POLITICAL BACKGROUND.

Liberia in West Africa is coastal country of approximately 3.3million people, of whom 1.3million live in and around the capital Monrovia. Approximately 80% of the population live below the poverty level on less than $1 (50p) per day. The country is in a state of recovery following 15yrs of civil war under the Presidency of Charles Taylor who is currently on trial accused of war crimes, in The Hague. Evidence of the war is all around with a number of seriously damaged buildings and others with more superficial damage. In 1990 there were 30 functioning hospitals in the country. Post war this number dropped to 18. The hospital component of the health sector is under-sized and its technical capacity is grossly inadequate. For the past 2yrs, under the Presidency of Mrs Ellen Johnson Sirleaf and the United Nations, there have been several positive changes including awareness-raising by the government that the country will regain stability, but that it will take time. Citizens are being asked to be patient. Large placards sit alongside all the main roads with messages such as “Corruption is not paying your taxes” and “Paying taxes means that we can have good healthcare, education and houses.” There are also stark warnings of the consequences of violence of all types against women. (Liberia has one of the highest rates of domestic & sexual violence against women in the world.) The United Nations vehicles are very visible and there is a team dedicated to Liberia UNMIL (United Nations Mission in Liberia). Overall there is a real sense that things are getting better with businesses returning to the country, new investment including the building of major roads by the Chinese who wanted to bring in their own labour, but were told by the President that they could only have the contract if they used the local workforce. There is no doubt that the President, the first woman President in Africa is a force to be reckoned with, and it shows.

BACKGROUND TO VISIT

In November 2005, during the first visit to Chad by members of HFGK, we met Dr Koudaogo Ouedraogo MD, MPH, from the UNFPA who has remained within our communication network. In the summer of 2007, Dr Ouedraogo contacted HFGK requesting that we consider assisting Liberia as a priority, as well of course as continuing to support the National Reference Hospital in N’djamena, Chad. With the obvious success in Chad where more than 2000 women and their babies are alive and well as a result of our support, he felt that we could assist Liberia in addressing the tragedy of a maternal mortality rate of 1:8. In the autumn of 2007, via a contact within the Welsh Assembly, I was invited to join a group of people who had a non-health related link to Liberia, were based in Swansea and who had already begun the arrangements for their visit to Liberia in January 2008. Two of the group are from a group called Women4Resources who are supporting a group of about 25 women who have chosen the name Concerned Women for Progress 4 Liberia working on personal and economic empowerment, gender sensitization, against sexual and domestic violence against women and skills training. The support has included the provision of sewing machines, materials and paying for a teacher. They are also given a nutritious meal at the end of the sessions, held three times a week in the local school. Healthcare provision is of great concern to these women. At the moment all medicines have to be paid for, including those for children. So whilst the agenda for my travelling colleagues would seem to be unrelated to mine, the holistic approach to their needs could not be ignored. The opportunity clearly provided an opportunity to undertake a firsthand assessment of the situation and the extent to which we in the charity could be of assistance. It was agreed that the priorities would be visiting clinical areas and setting up robust lines of communication and accountability so that individuals supporting our charity could be assured of the realisation of their expectations.

ACHIEVEMENTS DURING THE VISIT.

On the evening of our arrival, I was introduced to Rev Chuod Walleh, who has overall responsibility for the establishment in which we were residing. Chuod’s wife died last year, of eclampsia and his grandmother died of the same condition. He has offered to assist in any way possible and he accompanied us to the significant meetings in order to assist with providing any further background information.

One of the first tasks from day one was to make the arrangements to meet those individuals who could assist in providing a comprehensive view of the situation related to maternal mortality. I was taken on Thursday 24th January, by taxi from one Government Department to the next, making the appropriate appointments.

Friday 25th January. Prior to the visit I had been put in touch with Mrs Rose Gakuba, the UNFPA Representative in Liberia, whom I had briefed on the purpose for the visit and who had given me the telephone numbers of several Ministers including the Health Minister. I felt it important to make Mrs Gakuba my first point of contact and we met that evening. During the meeting she mentioned that only that day, she had been given MDG Number 5, (a reduction of 75% in Maternal Mortality by 2015) as a priority and clearly saw us as an unexpected but welcome asset. It transpired that she had briefed Dr Bernice Dahn, the Deputy Health Minister/Chief Medical Officer for Liberia on my visit and during the meeting Mrs Gakuba rang Dr Dahn to say that I was in her office. Bernice’s words were that “I am coming straight over!” I sat and listened as Dr Dahn told me that midwives were washing and reusing gloves; that they were short of so many consumables including Magnesium Sulphate and the difficulties in caring for women in the rural areas. I explained that my intention was to visit, listen, watch and then report back to my charity colleagues. It would then be down to a decision whether to change the charity’s remit to extend beyond Chad. I also explained the process in the event of this happening in relation to the Charities Commission etc.

