This post has a scatological theme, hence the “cool urinal” above, filled with ice cubes. This picture was snapped at the posh Goha Hotel in Gondar. Please stop reading now if you are easily offended.
Food in Ethiopia is generally excellent. However, it is not unusual to suffer from “Travellers’ Diarrhoea” following a visit to a local restaurant. On Wednesdays and Fridays, traditional “fasting food” is served. This is vegetarian, mainly consisting of beans, chickpeas and lentils in a spicy sauce. These ingredients are renowned for their potential to produce flatulence. On the morning of my journey back to UK, I started to have the warning signs. The clinical term is “borborygmi” – an excess of gas and liquid gurgling through intestines, often audible to others across the room. My tummy felt bloated and uncomfortable, but I dare not pass wind in case, well, I think you know what I was going to say.
Over the course of the day, the diarrhoea settled, but the gas persisted. The pressurisation of the aeroplane on the flight from Addis Ababa to Cairo played havoc with my guts, and I needed to visit the on board toilet frequently. Luckily, the ambient noise of the engines drowned out the noise generated by my bowels.
After landing at Cairo, I needed to get to a lavatory quickly. As soon as I sat down, I had no choice but to let fly a cacophony of disagreeable sounds. Two Egyptian men chatting at the urinals stopped speaking for a few moments, until the noise from my water closet had subsided. I waited for a minute or two, hoping that they would depart and I would not have to do the “walk of shame” to the wash basins. But they kept on talking. Finally I decided I had to flush and face the music. But the flush mechanism didn’t work. I pressed the button again, more frantically, but there was not even a gurgle.
I looked around for a solution. The cistern was not visible, hidden behind the wall. Near the floor, there was a metal flexible connector tube with a tap, running from the wall to the toilet bowl. I had a brainwave. Obviously the toilet was not working because the cleaners had turned off the water supply to the cistern. I can fix this, I thought. I bent down, turned the tap and was drenched by a high pressure jet of water squirting out from under the rim of the toilet bowl. My shirt and trousers were soaked. At least the water was clean. Well, it probably was clean, I think.
I panicked and this brought on another bright idea. The toilet must have a wall-mounted hot air drier and I could shimmy up against it to dry off. I opened the toilet door and came face to face with the two Egyptian men, who had now stopped chatting. They stared at me, open mouthed. I made some excuses in English, but they clearly did not understand. To my shame, one of them peered behind me into the cubicle. Apart from a pool of water on the floor, it didn’t look too bad, actually.
I hurried over to the wash basins to find the air drier was not working and I used some paper towels to dry my shirt and trousers as best as I could. I left the toilet and tried to walk inconspicuously to the departure gate. I must have looked like a cowboy after a long horseback ride. We were not yet boarding, so I sat down in the waiting area on a plastic seat. I covered my wetness with my carry on bag, but it clearly wasn’t concealing the problem. Without making eye contact, several passengers either side of me got up and left to sit elsewhere.
The flight was called and I had to pass through the metal detector doorway. Although there was no beep, I was selected to be searched by hand. “I am rather damp, but I can explain,” I said. I don’t think the attendant understood English very well, but the pat-down was very perfunctory after he realised my clothes were soaking wet. I boarded the plane and slowly dried off in the five hours it took to fly to London.
TBAs have been helping women give birth for thousands of years. They continue to provide a service in low income countries, especially in rural and remote areas. According to UNICEF, only 10% of deliveries in Ethiopia take place in a health centre or hospital. But maternal mortality is extremely high, with as many as one in twenty seven pregnancies ending in the mother’s death.
The obvious solution to this problem would be to improve the training of TBAs. Earlier this decade, selected TBAs in 45 districts (kebeles) attended a month’s training course to enhance their midwifery skills at a health facility. Unfortunately, this appeared to lead to an increase in maternal mortality and morbidity. This was perhaps because the training gave TBAs a false sense of confidence in managing difficult deliveries, when the pregnant woman should have been referred on. For the past three years, the policy of the Federal Ministry of Health has been to encourage all women to deliver in a health centre or hospital.
The aims of the TBA training were to help them identify pregnant women who were at risk of running into problems, to encourage attendance at antenatal clinics, to refer women in early stages of labour to the health post or health centre, and to conduct post natal visits to check on mother and newborn. However, during the introductory “getting to know you” period, it became clear that their main difficulty was persuading pregnant women to attend the health centre. I collated this information and we used it to modify the subsequent midwifery training.
