Background To Visit

In preparing this report, I am assuming that the recipients have received the first report, which was circulated following my initial visit to Liberia in January 2008. The purpose of the first visit was to gain an understanding of the country’s situation following the civil war, which ravaged the whole country, its effect on the infrastructure of health provision for the Liberian people and in particular for pregnant women.

The conclusion following the first visit was that there is a need for sustained support of all types, in particular the provision of:-

· medicines to treat pregnancy related conditions

· education & training for midwives and if possible medical staff

· basic equipment such as fetal monitors

· trust/communication/governance/accountability between individuals in both partner countries.

At the conclusion of the visit, I was confident that we in HFGK could begin the process of providing as much of the above as possible, within the available resources and with the support of UK based organisations. These include pharmaceutical companies and in particular the Welsh Assembly Government. My recommendation to my charity colleagues on my return was that we extend our remit to include Liberia and this was agreed.

OBJECTIVES & STRATEGY FOR CURRENT VISIT.

The purpose of the latest visit was to address in more detail the issue of training, build on relationships established during the previous visit and to obtain specific data on the future requirements of medicines so that a regular supply would be provided to named individuals and appropriate reporting on usage relayed to us as requested. To those ends, I was accompanied by a Sarah Davies, a practicing Senior Midwife with 18yrs experience including working in the developing world and Senior Sister Serena Woodrow-Clark a neonatal colleague of 15yrs experience along with significant first-hand knowledge of many countries in Africa.

Monday 5th May We arrived at our accommodation at about 6am and after a couple of hours sleep, we visited the local school. Several gifts had been given to us to pass on to the children, so we decided to make this our first commitment. We knew that what we carried in our bags would bring great excitement as some items such as bubble mixture would never have been seen before. We had taken 2 globes, items such as materials for artwork, crepe paper, crayons and lots more. Everything had the expected response with squeals all around, including from us! From the Daniel the Headmaster the greeting was “You came back” and then explained that many people visit and say that they will be back and never do. We spent a long time with the children and then returned to our accommodation before visiting the women’s sewing group in the afternoon. Again, the greeting was “you came back!” These women, all of whom knew or were related to someone who had died in childbirth are trying to lift themselves and their families out of poverty by learning to make simple garments and selling them. They are being supported by a group of women based in Swansea and again I had carried items to them from Wales.

Tuesday 6th May was spent visiting 3 hospitals, JFK, Redemption & ELWA. Our group comprised of Sarah, Serena, Chuod Walleh our significant contact in Monrovia, Lorpu Sherman a senior midwife who is currently working with the Liberian Government and me. As we went to each maternity unit, Lorpu collected figures on the number of women suffering with eclampsia each month so that we could establish the Magnesium Sulphate requirement for each hospital. It was agreed that Sarah & Serena should visit the clinical areas before the teaching began, as not having an awareness of the resource poor environment within which the midwives worked, would be an obstacle to the impact of the training. They needed to know what is, or more significantly, what is not available to the staff. Some of the midwives remembered me from the first visit and I was greeted with “you came back!” I quickly realised that they also had been visited many times by people/organisations promising help and return visits, which never took place. In JFK Hospital, we saw two babies whose mothers had died. One baby was delivered prematurely when his mother was brought in following a road accident. Incredibly this baby survived despite weighing less than 1kg and needing only ambient oxygen in the incubator. However the incubator was not switched on, the doors were held in place with sticky tape, and one tube entering at the back, delivered oxygen via a condenser. The other baby’s mother had died as a result of eclampsia, complicated by a heart condition. The staff were very concerned about the fact that they had little in the way of formula milk for both babies as the WHO has very strict rules on the availability of formula milk, because of poor hygiene/water quality in preparing the feeds leading to severe gastro-enteritis. This was a real dilemma for the staff who also commented that families will often ignore the instructions and make up the feeds in a more dilute form in order to make the feeds last longer and save precious money. Clearly little thought has been given worldwide, to the needs of babies whose mothers do not survive, for whatever reason and where there was no other source of breast milk. All we could do on a practical basis for these two babies at that moment was to offer lots of the baby clothes which we had brought from the UK.

