Southern Ethiopia - Gwent Health Link

Date of visit: 29.02.08 – 12.03.08

Personal background: As practice educator midwife I am responsible for organising and facilitating the mandatory training for all midwives, nurses and ancillary staff in the maternity units in Gwent.

Role in the Link: I am Lead Nurse/Midwife of the Southern Ethiopia Gwent Health Link and have been involved in the Link for the last three years.

Specific role/contribution to the work in this visit: This was my third visit with the Link to Southern Ethiopia. My role on this occasion was to visit the three designated health centres (YirgaCheffe, Alaba and Wondogenet) with other members of the Link in order to support and teach the midwives, health officers and clinical nurses in emergency midwifery skills.

Personal objectives for the visit:

• To provide teaching resources and equipment for the three health centres.
• To teach health personnel at the health centres in the recognition and management of obstetric emergencies.
• To assist with the evaluation of link activities at the health centres.All of these objectives relate to the main aims and objectives of the Link with particular reference to maternal and neonatal services.

Activities undertaken during the visit to meet the objectives:

Teaching resources provided -

• Laerdal Baby Anne Resuscitation Doll (YirgaCheffe, Wondogenet)
• Neonatal Resuscitation Ambu Bag (YirgaCheffe, Wondogenet)
• Stethoscope (YirgaCheffe, Wondogenet)
• Doll and Pelvis (YirgaCheffe, Wondogenet)
• Folder of midwifery emergency presentations (YirgaCheffe, Alaba, Wondogenet)
• ALSO CD ROM (put on the computers) (YirgaCheffe, Alaba, Wondogenet)

Some of the teaching resources were not left at Alaba Health Centre as there was no teaching room/library to leave them and it was felt that they would not be used appropriately.

Equipment which was left at YirgaCheffe, Alaba and Wondogenet Health Centres

• Ventouse
  • YirgaCheffe - 10
  • Alaba - 15
  • Wondogenet - 15
• Folder of partographs
  
  • YirgaCheffe - 50
  • Wondogenet - 100

Partographs were not left at Alaba Health centre as they used Ministry of Health records which incorporated antenatal, intrapartum (partograph) and postnatal care.

Using the teaching resources listed above, I taught emergency midwifery skills to midwives, health officers and nurses in each of the three health centres. These skills included the recognition and management of shoulder dystocia, vaginal breech birth, neonatal resuscitation and use of ventouse. I had also planned to teach use of forceps but it became apparent that they were not used at all the health centres and so I concentrated on the other four skills.

At YirgaCheffe Health Centre I met Debrework, a midwife I had taught on the previous midwifery course in Hwassa Hospital in October 2007. This was very useful as it provided me with an opportunity to assess his knowledge and practice in the skills he had learnt on the course. I was very pleased with his knowledge and also his level of understanding. He stated that he had used the skills he had learnt to help resuscitate babies and to manage effectively one case of shoulder dystocia. At the health centre I was able to teach 4 staff, 1 midwife and 3 clinical nurses. There was no health officer at YirgaCheffe.

It was also gratifying to note that some of the posters we left on the previous visit were on the walls for staff to refer to. The books and Midwifery Teaching Modules CD ROM were available in the library and there was evidence that they had been used.

At the health centre, Biku, Robyn, Meselech (Head of Midwifery, Hwassa College of Health Sciences) and I visited each of the departments with the aim of advising them on the facilities and the organisation of each. There was an overall lack of leadership at the health centre which they were advised on. In the maternity department, the midwife was advised to keep the equipment in the cupboard in an orderly and tidy fashion and also to consider moving the equipment into the delivery room so that it was more accessible when needed. Debrework was advised on the cleanliness of the facilities. One of the delivery beds was particularly bad in that the cover was worn and old blood was dried on the foam padding in the cover. Fortunately we were able to purchase a new delivery bed for the health centre in Addis Ababa prior to our departure. Additional advice was given in respect of a wooden step which was covered in dried blood due to women using it to get onto the delivery bed. This was cleaned and painted within 15 minutes which demonstrated that some things take very little time or resources.

It was particularly pleasing that Debrework had been chosen and agreed to collect data for the evaluation which will be co-ordinated locally by Meselech and Dr Aberra.