Twenty six TBAs attended the training. Most were elderly women, with between two years and fifty years experience of delivering babies. Some said that they had delivered over a hundred babies. The majority of TBAs had learned their craft from family members, but one proudly showed me the tee shirt she had been given for attending a family planning training course several years ago. At first, all the women said that they had given up delivering babies two to three years ago; they referred all pregnant women to the nearest health post or health centre for delivery. In the subsequent discussion of “problem cases”, it became clear that TBAs were doing deliveries in the community but they were frightened to admit this in case they were punished. The translators told me that it was obvious that the TBAs were not telling the whole truth.
From my experience of training TBAs in West Africa, I knew that a formal didactic teaching method was not going to work. The TBAs gelled as a group and it came to resemble a village meeting. One TBA would take the floor and talk about her experiences, while the others would react to the story by nodding sagely, making hand gestures, or tut-tutting. No one interrupted, even though some of the midwives’ stories could become repetitive and long-winded. They were all having their say.
We asked why pregnant women did not want to deliver at the health post or health centre.
– The mothers lack awareness of the options for safe delivery
– The mothers refuse to go even when there is an obvious problem. I told a pregnant woman that her womb was abnormal (she had multiple large fibroids which would have obstructed labour), but she declined to go to the health centre. After 14 hours in labour, she consulted me again and this time I persuaded her to go. She was transferred from the health centre to Gondar Hospital, where she had an operation, and the baby was born alive.
– Women who do not have a husband will not attend the health centre.
– It is too long to walk to the health centre when you are in labour.
– There is no transport available to take women to the health centre in my village.
– There are some Bajaj taxis where I live, but they are costly and the women cannot afford them.
– Lack of money for expenses after the delivery in the health centre.
– The health workers (HEWs) sometimes do not have gloves. Sometimes, they do not have attendance cards.
– If the TBA sends a woman she considers at risk to the health centre in early labour, the midwife will often admonish the woman because she is not ready to deliver. There is no place for women to stay near the health centre while their labour becomes established. The women are very tired after walking for a few hours to the health centre and they feel the midwives do not understand their plight. Some women have been turned away, only to deliver on the path back to their village.
– Some midwives do not treat the women with respect. We have spoken to the woreda about this and they have talked to the midwives to be more respectful.
– There is no privacy at the health centre. Their bodies and private parts are uncovered during examinations or when actually giving birth. They are shy and embarrassed.
– Why can’t midwives examine pregnant women under their clothing, as TBAs do? TBAs do not stare at the genitalia, as midwives do.
– Some say that when the midwife touches the pregnant woman’s abdomen, the baby could be affected by disease.
– Men refuse to allow anyone to see the private parts of their wives. Some men have refused to allow a midwife to do a vaginal examination on their wives. Some men feel the midwives are violating their wives.
– There is no water at the health centre. They cannot wash or clean themselves after delivery.
– My own daughter refused to tell me she was pregnant as she knew I would be pressing her to go to the health centre to deliver.
– Women go for antenatal care once or twice but then think that they have done enough. “I went once, I’m done.”
– Some women will not inform the TBA because they are tired of being told the same thing: “Go to the Health Centre.”
– It is very shameful to pass a bowel movement when pushing out the baby. In the village, the TBA gives herbs to ensure the bowel is empty prior to delivery.
– Some women would rather take their chance having their baby in the village: “Let me die before I go there (health centre)”
– My own daughter had a breech presentation and she still refused to go to the health centre.
– It is normal to deliver in the village. Their mothers delivered in the village. They may have delivered in the village. Why should they change?
– “I’ll never go to the hospital. Let me die at home, it is better than dying at hospital.”
– Pregnant women lack discipline. They ignore my instructions to go to the health centre and argue with me.
– The midwives lack skill, they are no better than a TBA at delivering babies. If the TBA refuses, I will ask my mother or my sister to help.
– My village is not far away, but there is no road and you have to cross a river to get to the health centre.
– When you are brought on a stretcher (“helicopter”) to the health centre, you have to recompense the people carrying you.
– If the woman is sent from the health centre to Gondar Hospital, she will be very afraid. The ambulance journey to Gondar was costly, but now it is free. But she may not have money to get transport home.
– We all know of women who have gone to the health centre, then been referred to Gondar Hospital where they have died. They would prefer to die at home, instead.
– Some women are frightened of being tested for HIV, so they avoid antenatal clinics.
– They prefer to deliver at home, but when it goes wrong, they come to us and we have to help
I was concerned about men refusing to allow their wives to be examined properly. I suggested that when the TBAs come across this problem, they ask the men if they would go to the market to buy mangoes when they were blindfolded and were forbidden to touch the fruit. This provoked laughter but we may need to address this matter specifically in future training sessions.