Wednesday 7th May Midwives had been invited to the workshops by Chuod Walleh on our behalf from 4 hospitals, through their individual Hospital Administrators. The events were to be held in Redemption Hospital and we were directed to an external storage area, open on one side and approximately 10-15yards from the mortuary, which significantly was adjacent to the Obstetric ward. After the welcomes, we held some group work so that the group would get to know each other. Questions such as “What do you enjoy about your job/what frustrates you about your job/what would help you to do your job better and what topic would you like more training on?” The midwives didn’t hold back and predictably what frustrates them is not having the resources such as Magnesium Sulphate & Ambubags available. Again and predictably, the same answers arose from each group. The skills training began with Sarah Davies leading group work where the management of Eclampsia and Post-Partum Haemorrhage were discussed. The rapport between the midwives and our team increased and improved as the day progressed. One issue which arose and was the source of great concern to the midwives was the major problem of pregnant women being attended by TBAs, (traditional birth attendants) who fail to see when a woman needs to be transferred to hospital until it is often too late to do anything for her. We had agreed prior to the visit that we would fund a substantial meal for them and reimburse travelling expenses. Two midwives had travelled 45miles to attend and had stayed overnight in Monrovia. I had been given a sum by a company as an individual and decided to use some of this to fund the food and expenses. The day ended at 4pm and all who attended appeared to have found the day very informative.

During the course of the day, we learned that a woman had been brought into hospital having suffered eclamptic fits at home. She died soon after arrival and was taken to the mortuary as we sat in the workshop. A second eclamptic woman had died that day. What we didn’t appreciate at that moment, but discovered two days later was that there was a small supply of Magnesium Sulphate available, but that the overall management of the women appeared to be inappropriate, leading to some of the deaths. The body of another woman lay in the Obstetric Ward amongst the labouring women. She had undergone an illegal abortion, developed an overwhelming infection and died.

Thursday 8th May and the second day started with Sarah explaining the benefits of a Partogram, a large chart which displays the progress of labour in an easily understandable form. A Partogram is currently being devised for use in Redemption Hospital. The next topic dealt with Shoulder Dystocia a condition in which the progress of the baby’s shoulders through the birth canal is obstructed by one area of the pelvis. We had borrowed a very old and well used baby and plastic pelvis from our own hospital which enabled the training to be brought to life and lifesaving manoeuvres to be described in graphic 3D! I now know what a McRoberts manoeuvre is! They enjoyed their lunch and the rest of the day was spent discussing neonatal resuscitation led by Serena. It was clear that some of the clinical practices may have unwittingly contributed to neonatal mortality and morbidity rather than improved them. All the information and advice we gave was accepted in the spirit intended, but as the two days concluded it was evident that the midwives themselves realised that their education needs were significant. I had devised a simple evaluation form and they willingly completed them, asking for further workshops for up to 2-3weeks, to extend the training throughout Liberia, covering topics which had been discussed during the event in greater detail. (I have brought the forms back with me). The midwives left having made new local contacts, with all their expenses paid for them, gifts which we had brought including Midwife Resource Packs, Stethoscopes and having enjoyed a nourishing meal on both days.

During the course of the two days, I was additionally involved in discussions with the Senior Pharmacist John Harris who has been given the responsibility by Denise Walsh for receiving and recording the usage of any medicines which we send. John has taken on this role willingly and with overwhelming enthusiasm and as I sat next to him at the computer, he explained in great detail what information he will be sending us via a spread sheet. He has agreed to distribute resources in the form of medicines to named individuals at the other two hospitals, only on the basis of clear record keeping and accountability. Chuod Walleh is also going to be involved. Records will be sent to us, as often as we request them. Any staff we send in the future will be at liberty to undertake checks on the stocks and records. At this moment I believe that we have made this as sound as we possibly can and will have to review the system as it becomes live. The completed spread sheet was on my computer before I had arrived home along with a set of very strongly worded guidelines on the procedure for requesting Magnesium Sulphate for each patient and the consequences of any abuse of/the use or sale of donated medicines.

Friday 9th May We had decided that having undertaken the training, it would be useful to see the midwives at work, so we returned to Redemption Hospital to find an eclamptic woman with a BP of 200/140, whose baby had already died. The woman was at great risk of suffering a cerebral haemorrhage and death but was refusing to have a Caesarean Section. She had received Magnesium Sulphate and another drug to lower her BP but what the midwives failed to realise was that administering these drugs is only one part of managing eclampsia. Their understanding seemed to be that this was all that was required, with no further monitoring etc. needed. Sarah was asked to advise them on the woman’s management and her detailed advice and instructions were taken without question. On reflection and based on what we were witnessing at that moment, it was likely that the woman who had been brought in on Wednesday and died, had been given the medications and then sent home where the BP began to rise again and she began fitting. Denise Walsh, the hospital’s Chief Nurse had obtained older model fetal monitors from the USA and Sarah undertook training in their use, giving two happy mothers the opportunity to hear their babies’ heart rates.

We called to JFK Hospital to deliver a large number of clothes for the two babies whose mothers had died and spoke to the staff caring for them. A further four babies had been admitted to their NICU since our first visit although they looked in good condition indicating that their stays were going to be brief. The standard of the equipment including suction units was poor.

