Southern Ethiopia - Gwent Health Link

19th October - 30th October 2006

I boarded the flight in Cardiff with colleagues from Gwent and Cardiff in the early hours of October 19th 2006. I was excited at the prospect of travelling to a developing country and teaching midwifery, something I had always wanted to do. I was also a little apprehensive, as I had been warned that it would be very different from anything I had experienced in the past and the reality of some of the conditions in Ethiopia could be quite difficult to cope with.

Visit to Health Centres

The following morning, after a good rest, we visited two health centres in the area – Leku and Chuko. Both health centres appeared to be closed, probably as it was the weekend, but some staff quickly appeared to show us around. There were no midwives at the health centres but nurse/midwives. The health centres consisted of several small, single storey buildings. The grounds of Chuko health centre had been dug and healthy vegetables were growing in the plots. Access to the health centres was by bumpy, dirt tracks.

We were shown to the antenatal clinic and delivery rooms as well as the admissions ward. All the rooms were small and sparse although there were several posters on the walls with educational material and guidelines for treatments. The delivery rooms were small but could accommodate two birthing women. Unfortunately, ensuring privacy could be a problem if two women were giving birth at the same time. Birth took place on a delivery bed with the woman in lithotomy position. Staff commented that it was difficult to keep the rooms clean, as it was the end of the rainy season. At Leku health centre, a woman was in labour.

The birth records in both centres were very good and were hand written in English. They provided us with very useful information. Women appeared to arrive at the health centres when they were in established labour, cervix usually dilated to 7-8 cms, many women had episiotomies and were given prophylactic antibiotics. Babies were all of a good birth weight, 3kgs and over and had good apgar scores. Women with complications e.g. breech, retained placenta were transferred to Yirgalem Hospital about 20 miles away. Twins were birthed at the health centres. Ergometrine was given for the third stage of labour.

Both health centres had about 1000 births per year. In both centres the staff were very friendly and smartly dressed in clean uniforms.

Visit to Yirgalem Hospital

In the afternoon we visited Yirgalem Hospital. This was the main hospital in Southern Ethiopia. Dr Yifru, Dean of Medical Faculty, showed us the maternity department. There was one delivery room which had two beds. Facilities appeared much better here than at the health centres with more equipment available but the hospital seemed quite old. Ventouse could be performed and there was better equipment for neonatal resuscitation. However there was still no facility for privacy if more than one woman was birthing in the one room. Women birthed in the lithotomy position.

The birth register again provided us with interesting information. The records showed that many women were admitted and treated for ruptured uterus, approximately 25 - 30%. Most women recovered and went home. Clearly this remains a huge problem for women during childbirth in Ethiopia. We then visited the other parts of the hospital. The wards were full and most patients had their relatives with them.

It was extremely valuable to visit the health centres and hospital, as our participants would be coming from these and similar centres. It gave us a good insight into the facilities and conditions in which they have to work.

Hwassa Hospital

On Sunday morning, after a night with a bat and an early morning call to the fish market, we visited Hwassa Hospital. This hospital was a relatively new, modern hospital but parts of it remained unopened. Dr Yifru showed us the maternity unit. He was keen to show us the delivery suite where women could give birth in private. There was a row of about eight single birthing cubicles. The unit was clean and bright. Protocols were visible on the walls. There was one qualified midwife at Hwassa, all other staff were nurses. Again the birth register indicated a high proportion of women admitted with ruptured uterus. We were shown around the rest of the hospital. It seemed a shame that much of it was still not in use. In the afternoon we prepared equipment and teaching materials for the week ahead.

The Course

Monday morning, we arrived at the hospital with a little time to finish off last minute preparations. Unbeknown to us, it was a Muslim holiday. We were not sure how many participants would turn up for the course. It was therefore extremely good that 22 nurse/midwives arrived for registration. After lunch, the opening ceremony took place with local health dignitaries and WHO representatives. After the speeches we were able to commence the course.