I felt that most of my objectives were met at this health centre although I would have liked to have taught more staff but many of them were involved in busy clinics.

I was not able to assist with collecting information for the baseline evaluation which Robyn took the lead on as most of my time was taken up with the teaching.

Alaba Health Centre was the next health centre to be visited. There was a health officer at this health centre but she was not the person in charge, instead this was a nurse. There was a midwife at this health centre but unfortunately she was not the one that was there on our previous visit. He was now in Hwassa College undertaking a health officer training course. The midwife at the health centre was on night duty, so after a very brief initial meeting there was no opportunity to meet her again.

There appeared to more organisation at this health centre than at YirgaCheffe and they were expecting us. Neither the books nor the Midwifery CD ROM were available for us to see. The teaching log was present and there was one entry which the previous midwife had made. I was able to teach 7 staff at this health centre, 6 clinical nurses and 1 health officer. I felt the teaching went very well and all staff were very interested and receptive to new ideas.

I also had the opportunity to help out in the antenatal clinic which seemed quite busy with women attending throughout the day that we visited. I shadowed one of the clinical nurses in the Vaccination Clinic.

The teaching resources were not left at this health centre as there was no teaching room or library in which to leave them. The teaching resources previously left were no longer available and so we were not convinced that these resources would either be used or available on our next visit. We will review this at our next visit later on in the year. I took the resources home with me. They will be taken to the health centre on our next visit.

On further examination of the various departments there were many recommendations made. The maternity unit appeared to be well run. Equipment was available in the delivery room. It was orderly and clean but unfortunately there were no screens between the two delivery beds, so no privacy was available for the women delivering in the room simultaneously. This was pointed out to the staff. It was also noted that a scalpel had remained in the receiver at the bottom of one of the delivery beds for two days despite it having been mentioned to staff! We emphasised that it was the responsibility of all staff to deal with sharps even if they did not actually leave the scalpel, once they saw it, it then became their responsibility. It was recommended that the walls of the postnatal room be painted.

It was also noted that two inpatients in the admission room appeared to have had little ‘care’ during the two days of our visit. On review of their records, there was an entry on admission with no date or time and no further recordings were made. Both patients had intravenous infusions is situ but there was no evidence either witnessed or recorded of any vital observations or fluid intake and output etc.

Most of the objectives had been achieved at this health centre, the teaching had gone well, but it was particularly disappointing that more contact could not have been made with the midwife.

Wondogenet Health Centre was the third health centre visited by the Link. This was a well run health centre with evidence of good leadership. We had met the health officer in charge of the health centre, Metasebia, on a previous visit in October 2007. We had a big welcome from the staff. The gardener was busy cutting grass and tending to the plants. What a difference the well kept grounds made to a place. The cleaners were busy cleaning windows and doors as well as the floors.

There was a new midwife at this health centre although we had met her briefly on our previous visit but she had not attended the midwifery skills course at Hwassa College. Her name was Ieualum. Her English was quite good and she was very eager to learn. On the first day I was able to teach Ieualum and 2 clinical nurses.

The following day I was able to teach some more staff as they were not involved in clinics. This was a Saturday and Metasebia had organised for staff to be available in the health centre for teaching. The first group consisted of the midwife, Ieualum and 6 clinical nurses. Meselech was with us again on this visit. Ieualum taught shoulder dystocia as she had been taught this the previous day by me. This again provided me with the opportunity to evaluate her knowledge and teaching skills. She needed some support but generally was very good. She had obviously grasped the essentials. The next group consisted of 7 clinical nurses. As time was getting on, Meselech took half the group and I taught the other half.

In total 16 staff had been trained at Wondogenet Health Centre.

There was evidence that previous teaching on emergency midwifery skills had been used with anecdotal and written evidence of a vaginal breech birth and shoulder dystocia.

On our visit around the health centre to advise on ways of improvement, we suggested to Metasebia that she should consider separating the post abortion area from the delivery area. Currently both were situated in the delivery room and there could be women using both facilities at the same time. There was no curtain in the room to provide privacy. We felt that the postnatal room next door could be used for the post abortion women. Postnatal women could use the antenatal room or the female ward if necessary.

