September 2013 archive
Dr Achem came to see us off from the Gombe Jewel Hotel:
and headed straight back to his busy antenatal clinic. We really were so very grateful for all of the support he and the Society of Gynaecology and Obstetrics of Nigeria had given us throughout our stay. Luckily it was ‘goodbye’ for only a few weeks as we would be seeing him again in Addis Ababa at the FIGO conference in early October. We’ll be looking forward to that!
Dr Adeoye agreed to do a short interview outside the airport terminal as Ross went ahead to start the paperwork battle inside! He spoke about the importance of maternal death reviews to improve care. When deaths are recorded not only in number and location but also in terms of their clinical context, lessons can be learned and standards driven upwards.
As I walked through the VIP lounge I let out a huge sigh. So much money in Nigeria, clearly. Not shared among very many. What huge healthcare reforms could be made with the amount of cash on display in the lounge and on the apron.
And so after the usual paperwork fiasco we set off for Port Harcourt.
We could tell when we were getting close as we came across oil facilities!
The tower at Port Harcourt encouraged a round-about route into the airport, somewhat frustrating as there didn’t seem to be any other traffic around. As we eventually entered onto final approach the plantations below were the biggest and the greenest I think I have ever seen!
Our security was waiting to escort us to the Shell Residential Area. Shell were to be our hosts for the next 2 days. Security was to be extremely tight because we were ‘High Value Targets’ for kidnap. Infact, we only realised afterwards that the Archbishop of Port Harcourt had been kidnapped the previous weekend…
We settled into our very comfortable lodgings and met the Shell medical team for dinner. There were to be an exciting 2 days ahead!
A relatively relaxed start to the day (neither of us had realised quite how much we needed a bit of extra sleep!) was followed by a short drive to the Sudanese Embassy. We’ve been trying to get our visas ahead of time so that the chance of an immigration problem when landing in a new country is minimised! Our medical friends in Sudan had written especially via the London embassy to facilitate our visas in Abuja! One less weight off our minds!
Next we dropped by the Wellbeing Foundation Office to meet the Executive Director Mr Temitayo Erogbogbo and to discuss our visit to Ilorin, the patient held maternity record that the Foundation have developed for continuity of patient care and information, and the delivery kits which they hope to disseminate within Kwara State. Oh – and they asked us to sign our FEM poster!! We promised to be in touch for continuing discussions about maternity issues in Ilorin and Kwara State.
Dr Achem suggested that we also made a visit to an out-of-town maternity, and for this he chose Nyanyan in a densely populated Southern Suburb. We were joined for this visit by Lilian, a journalist from the Nigerian Guardian Newspaper, and who was keen to interview me about Flight For Every Mother. As we turned off the highway and onto the non-tarred roads the traffic really started to build, partly due to a huge open-air market paralleling the road. We tipped a motorcyclist to show us the way. After briefly explaining the purpose of our visit, we shown around.
Unfortunately, a teaching session wouldn’t be possible today! The pre-labour area and labour area were housed under one roof, the antetnatal and postnatal under another.The unit was very compact and busy but was clean and seemed to functioning efficiently. The midwives were very happy with our midwifery kit donations.
Lilian was keen to make the most of the market before going back to town, and so she conducted my interview in the back of the car in a side street! There were a few distractions, but not too many!
And so we drove back to town. Through the market area, back onto the highway (luckily against the traffic), past the presidential palace and military barracks, the main mosque and back to our hotel, the Gombe Jewel. To await Dr Achem’s return from Lagos and our second ‘Point and Kill’ of the trip!
I had first visited the University Hospital, Gwagwalada in February 2013 when I was teaching in Abuja with the LSTM. On that particular day, I remember frantically typing my lecture for the Gynaecological residents on ‘renal disease in pregnancy’ in the car on the way to the hospital. Luckily for me it was a relatively long ride out of the (new) city centre to the (old) centre of Gwagwalada, where most of the medical education is carried out.
Dr Adeoye and I had a similarly long drive this morning, including a hold up at the obligatory road block for vehicles entering Gwagwalada. If only we hadn’t been running late, it would have been quite a relaxing drive as my presentation was ready to go!