From JFK we travelled to an orphanage where 30 children ranging from 2yrs to teenagers put on a show for us with lots of singing and a short play depicting the “Wisdom of Solomon”. As we left the orphanage and in what seemed like a matter of seconds the sky turned a menacing shade of grey and the first spectacular storm of the wet season began.

Saturday 10th May All agreed that some rest and recuperation was badly needed and lots of time was spent reflecting on the very busy week, possible future workable plans and the next steps on return to the UK. The women in the sewing group had, despite their meagre incomes, generously invited us back to eat with them in the evening. Items which had been made by the women to be brought back to the UK for sale and reinvestment in their group were handed over to us, including 30 kaftans.

Sunday 11th May Sarah & Serena attended a church service, where Lorpu Sherman was crowned Mother of the Year. I had intended going but woke to find that overnight, a mosquito had bitten me on my left eyelid, causing it to swell to almost closure and throb to the point where I only found relief in sitting with ice on my eye. We were due to leave later that day and luckily I had packed most of my belongings. It was noticeable that our bags were considerably lighter for our return journey!

OBSERVATION/COMPARISON OF CHAD v LIBERIA

IT IS WORTH REITERATING, AS PART OF THE OVERALL EVALUATION OF THIS VISIT, THAT THE SITUATION IN LIBERIA IS VERY SIMILAR TO CHAD IN THAT MANY OF THE PROBLEMS LEADING TO MATERNAL MORTALITY/MORBIDITY ARE FOUNDED IN EXTREME POVERTY. HOWEVER, AN ADDITIONAL ISSUE IS THAT CHAD HAS A VISIBLE PRESENCE OF MEDICAL STAFF IN THE MATERNITY HOSPITAL AND THAT ONCE GIVEN THE PRECIOUS MEDICATIONS & OTHER RESOURCES, THE WOMEN ARE KEPT IN HOSPITAL WITH THEIR BLOOD PRESSURES MONITORED UNTIL DELIVERY LEADING TO A SPECTACULAR REDUCTION IN THE MATERNAL & NEONATAL MORTALITY RATES. (14% IN 2005 REDUCING TO 2.3% IN 2006 FOR MOTHERS & 23% REDUCING TO 7.3% FOR NEWBORNS.) IN THE CHADIAN CAPITAL’S MAIN MATERNITY UNIT AT HGRN, THE MORTALITY RATE HAS NOW REACHED AND EXCEEDED THE UNITED NATIONS MILLENNIUM DEVELOPMENT GOAL NUMBER 5.

CONVERSELY, IN LIBERIA THERE IS AN OBVIOUS ABSENCE OF MEDICAL STAFF, CAUSED BY THE PROTRACTED CIVIL WAR. THIS MEANT THAT MEDICAL TRAINING CEASED WITH NO DOCTORS BEING TRAINED SINCE 1990. THE CONSEQUENCE OF THIS DEFICIT IN THE NUMBERS OF MEDICAL STAFF IS THAT MIDWIVES HAVE, BECAUSE THERE WAS NOBODY ELSE AVAILABLE, TAKEN ON EXTENDED ROLES AND DECISION MAKING, WHICH IS NOT BACKED UP BY CLINICAL KNOWLEDGE. BASICALLY THEY HAVE DONE THEIR BEST IN EXTREME CIRCUMSTANCES. THE MOST OBVIOUS EXAMPLE IS THEIR MANAGEMENT OF ECLAMPSIA WHERE IT SEEMS THAT THEY VIEW IT AS A CONDITION WHICH IS DEALT WITH BY GIVING MAGNESIUM SULPHATE, PLUS PERHAPS ANOTHER ANTI-HYPERTENSIVE AND THEN, AS WE WITNESSED, SENDING THE MOTHER HOME.

CONCLUSIONS.
1. There is an obvious need for a sustained provision of lifesaving medicines, most significantly Magnesium Sulphate.

2. The training of midwives in the delivery and monitoring of the effects of the above medicines is crucial to outcomes.

3. The training of midwives and medical staff in the management of clinical procedures for both mothers and newborns needs to be undertaken on a regular and consistent basis. Where and when possible the training should be extended beyond the hospital environment.

4. The provision of basic equipment within available resources should be explored including approaches to appropriate companies.

5. The procedures in place for accepting, recording and distributing the medicines are already as robust as can be expected. I am confident that any unforeseen problems in that regard can be solved with little delay.

RECOMMENDATIONS.

1. That education and training be given the highest priority within the resources available. Ideally, having suitably experienced individual/individuals in the country on a longer term basis would provide the most cost effective and consistent training.
2. That we seek to maximise all resources available as listed above.

ANGELA GORMAN 18TH MAY 2008.