Simien Mountain Profile

A gelada from the mountains of northern Ethiopia.

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This is a cheeky photograph of a gelada baby baboon feeding from mother – from her expression, he isn’t sucking gently. He is in profile, however.

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Entrances and Doors: Biete Mariam

Ethiopian Cave Church Doorimg_8438

This is a door of a small chapel, carved out of the rock in Lalibela in the Ethiopian Highlands. The door leads to the courtyard of Biete Mariam (Mary’s House), one of the eleven monolithic churches in the small town.

It is said that King Lalibela wanted to create an Ethiopian version of New Jerusalem, compete with the River Jordan running through it, more than 700 years ago. He was helped by angels, who did a lot of the work at night.

Community Project Visit to Kolladiba Health Centre 2013

Introduction

Traditionally, Health Action Leicester for Ethiopia has concentrated on secondary care. Nine years ago, Ian Cross looked at expanding the link to primary care, but he felt that there would be too many problems working with health centres and health extension workers (HEWs).

Four years ago, Christine Iliffe became aware of the link between Abergavenny NHS Trust and Jimma, in the Oromo Region, which concentrated on maternal and child health in primary care, important because Ethiopia has high maternal and infant mortality. With support from Dr Shitaye Alemu, she initiated a five year project aiming to improve health services in Kolladiba Health Centre. She focused on obstetric care and laboratory services, replacing equipment and a generator to be used when the local power supply failed.

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Once the delivery room had been renovated, with new beds, lighting, resuscitation equipment, an oxygen concentrator, a hot air steriliser and new instruments, Christine recruited three British midwives to provide refresher training for midwives working in health centres. Becki Crook, Rachel Giaccone and Zaheera Essat collaborated with three Ethiopian midwifery tutors – Tatek, Abdella and Endershaw – to provide the first training course for 22 midwives working in the community and five midwives employed at Gondar Hospital in 2012. Unfortunately, plans to give further training to health extension workers (HEWs) were thwarted because they were recalled to participate in a political rally at the last minute.

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Aims and Objectives

1. To promote use of  the Motorbike Ambulance at an Open Day at KHC.

2. Obstetric training for HEWs and TBAs.

3. Promote closer collaboration between MWs, HEWs and TBAs.

4. Observe maternity care in action at Gondar Hospital.

5. Continue to support renovation and improvements at Kolladiba Health Centre.

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Changing Plans

Two weeks before we arrived in Ethiopia, we found out that it was government policy for all pregnant women to deliver in hospital or health centres. TBAs were discouraged from assisting women in labour; instead their role was to refer pregnant women to health centres. However, 90% of Ethiopian women deliver at home, without professional help. We decided to amend our plans for TBA training to concentrate on identifying pregnant women at risk and overcoming barriers to referral. We included training for obstetric emergencies occurring in a village setting, when it was impossible to transfer women to health centre or hospital.

On arriving in Kolladiba, we discovered that there were new plans for the HEWs to take part in vaccination programmes on the dates which had been agreed and allocated for training. If we could not train the HEWs, then we could perhaps teach the health centre midwives to train the HEWs in their areas. We could not train all the locality midwives at the same time without adversely affecting the service, so we trained half the midwives for two days at Kolladiba and the remaining midwives at Tchoit. At the last minute, the Woreda relented and released the HEWs for two days (one day less than planned), starting the following day. We decided to continue with the plans for the midwives’ training, changing it into a refresher course.

Motorbike Ambulance

The motorbike ambulance (MBA) arrived at Kolladiba in November 2012. We had expected that it would be being utilised as agreed verbally with the Woreda, Area Health Bureau in Bahir Dar and the health centre manager. But we discovered it was parked at the health centre, unused and gathering dust. There were suggestions that one of the three health centre pharmacists could drive the MBA, but it was not possible for him to do two jobs. A year ago, we offered to pay for a driver to undertake bajaj training, so he could be licensed to drive the MBA, but this had not happened. The health centre manager explained that there was no job description, no official role of MBA driver in the establishment, so they would have to await official notification from the Ministry of Health before a driver could be employed. One of the vehicles in the health centre compound was wrecked, its driver still employed but not working, but he could not be allowed to drive the MBA as a temporary measure.