The TBAs from remote areas all felt that lack of transport was the main factor preventing women from delivering in health centres. We were already aware of this problem when we agreed to provide the motorbike ambulance (MBA). Following further discussions with the woreda, the health centre manager and the zone health officer in Gondar, we hope that the MBA will be in action next week after the employment of a driver with a Bajaj licence.
It was clear from the discussion that women felt the services offered at health post and health centre need to improve. Women deserve respect from the midwives. Where possible, they should be allowed to deliver without their genital area being exposed unnecessarily. The women want more privacy and to be able to cleanse themselves after delivery. We included all these issues in the subsequent midwifery refresher course which took place in the following week.
When all the TBAs had finished talking, we stimulated discussion by asking questions about their experience. We asked what problems they had encountered when they were active in delivering babies. We also asked if any of the babies or the women that they attended had died around the time of delivery.
– One of the ladies I referred to the health centre refused to go. After labouring for a day, the mother consulted the TBA, desperate for help. The TBA diagnosed an oblique lie and did external cephalic version, but the baby was stillborn at delivery.
– A pregnant woman came to see me with a baby’s foot coming out of her vagina. The labour was taking too long, so unknown to her, I asked a man to shoot a gun just behind her. The shock was so great that labour proceeded rapidly and the baby was born alive a few minutes later.
– I have attended births on the road, in the market and in the fields. The problem is often finding something to tie the cord securely. I have used the string of my necklace more than once.
– I remember when I was nearing the end of my pregnancy, I examined my abdomen and realised the baby was breech. I asked two men to turn me upside down and tie me to a tree for two hours (!). The breech disimpacted and I was able to turn the baby around with my hands. A healthy baby was born head first a few weeks later.
– A common problem is retained placenta.
– When we get a problem, we wait and pray. Sometimes our prayers are answered.
– If there is a post partum haemorrhage, we burn herbs and incense in the hut and walk around it, saying prayers. Usually the mother dies.
– Some say that covering the mother with the skin of a hyena helps to stop bleeding.
– When there is delay in the second stage of labour, I ask the husband to come into the hut and to undo his belt…this usually causes the woman to push out the baby.
– If a young girl has an unplanned pregnancy, she may be ashamed. I have known a girl deliver in a toilet in secret. She killed the baby.
– There is a mad woman in our village that lives on the street. She has no family. I make sure that she had plenty of family planning supplies. But I went away and no one looked after her. Now she is pregnant and she does not want the baby.
– I hear what you are saying about diseases in pregnancy, but the commonest problem we see is vomiting. This is caused by the hair on the baby’s head tickling the mother’s stomach.
Some of the TBAs had witnessed women having severe postpartum haemorrhage resulting in death. Occasionally, babies died with the umbilical cord wrapped tightly around their neck. Premature rupture of membranes was another complication recognised by the TBAs which often resulted in a neonatal death.
When I asked about problems in early pregnancy, such as miscarriage or ectopic pregnancy, the TBAs said that most women do not consult them until the pregnancy is well established. The women keep their pregnancy a secret until it is obvious.
The TBAs knew a little about the dangers of eclampsia and malaria in pregnancy, but were unaware of gestational diabetes. A few of the TBAs knew about different presentations which can cause obstructed labour.
During the afternoon session, the TBAs joined the HEWs for some classroom theatre, role playing a delivery followed by a postpartum haemorrhage. One of the TBAs was caught up the drama and volunteered to help. Her management of postpartum haemorrhage was to “keep your legs together”. The team explained how to rub up a contraction in an atonic uterus and failing this, how to apply bimanual pressure to halt the bleeding as an emergency measure.
The final session of the day dealt with post natal problems, breast feeding and neonatal illness. The first two items were covered well, but when I talked about how to recognise a sick baby, the TBAs told me that they knew all about this, it was late, and most of them had to walk a long way to get home. They had participated so enthusiastically, they deserved an early finish.
Our original plan was to train TBAs to recognise when to refer “at risk” pregnant women to the health centre and to be aware of danger signs in the mother and baby following delivery when they have returned home. This plan was changed when we discovered that it is government policy to discourage home births conducted by TBAs; all women should be able to deliver under the care of a trained health professional in a health centre or hospital. Latest national figures suggest that up to 16% of women deliver in a health centre or hospital. Kolladiba Health Centre (KHC) has a catchment area of about 40,000 people. As the Ethiopian Crude Birth Rate is 31 per 1000, we would expect 1,240 births per year, but KHC has just 350 births per year, representing 28% of the total. This is better than the national average.
