5 yrs experience as a nurse.
They have 2 intakes per year, with 60-68 students.
Accommodation is available to those who can’t travel. A canteen is also on site and alternative cooking facilities for those that couldn’t afford this, was outside by the well.
Uniforms are worn by the students in and out of school, including hats and are made on the premises in a little hut.
The Computer room contained 30 pc’s half of which were up to the date Dell pc’s. This room also housed a small library, which had a sparse supply of books, but those it did have were relatively current, and widely used in UK training.
The Clinical Skills lab facilities where impressive (largely donated by outside sources mainly Holland and Finland) and appeared to be well respected and replaced after use. We were advised that all students are encouraged to buy their own essential equipment e.g. Pinardstethoscope. Certainly a good idea seeing how poorly the workplace is stocked.
The training programme is structured to ensure one group is on placement whilst the other is in school.
A detailed plan was displayed on the wall. The first 6mths training in school is physiology based.
Placements are situated throughout the country, which makes monitoring/ visits difficult. This can be at a Community Health Centre, Community Health Post or Hospital. Sometimes two students are allocated to one unit as there are insufficient Midwives to mentor them. Previously supervision was performed by the MCHA’s. The focus of the placements is to learn basic essential obstetric care. However placements are problematic due to accommodation, communication and acceptance. So the intention is to set up a forum to deal with any issues.
Students have internal examinations at the end of every block of studies. These may be retaken if they should fail, apparently this is very rare. Finals are set for the Country, so both Makeni and PCMH students sit the same examination.
During our visit we encountered a class underway, we saw Fanta and Amie who we met at Lumley hospital last year and were very encouraged that they remembered the teaching sessions that we had done with them.
We were shown the course documentation, which appeared to be very extensive and European based, which is encouraging. We also viewed placement evaluation and assessment sheets, which require completion by the student and mentor, again very similar to what we use in the UK. Completion is the responsibility of the student.
It would appear that the Dutch Midwives, one of whom we met at Lungi airport FrankaCadee, have had an influence on the programme. The published book in 2012, by (KNOV) Royal Dutch Organisation of midwives of which Franka was an editor, ‘Twin2Twin Midwives Empower Midwives’, an inspirational step-by-step guide was supplied and sitting on the desk awaiting distribution.
A week seminar was also currently being held on the 2012 Review of Maternal Mortality, for which delegates had to pay. Francess advised conferences provide a good income to the training school. It appeared well attended and Karen was very curious, keen to be a silent observer, although we felt it wasn’t wise to gate crash. However we hope to learn more from the senior midwife from Lumley that was attending and again felt encouraged that they were reviewing cases in order to learn and move forward, with hopefully improved practise.
Another very interesting and beneficial day, spent by the Link team, despite the long four hour journey over the hills there and three and a halfhour return, via the by -pass currently under construction.
Establishing the current approach to teaching midwifery was very encouraging and helped us to confirm that the training we were carrying out was pitched at the correct level. Francess advised us that the intention is that in the future the Midwives trained at Makeni will be able to attend a mentor course.
Currently there is no follow up or update courses available. She was therefore interested in our Link and happy for us to maintain contact that could benefit all concerned.
We had planned another afternoon of teaching at LGH today but when we arrived the obstetrician, and doctor in charge of the unit, was in her office. This was the first time that she had been at the hospital when we had been there so I went to speak to her with the Matron while the rest of the team started the teaching. The doctor was very upset about several issues to do with our visit. We discussed as many of them as possible but it was clear that the doctor did not want to resolve them. It is unclear as to why she finds it difficult to work at Lumley and has asked the Ministry several times for a transfer to another unit, unfortunately this has not been possible and so she has been asked to remain at LGH for the time being. It became increasingly obvious to us that the doctor of the unit is in charge of every aspect of the day to day running of the hospital. It is their responsibility to authorise all supplies ordered, ensure staffing levels are adequate, which patients are transferred, where and why, etc etc. Lumley is in desperate need of many things but perhaps one of the most vital is leadership in the form of a dedicated doctor who genuinely cares about the unit, the staff and the women who come to have their babies there.
We managed to arrange a last minute meeting with Mr Sengupta, country director of Marie Stopes, Sierra Leone.
The Marie Stopes charity originated as a result of Marie Stopesfounding the first birth control clinic in Britain in 1921 and campaigning for women’s rights. Millions of the world’s poorest and most vulnerable women trust Marie StopesInternational to provide quality family planning and reproductive healthcare.
Within Sierra Leone:
Marie Stopes provides 50% of the family planning service in Sierra Leone, offering a full range. The implant is currently the most popular choice.
We were advised that 2000 tubal ligation procedures were performed in the last year.
Post abortion Care.
They also provide post abortion care for women who have sought terminations through other facilities. A small obstetric unit is situated in Freetown, which is supported by a 70yr old doctor. Counselling facilities are also available.
Marie Stopes has 12 out-reach teams comprising of a SRN, Nurse and driver. They travel to the out- lying villages.
The Blue Star franchise.
This provides training and medication to the private sector.
Mr Sengupta was happy to confirm that Misoprostol is licensed for PPH and available through Marie Stopes. However in Sierra Leone oxytocin is the registered drug of choice.
We also discussed with him the purpose of our Link and he felt that continuing to support one unit was probably more beneficial in building relations and improving outcomes. He acknowledged the difficulties we were experiencing with little surprise and urged us to try and build bridges with the doctor of the unit in order for the link to continue effectively. He offered his support and urged us to continue and not be deterred.
The short meeting we found to be both informative and interesting, proving to be another positive link to our ‘networking’ in Sierra Leone.
Unfortunately while Kathy and Helena were meeting with Mr Sengupta an incident took place at LGH with Karen and Pat that we felt might have been avoided. A woman delivered her baby while Karen and Pat were at the hospital and the baby required resuscitation, unfortunately the resuscitation equipment had been locked in the filing cabinet that had been kindly donated by the manager of ‘Family Kingdom’ – the hotel where we were staying. It was unclear as to how the cabinet came to be locked but the ambu bag that was needed to provide life saving breaths to the baby was unobtainable. The history of the woman and her labour was not discussed and so it was difficult to determine how effective resuscitation would have been but not being able to try was very frustrating. We are fully aware of how frustrating and exasperating managing this Link can be but lessons can be learned from these incidents and reflected upon to improve practice in the future. Reflective practice is something that we will be discussing at length with our colleagues on the next visit.
Summary of Conclusions
1. Training sessions were delivered as requested, further discussions of future requirements for the unit as a whole were very positive
2. Further encouragement given to implement changes in practice from the teaching sessions from last year and reiterated from the sessions on this trip.
3. Visiting the midwifery school in Makeni and Princess Christian Maternity Hospital expanded our knowledge and understanding of the training that the midwives have and the extended environment that they work with on a daily basis.
4. The professional relationships and friendships were strengthened enormously which leads to a more trusting and engaging base from which to start on the next visit.
5. Several new contacts were made with other charities and NGO’s currently working in Sierra Leone which will prove mutually beneficial in the future.
As Lord Nigel Crisp states
‘Change is about evolution, not revolution’
Helena White………………………………………………………………….February 2013