The residents welcomed me warmly, but asked me to hurry up a little so that they could attend to their morning clinical activities! And so to ‘maternal collapse’ in less than 15 minutes! The post-lecture questions centred around the estimation of blood loss at the time of delivery – frequently underestimated by doctors and midwives – and the use of the ‘anti-shock garment.’ The latter is a relatively new ‘tool’ that I have had little experience with, but which was rated highly by this group. It is a full body suit that directs blood from the extremities to the internal organs in the case of blood loss to ‘buy time’ and allow transfer to a more comprehensive health facility or to the operating theatre.
Next stop was the School of Midwifery – on the same hospital site but quite difficult to find! Luckily by getting slightly lost we passed the donut stall! The Midwifery Principal was busy with an unexpected visit from her Director and so after a little bit of polite persuasion on the part of Dr Adeoye the Vice-Prinicpal agreed to ask her midwifery-teacher colleague if we could interrupt her students’ practical lesson.
The students found the story of Flight For Every Mother very inspiring and treated me like some kind of celebrity! They were asking very pertinent academic questions too including how to manage a woman who was bleeding post-delivery who refuses to accept blood products on religious or social grounds which showed to me they were really listening and thinking through the issues. Practically they did very well too and enjoyed the simulated scenario. Could I not leave my mannequins with them to continue to practice? How I wish I could have!
When Dr Adeoye finally were able to pull ourselves away we couldn’t believe how many pleasant hours we had spent with that great group of young girls!
We left Ilorin bright and early with our Well Being Foundation host Dr Luther King Fasehun as the former Governor was in town and there was concern about the effect his visit would have on the town's roads!
We soon left urbanisation for countryside again and crossed the River Niger:
and before too long were approaching Abuja, clearly a busy airspace!
“Expedite from the runway, traffic behind!”
What a busy airport, FULL of private jets!
After a delay on the apron and a ramp check (thank goodness our papers were in order!) we made our way through the VIP lounge to Drs Achem and Adeoye from the Society of Gynaecology and Obstetrics of Nigeria who were waiting! They had with them a delegation from the Nigerian Women’s Society who even managed to talk themselves back onto the apron to look at our aeroplane and so that we could pose for more photographs!
They were very vocal about the need to empower Nigerian women and hold their health status in higher esteem. Here here!
And so after a world-class welcome we arrived at our hotel in town and for ‘point and kill’ (the famous Abuja catfish dish) and to prepare well for a busy day to follow!
I spent the entire day in my pyjamas! It is amazing how tiring and all-consuming our journey was becoming…
The midwives at the Civil Service Clinic in Ilorin were very keen for clinical skills training; infact, they had been waiting for our arrival already the day before (but the customs in Lagos had put that plan on hold!).
While we were waiting for the group to gather, we had a look around the small maternity unit:
This lady had had a caesarean section the previous day for obstructed labour and was doing well, recovering in a small room with one other patient who was herself further on in her caesarean recovery and due for discharge. Note the mosquito nets on the windows as malaria is a real risk.
The delivery room was one of the more private we had seen on our travels; luckily this unit was able to manage with 2 delivery beds, each in a separate room.
Today’s teaching was challenging for me in that I was without a projector for my slides and using only a whiteboard and markers as aids. So lots of concentration was required but I managed! Maintaining order during the practical was also a challenge with very animated discussions in particular about issues such as who (doctor / midwife?) should perform cannulation in a emergency where staffing of all cadres are stretched. There was also some upset that I had not provided pens, notepads and handouts for each participant. Maybe there was less forgiveness than there would have been if I had been able to project a photo of my aeroplane? I wouldn’t make that mistake in Nigeria again!
After a quick lunch, we headed to the Kwara State College of Nursing and Midwifery across the other side of town. Approximately 100 second and third-year midwifery students and their tutors were anxiously waiting (we seemed to be late – not my responsibility!!) and all stood up from their chairs as we entered the lecture room. The students were incredibly smartly dressed in white. ‘Fake blood on white uniforms’ did cross my mind!
It was a very formal affair with faculty introductions prior to the session. As we progressed through the talks, there was a lot of surprise about the discrepancy in maternal death rates between my home country (the UK) and Nigeria. What is being done to change this? What help is being offered?