Again we were able to buy a delivery couch for Wondogenet health centre in Addis Ababa prior to our departure. Metasebia was with us and she took the bed with her. She was extremely pleased.

Additional unplanned activities -

Whilst at Wondogenet health centre I was able to observe the midwife and some of the clinical nurses care for a woman in labour. A woman, Arbermesh, had laboured at home with the traditional birth attendant (TBA). She was gravida 7 para 6 and lived about 30 mins from the health centre. After two days of labour at home the TBA brought her to Wondogenet health centre. It was interesting to see the care she received. No partograph was used despite the woman potentially having an obstructed labour. One was brought for me to see when I asked but it was not used even after I suggested that it should. There was little privacy for the woman, people were constantly walking in and out of the room even when the woman was in the second stage of labour. She was obviously embarrassed when two male clinical nurses came in to observe. At one time I counted nine people in the room including the cleaner. I suggested that some of the observers went out and they did. There was an obvious lack of ‘basic care’ for the woman eg supporting her in an upright position despite her trying to sit up by herself, she was very hot but no-one tried to cool her down and she was thirsty but no-one offered her a drink despite her bringing some orange pop in with her. Once I started to provide her with some basic comfort eg using a piece of paper as a fan and supporting her in a sitting position, I encouraged the clinical nurses to do the same and take over from me, which they did. I explained to them that they could still observe the birth whilst caring for the woman. The woman eventually gave birth to a baby boy who weighed 4.1kgs, an enormous size for such a small woman. The midwife’s inexperience showed (she had been qualified for six months) by her checking with Meselech and myself as to what she should do. I was very glad we were there.

I feel that more needs to be included on how to provide ‘care’ for a labouring woman in the next midwifery skills course, perhaps through the use of role play.

On the last day in Hwassa, Robyn and I met with Meselech and a group of midwifery students at Hwassa College of Health Sciences. The purpose of the meeting was to introduce ourselves and the Link to the student midwives, to present the teaching resources to them and for Robyn to collect some information from them towards the overall evaluation.

I was asked to teach vaginal breech to them using the doll and pelvis we had donated. However, with just one doll and pelvis available the session was not as I would have liked it but I think they appreciated it.

Robyn and I reviewed the Midwifery Curriculum at the University and we discussed our comments with Meselech. Throughout the curriculum there was a lack of emphasis on Midwifery. It was not possible from the document to ascertain when and where students gained their practical experience. The amount of practical experience was less than expected from midwifery students in the UK. The assessment process and criteria was also lacking so it was not possible to see from the document when and how the students were being assessed and the criteria used.

It was interesting to note that of the 45 students only two were female despite the curriculum stating that preference would be given to females. We were to learn that most of the males did not want to be midwives but used it as a means to become health officers. What a waste of money and time!

I feel that Meselech needs some support with the curriculum (although it was not obvious what part she played in its production, if any) and with the teaching of the midwifery students. To this end she should be involved in the next midwifery skills course acting as interpreter, supporting the group work and maybe presenting some of the sessions eg Infection Control and HIV, Why Mother’s Die etc

3 Key Impressions from the visit

1. The effect that poor leadership has on the organisation of the health centre both for the staff and the people who use it was very evident particularly when comparing the health centres at YirgaCheffe and Wondogenet. Meetings with the data collectors, Meselech and Dr Aberra in each of the health centres in turn should provide an opportunity for the staff from each of the health centres to learn from each other.
2. All staff were keen to learn and agreed to continue to practice the emergency midwifery drills and to teach colleagues. In future, when midwives from the link teach at the health centre the teaching log should be completed with names of the staff taught together with the particular topics.
3. The ‘Memorandum of Understanding’ signed in each of the health centres was a particularly memorable occasion. It marked a definite move forwards in establishing each of the health centres as exemplar teaching centres. It will be extremely interesting to monitor what each has achieved by the next visit of the Link.