The TBA training gave us a golden opportunity to explore why so many pregnant women were eschewing health centre and hospital care. Pregnant women want excellent maternity services which are sensitive to their needs and easily accessible. During the refresher courses for midwives, we were able to discuss ways of improving the experience of women having babies at health centres. We already have the solution to improved access – the Motorbike Ambulance.
 When I told this story to some other health workers, they were not shocked. They said it was quite common to shoot guns to speed up labour.
 Verbal information from Dr Halima Abate at Ministry of Health, Addis Ababa
 Latest estimates from UNICEF in 2011
One of my readers has asked me to provide a bit of background information about Gondar. Until the late 16th century, the rulers of Ethiopia (then Abyssinia) had no fixed capital. They lived a nomadic lifestyle in tents, camping in the high plains. Portuguese missionaries arrived, bringing Catholicism and European ideas of military architecture. in 1635, Emperor Fasilides built a permanent fort as his capital on a hilltop at Gondar in the foothills of the Simien Mountains. After 200 years, Emperor Tewodros II moved the capital to Magdala.
Following the Italian invasion of in 1936, Gondar was developed as the administrative capital for Italian East Africa. A piazza in the centre of the upper town is surrounded by buildings in the fascist art deco style favoured by Mussolini. In World War 2, Italian forces made a last stand in Gondar before being overcome by Allied troops. Much of the colonial architecture is gently decaying concrete, but still being used. The Italian Governor’s residence, complete with a Swedish cast iron cooking range in the basement, has been converted to the Fogera Hotel.
A left-wing military junta called the Derg came to power after the death in custody of Emperor Haile Selassie in 1975. Thousands of opponents of the new regime were tortured and killed in Gondar. Many middle class Ethiopians fled the city and walked 100 miles to the Sudanese border, before reaching the USA as political refugees. It is said that every family in Gondar has at least one relative in the USA.
I apologise for returning to this blog before returning to the borderland, but I have some travellers’ tales to share.
For the past 15 years, the medical schools of Leicester and Gondar have collaborated in a Link Project. This has primarily involved secondary care, but in 2004, I was asked to visit Gondar to see if the link could be extended to community health facilities, perhaps linking to mobile chronic disease management teams which visited a handful of health centres with a couple of hours drive of Gondar.
Unfortunately, I felt that there were limited opportunities to work with primary care. No doctors were working in health centres. I felt that logistical and language problems meant that it would be difficult to organise training, so I withdrew.
However, biomedical scientist, Christine Iliffe, was not so easily deterred. She donated some laboratory equipment to Kolladiba Health Centre, about 35km south of Gondar. Health Officers and midwives could do simple blood tests which would help them manage patients.
Four years ago, the link with Kolladiba Health Centre expanded to include upgrading the facilities, focussing on maternal and child health. The link provided an oxygen concentrator, steriliser, screens, beds, instruments, neonatal resuscitation kit and other equipment to improve the delivery room. It was cleaned and painted, the water supply was reconnected. To provide electricity at night, the link donated a small generator.
In order to improve rural women’s access to health care, Christine offered to provide a motorcycle ambulance. This is a trail bike with a robust sidecar, which could get to remote areas where tracks were unsuitable for four-wheeled drive ambulances.
Christine and I, accompanied by two midwives, Becki Crook and Rachel Giaccone, arrived in Gondar a week ago to make sure the motorbike ambulance was being used, and to train traditional birth attendants (TBAs), health extension workers and midwives.
Ethiopian Government policy is that all women should deliver their babies in health centres or hospitals, where there are trained midwives. However, currently 90 percent of deliveries take place at home. The aim of our training was to make TBAs and health extension workers aware of risk factors during pregnancy and to ensure that deliveries took place in the safest location. Pregnant women would have to find their own way to the health post or health centre – by walking, being carried on a modified stretcher called a “helicopter”, or getting motorised transport if they were fortunate. A motorbike ambulance could make it easier to transfer pregnant women.
We arrived at Kolladiba Health Centre last Monday, under the impression that we had earmarked three days to train TBAs and health extension workers (HEWs). But we found out that the HEWs had been allocated to mass vaccination duty (serotype A meninogomeningitis and polio) as well as carrying out mass treatment for trachoma, using oral azithromycin. It is not unusual for arrangements to be made and changed at the last minute in Ethiopia. We offered to alter the training, making it a refresher course for all twenty midwives in the Kolladiba catchment area. We must have looked very disappointed, because the deputy local government (Woreda) chief said he would try to rearrange the HEW timetable. Just before we returned to Gondar, we were informed that we had been allocated two days to train HEWs and TBAs.
I think that the midwives and I learned more during the training than the HEWs and TBAs. More about this in my next post when I hope to have better photographs to upload.