There was much interest in the fact I have managed to train in Obstetrics as well as flying especially given that fact that I am a woman.
I can’t remember exactly when I took part in my first simulation training, but for sure it was as a medical student. These students were part of such a session for the first time. They found it hilarious and most recorded it on their mobile phones!
The debrief demonstrated that for sure they also took some clinical lessons home!
We ended with a prayer lead by the nursing principle. Interesting, this was a Christian prayer even given the predominantly Islamic audience. I do enjoy the fact that in so many West African nations, and even within some States in Nigeria while there is trouble in others, the two religions are very tolerant of each other.
I was mobbed on my way out. Every student wanted to’snap’ with me! A nice feeling in a funny kind of way. I don’t think they would forget me in a hurry, and hopefully not the main messages of my teachings about maternal health either.
We did our final training session at the ‘Hopital de Zone de Suru-Lere.’ This was a district facility on the outskirts of the city and chosen for my visit by the Ministry of Health. They have 120 deliveries per month and 4 full-time Gynaecologists.
After our session on Ventouse extraction, the participants asked that I push the Ministry of Health for the necessary equipment because they had none at all. Not for the first time, how I wished I could gift those specific things needed to each facility I visit.
I managed to persuade Professor Alihonou to star in a short piece of video for my blog. We chose a location in front of the board at the hospital entrance detailing all of the medication prices for patients. He spoke about the importance of free/minimal cost healthcare for pregnant women, which is unfortunately not the case in Benin. Many women present to the healthcare facilities late, or not at all, if they are experiencing pregnancy problems and if they do present they often struggle to raise the funds necessary for their treatment. I find it difficult to conceptualise the restriction of emergency medications until they are purchased. Any kind of time delay with conditions such as severe infection, or postpartum haemorrhage, can easily lead to unnecessary loss of life.
On our way to the airport, we stopped briefly at both the Ministry of Health:
as a courtesy to say thank you for their support for my visit and to the World Health Organisation office, where there was much intrigue as to the practicalities of Flight For Every Mother!
Protocol is paramount in West Africa as I had experienced time and time again.
I negotiated the airport relatively seamlessly. Luckily for me, Ross had already been hard at work sorting out all of the formalities! I found him being hosted on a private jet, so it wasn’t all mundane for him!
And so to Nigeria.
The take off was beautiful, turning left to fly along the coast:
It took less than an hour to reach Lagos, where we had to stop to clear Nigerian customs before flying on to our final destination of Ilorin.
We were excited about our visit to a ‘proper’ gate:
But the excitement soon passed as the customs formalities took the best part of 3 hours. Even the tower were getting frustrated (because we were blocking one of the gates!!)
Finally we left:
grateful that we were up in the air and not on the roads of Lagos:
Thankfully we arrived just as it was becoming dark:
We felt a little like celebrities as the Wellbeing Foundation met us in the terminal, capturing every last detail on camera.
Now we were in Ilorin, Kwara State.
A bright and early start at the ‘Clinique de gynécologie et d’obstétrique du CNHU de Cotonou, Bénin’ saw my teaching programme delivered in French, including the simulated Obstetric haemorrhage with a delivery-suite midwife as the patient. My change from the patient role to facilitator worked well, and meant that I could be on-hand to guide and to prompt the scenario as necessary.
The Professor, of course, was on-hand to help with clarifications, particularly in French! All in all it was a fruitful session with lots of discussion.
We had a short tour around the facility afterwards:
Of note, the only aspect of maternity care that is free to pregnant women in Benin is a caesarean section. Perhaps some of those caesarean sections become necessary because the women present late to the hospital because they can’t easily pay for treatment.
The afternoon saw a visit to a secondary facility; there was much angst here during post-teaching questions about the intense political impact on maternal health and the limited environments in which the Obstetricians and midwives find themselves because of this. Desperately sad, especially given the apparently limited outside help and influence in the maternal health domaine.
Both hospitals were pleased with our donations.
In the evening, Professor Alihonou treated us to a fish dinner. He really seemed intrigued by my passion and believed in it!