Outline of future plans

It is evident that two main themes have developed for the midwives involved in the Link. One is the teaching of the week long Continuing Midwifery Education course for nurses and midwives in Southern Ethiopia. This course has evaluated well in the past and should continue particularly for the nurses/midwives who work in isolated rural health centres. As previously identified I feel that the numbers on this course should be limited to 30 so that all participants can practice the skills taught in small groups. At least 3 midwives would be necessary to teach on this course.

The second theme is ensuring all necessary equipment is provided for the midwives at the health centre and teaching the emergency midwifery skills to all staff. I feel that 2 midwives would be necessary for this.

Following discussions with Dr Aberra I will explore the possibility for midwives from the link to work alongside nurse/midwives in the hospital to ‘mentor’ them.

I will look into the possibility/practicality of using Magnesium Sulphate for women with pre-eclampsia/eclampsia in Southern Ethiopia. The WHO recommends its use in developing countries and is currently encouraging countries to agree written guidelines and protocols. Dr Yifru to be contacted to indicate the extent of the problem in Hawssa and to highlight the practicalities of using magnesium sulphate. It may be that training on its use could be included in the course for anaesthetic nurses.

On this visit we were able to purchase a number of items required by the health centres having found the relevant suppliers, particularly in Addis Ababa eg curtains, sheets, delivery couches etc. It proved to be much easier to do this than to transport the items with us. Thus, fundraising will be particularly important when we return so that more money can be taken to Ethiopia to purchase further items locally. Personally I will try to encourage staff to give via the payroll giving.

Personal Benefits

The visits to Ethiopia with the Southern Ethiopia Gwent Link have provided me with the opportunity to travel to a developing country and to experience a very different health care system. I am now much more appreciative of our National Health Service where everyone can access free medical care. I have also met many people, mostly professional staff in the hospital or health centres, who I feel have become good friends.

I have been able to witness at first hand a very different culture with Christians and Moslems living and working in harmony along side each other – something I feel we could learn a lot from in the UK. I felt nothing but friendship and respect from everyone I met. It has been fascinating learning about another culture.

I have had the opportunity to present an account of my visit to Ethiopia at the RCM Conference in Brighton in 2007, something I would never previously considered as public speaking is not something I relish. As a result of this new found confidence, I sent abstracts to the ICM Conference in Glasgow 2008 and to the CNO Showcase Conference in Wales 2008. Sadly neither were accepted. However, a presentation and a poster presentation have been accepted for the Nursing Conference in Gwent in May 2008. I will be able to inform staff of the payroll giving scheme and have forms available.

I recently wrote a story of my experience in Ethiopia for a THET competition and was successful in winning second place and a £500 prize for the Link.

It provides me with excellent evidence for my personal portfolio of CPD and KSF.

As practice educator midwife in Gwent I have used many scenarios I have witnessed or heard of in Ethiopia in my teaching for midwives in Gwent. The midwives are fascinated by the stories from Ethiopia and I feel it enriches my teaching and consequently their learning.

Benefits to the Employer/Wales

The Southern Ethiopia Gwent Health Link is a well respected Link not just in Wales but increasingly in the UK. It is becoming a flagship Link with well defined aims and objectives. It has been very successful in bidding for money. This serves to put Gwent well and truly on the map in terms of supporting developing countries. It goes a long way to ensure that the Trust achieves the government’s aim of supporting staff to work in and assist developing countries as recommended by the Crisp Report 2007.

The Link is going from strength to strength at the moment and this can only reflect well on Gwent Healthcare NHS Trust and also on Wales.

Additional information

One of the main aims of the visits to the health centres was to meet with health centre staff, community groups, Woreda Health staff and members of the Link. In each of the three health centres these meetings were very well attended and a useful exchange of views took place. In all three centres a ‘Memorandum of Understanding’ was greed and signed by members of each group. I have not concentrated on this aspect of the visit as it was not one of my particular aims. I trust other members of the link will deal with this in more detail.

I would like to thank once again Mr Biku Ghosh for organising another successful visit to Ethiopia. Also thanks to the group as a whole for making the visit all the more enjoyable and memorable. Thanks also must be extended to our friends and colleagues in Ethiopia without whose generosity and support all of this would not be possible. Particular thanks to the staff at the health centres, Misganaw, Meselech, Dr Aberra and Dr Yifru.