Saturday 26th January and along with Dr Dahn, I was taken firstly to the Redemption Hospital where I met the senior medical & midwifery staff. They deliver approximately 180-200 women per month and reported serious shortages in almost everything, but again top of the list were gloves, sutures, IV Cannulae and of course Magnesium Sulphate. I arranged to spend the following Wednesday with the midwives. I then visited the JFK Hospital where they deliver about the same number of women. I met Dr John Mulbah, Consultant in Obs/Gynae, Chairman of the Dept of Obs/Gynae and Programme Manager of the Fistula Project. Yet again I heard the same message related to the shortages; however their recorded maternal mortality rate didn’t seem to be as high as 1:8. At both hospitals I mentioned the possibility of UK staff travelling to Liberia in order to assist with training needs. This was welcomed without hesitation.

Sunday 27th January. I visited the ELWA Hospital, a private but not for profit establishment. As I walked in I was met by the sight of a midwife scrubbing a pair of gloves ready for re-use. Women who are cared for at ELWA at pay a small amount for antenatal care and delivery, all of which is reinvested into the hospital. They also deliver around 150-200 women per month. They were having a quiet day, with one new delivery, a healthy mother and baby boy. I sat and talked to Esther a midwife who rummaged in a cardboard box and produced a pack of 10ampoules of Magnesium Sulphate, their only stock. She explained that when it is used, they have to go to Administration, get a slip of paper and take it to the local pharmacy, where they will be given another box.

Monday 28th January. At 10am I was interviewed for the local Star Radio Station which was broadcast that evening. At lunchtime, along with my 2 colleagues, I visited the women in the sewing group. Some saw it as an opportunity to speak to me as a nurse about other health related issues including eye infections and infertility. I had spoken to Mrs Gakuba that morning who had invited me to join her on a 1:1 for dinner in order to discuss the potential for partnership working and how best to access the vital supplies, the absence of which were likely to be causing unnecessary maternal deaths. We spent 2hrs, going through the list of items which should be available to hospitals and health centres, but which clearly were not. Mrs Gakuba explained that there is emergency money available to access items considered vital and that the procurement process should be in place, with the main distribution centre being in Copenhagen. What we agreed is not happening, is a full awareness by those in the supply chain of the impact of not having these items available to clinical staff. The clinical staff no doubt assumed that the stocks were not available to them and therefore took no action. Mrs Gakuba explained that she was going to South Africa two days later and would hand the responsibility for accessing the funds and stocks to her deputy.

Tuesday 29th January was spent catching up on notes and consolidating the significant information I had already collected.

Wednesday 30th January was spent at the Redemption Hospital, where I met Dr Massabory Kamara, the Medical Director of the hospital and Mrs Denise Walsh, the Chief Nurse. Denise is an American who is undertaking this role for 1yr as a representative of the Clinton Foundation. She has, after 5months in the role made significant changes, not least of which was the provision of sheets for the beds and curtain rails/curtains for each bed space. Mrs Walsh was also very interested in the possibility of a training package for midwifery staff. I asked to spend some time in the Labour Ward and arrived just as a healthy new baby was being delivered and witnessed the extraordinary sight of the mother chatting on her mobile phone whilst the placenta was being delivered! In some ways I witnessed the 21st century in action and then in others, it was more like the early part of 20th century. In the post natal area was one woman who had been brought in following an illegal abortion with several perforations of the uterus. She was lucky to be alive.
I was then taken on a tour of the main hospital including the pharmacy & stores, where I saw boxes of out of date drugs which had been sent…. I wasn’t told from where. I was also shown the 4 boxes (about 120 pairs) of sterile gloves, all Size 8 (I use size 6) which was the total stock for the whole hospital. The Emergency Room was full, predominantly of patients with malaria, respiratory diseases and trauma following road traffic accidents. The Sterilizing Dept manager showed me one roll of gauze dressing, about the diameter of a toilet roll but twice as long. This, once he had cut it into a variety of shapes and then sterilized them would be the only sterile dressings available. The laboratory was last on the tour, with one of the technicians explaining that haematology (anaemia) were the only tests they could do because of the lack of equipment. Tests such as cultures for infections and blood chemistry could not be done. They had the technical ability to do them but not the tools!