Let’s not mention the post office. Just to say that I spent several hours on the way to the airport to pick up what turned out to be the most expensive jar of Nutella ever to save the sanity of my fellow pilot! Hmm…I’ll have to look for pay back!
Accra was an interesting airport. The authorities believed that I could carry 7 bags myself without a trolley despite paying over-the-odds for handling; my passport, however, didn’t need stamping! I arrived at the aeroplane intact but significantly lacking in humour. We could only move forwards from here!
Arrival in Cotonou was delayed, but nevertheless our hosts where waiting: Professor Alihonou and his friends from the Ministry of Health. We were whisked off directly for a meeting with the Dean of the Medical School, followed by a lecture to the postgraduate residents in Obstetrics and Gynaecology about the motivations and cause behind Flight For Every Mother:
French was back to challenge me! But I would battle through. To me, the inclusive nature of Flight For Every Mother is key.
Korle Bu Teaching Hospital was on today’s agenda, and concern about Accra’s traffic necessitated a 6am departure! I’m not so fond of very early starts and we seem to be having a fair few of them….
I arrived at the hospital with plenty of time to spare before the morning educational meeting to which I had been invited at 8am. As I got out of my taxi, I was again reminded of the strict behavioural expectations of the Ghanaian people – I bent down to pick up my many bags (equipment donations) and apparently a little of my back was exposed as my T-shirt rose slightly. And a lady passing by shouted at me firstly in her local language and then in English about how indecent I looked! Add this to the shoe situation of the day before, an occasion of standing when I had been invited to sit, various discussion about what was and what was not appropriate to wear on national TV and Ross not finishing his breakfast, and I was starting to feel somewhat uncomfortable in the city!
After a grilling by the maternity security, we together found the head of department. I was beginning to understand that an often suspicious and somewhat cold exterior seems to give way to a lot of friendliness and helpfulness.
The Professor and I had an interesting discussion about several interlinked Obstetric issues. First of all about equality of care across Ghana: up until 1990 there was apparently no Obstetrician/Gynaecologist at all in the Northern part of the country. Even now, a huge divide exists in terms of the number of skilled practitioners inside, as compared to outside, Accra, despite more medical students qualifying from within Ghana and postgraduate studies available in Accra rather than having to travel overseas to specialise. Doctors and midwives prefer to remain in the city for personal social and economic reasons rather than to serve the rural, less populated areas.
This lead on to discuss the topic of maternal mortality, which is of course affected by the number of skilled practitioners and their location in relation to the women needing pregnancy care. The numbers and rates of deaths are vastly different between Accra and the rural areas. It was his belief that deaths should be at a minimum in the areas served by Korle Bu and to this extent there had been no deaths from Obstetric haemorrhage for at least 2 years (haemorrhage is, overall, the leading cause of maternal death in sub-Sahara). Korle Bu publish their maternal health statistics on a biannual basis which is a very sound way to learn clinical lessons and to drive up standards of care.
The clinical meeting and a guided tour by the matron followed. There were four full floors of inpatient care, rotating as per day of the week for admissions, and two labour wards. Some of the wards had been sponsored by the families of women who had died there. Overall, an extremely busy and large maternity unit. But it seemed well staffed and equipment levels and quality pretty sound. I also found the first CTG machine (for looking at the fetal heart rhythm in utero) of my trip.
I spent the next few hours on the labour ward shadowing one of the residents in the ‘high risk’ area. This was an experience of mixed emotions and I left a little unhappy and frustrated. For me, egos and lack of teamwork had got in the way of good clinical care despite the best physical labour ward environment I had experienced so far in West Africa.
And so to town, and The Maternal Health Channel – a Ghanaian initiative headed by the brilliantly spunky Kwesi. Once a week during prime time they have a 30 minute TV slot to publicise and discuss female reproductive health issues., together with a radio and social media presence with followers on Facebook alone. We agreed that women are only just realising how unjust the inequalities of maternity care in Ghana, and beyond, are. We had a really stimulating discussion about so many issues, and agreed what a shame it was that we were leaving for Benin already the following morning so that we couldn’t make a Northern excursion together. There would have to be a next time!