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We organised an Open Day at Kolladiba Health Centre, at which two senior Woreda officials addressed an audience of over a hundred people from the locality. We were assured that the Woreda would authorise the employment of a MBA driver immediately, but the following week, the official was too busy to see us, and the issue was dropped.

We arranged an appointment with Ato Temaru, head of the Zonal Health Office in Gondar. He telephoned a civil service colleague in the finance department but failed to get authorisation for a driver. We spoke to Muluken Emagnu at Save the Children Fund, who promised to bring up the issue at the Forum between NGOs and government officials.

MBAs are not new to Ethiopia. Jimma’s health centres have been using them for three years. Courtesy of Kuwaiti Aid, 150 MBAs have recently been donated and distributed to health centres throughout the country. We fail to understand why there is not the political will to employ a driver in Kolladiba when the need is so great. On one of our trips to Kolladiba, we saw three patients being carried on stretchers to the health centre within half an hour.

Accomplishments of this visit

Fourteen HEWs attended a two day training covering standard antenatal and intrapartum care, basic practical clinical skills, such as taking blood pressure and use of thermometer, improving knowledge of obstetric emergencies, clearer indications for referral of at risk pregnancies, and health promotion. Feedback was excellent.

Twenty six TBAs attended a day’s training in identifying risk factors in pregnancy, the puerperium and infancy and dealing with emergencies in a village setting. None of them admitted to delivering babies since the change in government policy. They all referred every pregnant woman to their local health centre. This TBA training gave us a golden opportunity to explore why so many pregnant women were eschewing health centre and hospital care. Not surprisingly, we found out that pregnant women want excellent maternity services which are sensitive to their needs and easily accessible. Armed with specific examples, we were able to discuss ways of improving the experience of women at health centres during the midwifery training courses.

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We ran two 2 day intensive training courses for 25 experienced midwives in the Kolladiba area. The training covered normal physiology of labour, active birth, obstetric emergencies and recognition of danger signs. We encouraged the midwives to discuss their experiences openly, especially how they collaborated (or not) with HEWs. The training was modified to include points made by the TBAs to improve delivery services (more privacy, greater respect for pregnant women, better hygienic facilities, etc). Again, feedback was excellent.

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Our midwives spent two days observing routine practice on the Delivery Ward in Gondar Hospital, with Tatek. Most deliveries were done by medical students, not midwives. Attitudes to patient care could be better.

Over 100 local people attended the Open Day at KHC. The MBA drove around the town carrying a brave “patient” (Christine). We had invited community leaders and representatives from the church and mosque. The audience were delighted by the prospect of having better access to care using the MBA, but this enthusiasm was dampened by the politicians’ change of heart the following week. The event was therefore a partial success.

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Ian gave a talk to the Kolladiba HIV Mothers Support Group (registered charity) concerning the prevention of maternal – child transmission of the virus. The women asked us for help setting up an income generation scheme (a mini market) in the town.

We painted the delivery room in fetching shades of strawberry and cream, mended an examination light which was “non functional”, and ensured that the emergency generator could now operate by fitting modern wiring and energy saving bulbs.

Plans for the Future

1 Additional midwifery refresher training

The midwifery training was successful, but time limited. The midwives have requested more training in topics such as ventouse deliveries and how to do an episiotomy. Our midwives felt that more training in physical examination, use of the partogram and accurate assessment of fetal position would be beneficial. Ideally, further training should be practical, taking place in the delivery room, with direct observaction of their practice.

We plan to run an advanced course sometime in 2014.

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2 Support and supervision of midwives and HEWs

Attending a two day training course is useful, but knowledge decays and it is well recognised that further follow up is necessary to consolidate improved skills. We have plans to set up more formal supervision and support using a lecturer from Gondar School of Midwifery to visit MWs and HEWs in the field over the next 12 months. It might be possible to assess the outcome of this approach by comparing basic mortality and morbidity data with another Woreda which has not benefitted from midwifery training.

We hope to get a formal programme of activity from Tatek in the next few weeks. We will be meeting Elizabeth Draper, Professor of perinatal and paediatric epidemiology at the University of Leicester, in February to discuss the feasibility of  evaluating this pilot study.