I sat with Mrs Walsh in her office as children came and went from the nearby school. She seems to have an open door policy.. literally!

I returned to the Labour Ward, this being my main focus, to the sounds of a 19yr old woman with eclampsia thrashing around, a piece of wood like a large lolly stick in her mouth, which had been wrapped with gauze. I was sat about 15’ away from her, behind the ward desk wondering whether any of my midwife colleagues back in Cardiff had ever seen a woman having an eclamptic fit. The midwives were trying to put an IV line in her arm, but she knocked it out and they had no gloves to wear during the whole insertion and mopping up procedure. I had some Tesco’s non sterile gloves in my bag and gave her a pair. Aggie, the midwife explained that her relatives had gone to find money, before trying to find somewhere which could supply the Magnesium Sulphate. The woman was being held down by two of her relatives and Aggie left to go to the pharmacy to see whether there was any of the precious drug in stock. She returned with 10ampoules which had expired in July 2007. My suggestion was that she contacts Mrs Walsh. I remained well away from the patient and sent a text to one of my colleagues at UHW describing what I was witnessing and the feeling of helplessness I was experiencing. She sent a text back offering an alternative but less effective drug but this was not available. I had to leave as I was being collected to make the return journey to our accommodation at the ELWA centre, a journey of about 10-12miles.

Thursday 31st January at 8am… the day when an arrangement had been made for me to speak to Dr Walter Gwenigale the Liberian Health Minister. Dr Bernice Dahn and Choud Walleh accompanied me. Basically, the Minister echoed everything which had already been said about the shortages. When the issue of assisting with training needs was raised, he explained that a new School of Nursing & Midwifery was planned and that they had to try to address the problem of students coming to the capital, intending to return to the rural areas when they complete their training, only to settle in Monrovia thereby leaving a huge deficit in the healthcare provision for a significant number of Liberian women. The Minister expressed confidence in Dr Dahn and thanked us for visiting. I then travelled to JFK hospital in order to spend time with the midwifery staff on the delivery suite. The Labour Room was very busy with 5 women in a row of beds with no sheets or covering of any kind and no more than 10-12” between them. One had not long delivered and the others were in various stages of labour. A male doctor arrived and performed examinations on each woman, with no hand-washing in between, just taking a non-sterile glove for each. The examinations were performed without any lubricating gel as there was none available. He latter was added to my list of urgent needs! One aspect of the care which was in stark contrast to what I was used to seeing and hearing was the way in which the women were being spoken to by the staff. My thought was that it is no wonder women see themselves as being at the bottom of the heap when they are spoken to in this way, at a time when they are at their most vulnerable.

Friday 1st February and I had received a call on Wed 30th from Dr Gakuba’s Deputy, Jeanette Lingas asking me to meet her at the UNFPA HQ at 10am. I was there by 9am as the traffic, which is normally a major problem, was not on this occasion. Luckily I was able to spend 2hrs with Jeannette who was also a nurse and had worked in the very difficult rural areas. We were joined by one of her UNFPA colleagues who had been Dean of the School of Nursing & Midwifery. Mrs Gakuba had left Jeannette one specific task during her absence, that of sourcing the emergency funding and the items most urgently needed. We had a very productive discussion ranging from the speed with which Jeannette could access the urgent money & supplies, to the plans for future nursing & midwifery training and how the UK staff could assist and support training.

Saturday 2nd February. A day off and for me, a mild case of adrenalin withdrawal!

Sunday 3rd February. I returned to the JFK Delivery Rooms. I had promised to return when I was there on Thursday. The room was much quieter. One of the women was in labour but not making much progress. The midwife reached for a scrap of paper, wrote “Buscopan Inj” and signed it. She then gave it to the woman’s husband to go and purchase the drug from the pharmacy. What intrigued me was that as the few women laboured, staff were eating their lunches, others were trying on wedding outfits! The poor interaction between the staff and the women was as I had observed on Thursday.