Participants were asked to introduce themselves. In small groups, the participants were asked to discuss their expectations of the course and to describe cases they had had to deal with. It was very interesting hearing their reasons for attending the course as well as their many stories of difficult cases. It was obvious that many of them had a lot of experience of complicated cases/births. This set the scene for the rest of the week.

The following morning, 34 participants arrived, far more than we had expected which was very good. Some had travelled for 2-3 days to attend which showed their commitment to the course and to the women they cared for. All participants were asked to complete a pre course assessment, which would provide us with an indication of their prior knowledge.

The next four days were spent giving presentations, short talks from obstetricians, practical skills in workshops, discussions in small groups and watching videos. Group work and skills workshops appeared to be new forms of teaching for them but they quickly adapted and became very chatty as time went on. They particularly liked the practical skills workshops. Sessions included normal and abnormal labour, obstructed labour. Aweke, Head of Nursing and Midwifery at Hwassa presented a session on "Use of the Partograph". Practical sessions followed on malposition and malpresentation using manikins and dolls and pelves. Large posters demonstrating different upright positions for labour and birth proved very successful and participants wanted copies for their health centres. Obstetricians, Jo Weiner from Gwent and Dr Million from Hwassa, delivered presentations on twins and pre-eclampsia.

Further practical skills workshops followed over the following two days on obstetric emergencies including shoulder dystocia, breech, ventouse and neonatal resuscitation as well as perineal suturing. Some participants had difficulty with the language and so nurses who could understand English and had good midwifery knowledge were identified and one was placed in each group to facilitate the teaching and learning in the group. This worked very well. Discussion groups looked at mechanisms of labour, why women die and how might the nurses/midwives encourage women to attend the heath centres for childbirth. Further topics given by the obstetricians included manual removal of placenta, uterine inversion, postpartum haemorrhage and management of abortion.

On Friday morning, the last day of the course, a short presentation was given by Roger Pickford, a radiographer in Gwent, outlining an ultrasound teaching programme for midwives in the health centres which he is keen to commence. Following this, a presentation was given by Aweke on "Taking care of yourself- infection control". This concluded the teaching part of the programme.

At the end of the course, participants were asked to complete a post course assessment and an evaluation of the course. The programme closed with a presentation looking at the way forward for the nurse/midwives highlighting issues such as teaching their colleagues the skills they had learnt on the course, how they could make their health centres a place where women would want to attend for their birth, ensuring privacy for women during labour and birth, use of the partograph, use of upright position in labour and birth and limiting the use of episiotomy.

Contact details of all participants and course members were shared with the group so that contact could be maintained after the course. The closing ceremony and presentation of certificates was recorded by the Ethiopia television. The participants were all receptive to new ideas, eager to learn and willing to share their knowledge and skills with their colleagues when they returned to their places of work.

It had been a pleasure and a privilege to be part of this very successful skills course for nurse/midwives in Ethiopia. We returned to Addis Ababa during the afternoon and early evening.

Visit to Fistula Hospital

The visit to the Fistula Hospital in Addis was one of the highlights of the visit for me. Having read and seen television programmes about the fistula hospital I was looking forward to visiting it. I was not disappointed; this was clearly a flagship hospital, well organised and well run. The women all seemed very well cared for and happy. The doctor who showed us around spent a long with us showing and explaining everything. He explained that operations take place four days per week with Dr Catherine Hamlin still performing operations on one day per week. He was clearly very proud of the hospital. He introduced us to the famous surgeon Mamitu Gashie, an ex patient at the hospital, who has been trained to perform fistula repairs. Unfortunately we did not see Catherine Hamlin.

Addis Sights

We spent the rest of the day sightseeing and shopping. We visited the National Museum and saw  'Lucy' or rather her bones! She was a female hominid who lived in the northern region of Ethiopia 3.2 million years ago. We had lunch and ate injera in the Finfine Adaresh Hotel.

Before jetting back home, Dr Aberra kindly invited us to his house in Addis for one final meal. A mix of Ethiopian dishes and drinks and his daughter performed the famous coffee making ceremony for us. It was the perfect end to a fabulous experience in Hwassa and Ethiopia, a country I shall never forget and whose people are among the friendliest and kindest I have ever met.