We also want to try out a “buddy” system, where an experienced midwife is paired with a newly qualified midwife, who can contact the buddy at any time using mobile phones to get advice and discuss problems.

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3 Motorbike Ambulance

We have exerted as much pressure as we can on the Woreda and health centre manager. The zonal health bureau chief is sympathetic and has contacted the finance officer of the civil service to approve the establishments of the post of driver.

Save the Children Fund will bring up this issue at the next NGO / Government Forum. We do not want to transfer the MBA to another more compliant health centre at this stage.

We have notified Dr Sisaye about this problem and he will try to exert some pressure. We want to make contact with the local Rotary Club in Gondar which might be able to bring this situation to a satisfactory conclusion.

4  Mental Health

There is a glaring need for further training in mental illness at health centre level. Several patients were brought to see Ian for advice. Dr Shitaye’s hub and spoke model for delivery of the management of chronic disease applies to mental health problems too. Perhaps once the rehabilitation centre in Gondar has been completed, we can think about training health centre staff in mental health, so they can follow up patients in the community.

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Not for the squeamish

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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.

The corrugated iron structure is a pit latrine at Kolladiba Health Centre. It is locked, but I cannot fathom why. As soon as one urinates into the hole, clouds of mosquitoes emerge, looking for dinner.
The corrugated iron structure is a pit latrine at Kolladiba Health Centre. It is locked, but I cannot fathom why. As soon as one urinates into the hole, clouds of mosquitoes emerge, looking for dinner.

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.

Ethiopian Food

Ethiopian Food

Lamb Tibs

Kocho, a thick flatbread made from the ensete plant
Kocho, a thick flatbread made from the ensete plant
Kitfo consists of minced raw beef, marinated in chili powder and spice with clarified butter infused with herbs and spices. Here the butcher is making mince with two knives.
Kitfo consists of minced raw beef, marinated in chili powder and spice with clarified butter infused with herbs and spices. Here the butcher is making mince with two knives.
Pancake mix, Ethiopian style
Pancake mix, Ethiopian style
Shiro is made from ground up chickpeas and spices. Sometimes it contains meat. It is served here on a bed of injeera, pancake bread made from the fine grained t'eff.
Shiro is made from ground up chickpeas and spices. Sometimes it contains meat. It is served here on a bed of injeera, pancake bread made from the fine grained t’eff. When eating with friends, Ethiopians often wrap a piece of injeera around some meat or stew (“wat”) and feed the person next to them at the table. This is an act of friendship called Gursha.
These men are slicing off strips of raw steak, dipping it in spicy chilli powder, and wrapping it with injeera bread.
These men are slicing off strips of raw steak, dipping it in spicy chilli powder, and wrapping it with injeera bread.
Lunch for the midwifery refresher course, with green chilli, potato, cabbage and shiro. served on injeera.
Lunch for the midwifery refresher course, with green chilli, cabbage and shiro. served on injeera.
Doughnuts
Doughnuts

Traditional Birth Attendant Training

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

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A Helicopter - modified stretcher to carry patients to the health centre
A Helicopter – modified stretcher to carry patients to the health centre

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.[1]

–          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.

Tatek Abate, Midwifery Lecturer, Becki Crook and Rachel Giaccone, midwives
Tatek Abate, Midwifery Lecturer, Becki Crook and Rachel Giaccone, midwives

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.

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Summary

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.[2] Kolladiba Health Centre (KHC) has a catchment area of about 40,000 people. As the Ethiopian Crude Birth Rate is 31 per 1000[3], 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.

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[1] 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.

[2] Verbal information from Dr Halima Abate at Ministry of Health, Addis Ababa

[3] Latest estimates from UNICEF in 2011

Ethiopian interlude

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.

Gondar Castle
Gondar Castle
Coptic Christian paintings inside the church of Debra Selassie
Coptic Christian paintings inside the church of Debra Selassie

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.

Oxygen concentrator
Oxygen concentrator
Rusty old delivery bed
Rusty old delivery bed
New delivery bed
New delivery bed

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.

Motorbike ambulance
Motorbike ambulance

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.