Monday 4th February. I had planned to go back to speak to Dr Mulbah during a brief opportunity in his busy day but my transport didn’t arrive so I rang him and arranged to E mail him on my return to the UK. He would be in surgery all day on the Tuesday so no opportunity for us to meet. Along with my colleagues, I visited the sewing group. They had asked that I visit them and I anticipated a mini-clinic. The outcome was that I did offer very limited advice to a woman who appeared to show symptoms of having gallstones and another with fertility issues. We left with gifts of beautiful African dresses, complete with head-dress.

Tuesday 5th February and we travelled into Monrovia in order to set up a bank account for the women of the Sewing Group who wished to set up an NGO (Non Government Organisation). This gives them greater credibility and responsibility, thus empowering them. I decided that having heard such a lot about NGOs, observing the whole process of setting up an NGO would be interesting. It was also the day when at 2pm we were due to meet the Deputy Gender Minister Mrs Annette Kaiuw. This role also encompasses Development and we were quick to compliment Annette on her country’s proactive approach to gender based violence, including support teams, posters all over the city and help-lines. We told her that on this problem, the UK had a lot to learn from Liberia. I explained what my remit was in relation to maternal mortality and she was extremely interested and supportive of any assistance we can offer, particularly in relation to the training needs. We returned to our accommodation by 4pm as I was being interviewed for the BBC World Service Outlook programme along with Chuod Walleh whose motivation was supporting the provision of the Magnesium Sulphate so that other families would not have to lose their mothers as his had done. Tuesday evening we hosted a meal for all the people in the accommodation, who had helped us in any way during the visit.

Wednesday 6th February. After packing our cases we made a final visit to the village where the women live and hold their sewing group. In the village I met an 80yr old woman whose daughter died of eclampsia in 1990 leaving 10 children for her to look after. At 4pm we left for the airport, unaware of the very difficult journey home which lay ahead of us, but content that people’s lives could potentially be changed by our visit, not least of which were our own.

SIGNIFICANT INDIVIDUALS.

1. Dr John Mulbah… Described by Mrs Gakuba as a man of great dedication, honesty and integrity, who has turned down the opportunity of a lucrative post within the UNFPA because he wished to stay with his patients. The staff and his patients clearly love him and have composed a song to him. He assured me that if we do decide to support Liberia, then he can and will account for everything. The mention of his name brought nothing but smiles and compliments. He appears to be the Liberian “Grace Kodindo.”
2. Dr Bernice Dahn… In the event of a decision to assist Liberia, Bernice would be crucial in ensuring that resources are distributed appropriately. Bernice informed me that 2 doctors had been dismissed from one hospital because they had been found removing items which did not belong to them.
3. Mrs Denise Walsh…Is keen to assist us with any initiative to address maternal mortality, including minimising the “red tape” involved in getting any medicines or equipment into the country quickly and in setting up a training programme for midwives. Denise is 5months into her 1yr post in Liberia.
4. Mrs Rose Gakuba…Very enthusiastic about working with us and as you will have read, set the wheels in motion to obtain emergency money and supplies to the 3 hospitals I visited.
5. Chuod Walleh… Is Head of the Institute of Career Studies (ICS) and Head of an NGO. (I have photocopies of the official documents.) He has offered to be the person on the ground, who would ensure that anything sent to Liberia is collected and handed to the named individuals. He has significant contacts within the UN and other organisations which could be of use to us. His personal experience is clearly the driver for his desire to assist.

SUMMARY & RECOMMENDATIONS.

The visit was a positive experience, underpinned by the real desire to improve what is currently a service in crisis for pregnant women. There is very visible evidence of a country in recovery, including the booming construction, the return of Liberians from neighbouring countries, more airlines flying into Liberia, an increase in piped water, the new TV stations and the opening of stores, restaurants & supermarkets. This evidence, combined with a strong leader and the presence of a group of individuals who will take responsibility for any support given, means that I have no hesitation in recommending that we in HFGK change the Charity’s remit to include Liberia/SubSaharan Africa as requested by Dr Ouedraogo from the UNFPA in his E mail of May 2007.

ANGELA GORMAN 1st March 2008.
Chairperson Hope for Grace Kodindo Reg Charity 1116785.
www.hopeforgracekodindo.org