Monday, 31 May 2010

A shift on Delivery Unit Government Hospital

These are just the facts of what I observed on one short shift at the Makeni Government Hospital.
I arrived having seen some of my students providing antenatal care. I asked to go to the delivery unit to see how things worked - there were none of my students working there at the time.
A woman had just given birth vaginally to twins. I was not present at the birth but was there to witness a haemorrhage following the birth of the placenta. The floor was covered in blood - I've not seen so much in all my time as a UK midwife. The woman was tipped head down on the rusty old delivery bed - an infusion of syntocinon was put up and an injection of something that I did not get to read the label of the phial. The newly delivered woman was lying on a blue plastic sheet and I worried that she would slip off the delivery bed. Her legs were propped up on the bed by means of a chair that was wedged ontop of a portable set of steps. The whole thing looked incrediably dangerous. The clots were being expressed manually as she continued to trickle - the bleeding was by now less. Her Hb was done and was around 6.4 having had a booking Hb of 9 - so she had probably lost a significant amount of blood. There is no banked blood transfusion service in Sierra Leone - so relatives had to be traced to see who had the same blood group as this woman - as she had been prescribed 2 units - relatives permitting.
I wondered about the twins - the first a girl had lived and was wrapped in a cloth and left at the side of the delivery room - which was also the office, and place where staff got changed, put their bags and washed their hands in a bucket as there is no running water in the Government Hospital. The second twin a boy - born by breech died during birth - he looked like a fresh stillbirth to me. There were no signs of maceration - only bruising to his legs as I understand he was a footling breech. He was wrapped in a cloth too - and put on a table where everyone who came into the delivery room passed by.
Through a small curtain there is another room about 10x10 foot square with 3 really old rusty birth beds - just metal the rubber mattresses have long gone. Very dirty and one sink without running water. There were 2 other women in this small progress room. One woman had been in labour for 2 days and had transferred from another area. It was her second pregnancy - the first baby was born by cesearian section (classical) and had died at birth. This pregnancy the decision was made that she required a cesearian section too. I went into theatre. A nurse did the epidural (yes epidural) and the doctor proceeded to do another classical cesearian section. I can't recall any written consent or explanation being given to the woman. I also do not recall any form of intravenous fluid being administered. The baby's body was delivered (no fetal heart was listened into prior to the cesearian section)then part of the placenta came out of the abdomen with what I could see - a snapped cord with the head still in the uterus. It seemed like forever before the head was birthed. It came out like a cork from a bottle. The baby was covered in meconium and was flacid. The many staff present in theatre started to clean down the baby but at this stage no attempt was made to do a full resucsitation. Eventually an old dirty bag and mask was taken out of a cupboard. At this stage I instructed the operator of the bag and mask to bring the baby's head backwards and lift up the chin to get a clear airway. (I know what I will be teaching). There were 8 people round the table where the baby was - no one came back to the mother to let her know they were having difficulty with the baby. I felt for a heart beat and told the personnel around the table that it was 40 beats per minute. At this stage I felt the need to leave - I went back to the delivery room. I could see this baby was not going to make it. The staff brought the baby back into the delivery room - where they all thought the baby had recovered. I explained that the baby was taking its last gasps before she died. The oxygen is only obtained by means of a concentrator and the electricity is only put on for operations - then it is switched off.
When I returned to the delivery room I found the twin woman still in the same place awaiting blood from her relatives. In the progress room all 3 beds were full. 2 women birthed in that room - no curtains or privacy - within minutes of each other. The first baby had a urinary catheter pushed down its nose and throat to 'clear the airways' that did not need clearing. I asked the midwife (the only midwife on duty) to stop - the so called resucistation was very rough - the baby being held by its feet and in my opinion being hit rather hard. The second baby only had the urinary catheter pushed down its nose and mouth and was not subjected to rough handling. Both babies were not given to their mothers but put on tables in the delivery room where the twin mother was.
The third mother in the progress room - it was her first birth - witnessed the 2 births and looked terrified - no one reassurred her - I tried but she did not speak english and just looked terrified knowing she would be next. I understood there were 2 more women waiting in the courtyard in labour waiting to come in.
At this point I left.
Now that there is free healthcare for pregnant women, lactating women and under 5's - many women are coming to the Government Hospital when perhaps previously they would have birthed at home with TBA's. This is one way of stopping TBA practice but with only 95 midwives in Sierra Leone, births are being done by nurses, aides and others. There is a new Government Hospital being built - which is great - but without the staff to support all the births and provide a safer outcome - it is all going to take time. 60% of maternal and child health care is now free and the remaining 40% is provided by charities/faith hospitals - but they charge a small fee. I understand that these charity/faith hospitals are not busy now and one I know of is closing for a short period. If the charity/faith hospitals were paid to provide care - centrally - this would alleviate some of the pressure the Government Hospital are currently facing. The staff said they were exhausted - they have been on the go since the free health care was introduced on 27th April.
I will follow up the outcomes of the twin mother and the cesearian section mother when I next go to the Government Hospital.
The midwifery students return to classes 7th June.


  1. What a daunting day. Explains a lot about the mortality rates. Education is the key but where do you start to get it out there and replace the tradition and superstition with current knowledge when conditions are so basic? Any of these government bods ever consider the effects their bold pronouncement was going to have on an unprepared system? Probably not many women in charge at that level. Hope you find some working solutions without letting the situation overwhelm you.
    Much love, Jane XX

  2. That's pretty grim reading, Alice. Do you reckon these staff would be able to give decent maternity care if they had fewer patients, or is the problem also that they are poorly trained on top of being exhausted? Human resources seems to be the massive sticking point in so many countries - a lot of people talk about the need to increase facility delivery levels, but this kind of report is like a warning sign! The right answer is really not obvious though - in Bangladesh, 85% of births are at home, but maternal mortality is 'only' 320 / 100 000...


  3. Hi Alice. Needless to say I've been following your blog religiously. This post makes for hard reading, so I can't imagine what it was like to witness. Chin up. You're doing an amazing thing and you'll be making such a big difference now and for generations to come. All our love, Sam, John & Mac xxx

  4. hi gorgeous! My God you are really witnessing what goes on. Take care not to try and help so much you forget about yourself. Could not cope with the cockroches that's for sure. You are so very brave and passionate. Sister ? in the st albans gynae would be proud of you, ha, ha! Big hug Lena & Paul xxxxxxxxxxxxxxx

  5. Hi Alice, I've just come to the blog for the first time since you left, and it's 12 days since your last entry. Operative deliveries without running water! And the midwives sound demoralised. I hope you are keeping going OK. I'll watch out for your posts.


  6. Very sad stories indeed. Lack of blood is a common cause of maternal mortality in developing countries, Haemorhage and infection are the two leading causes of maternal mortality.

  7. Hey, nice site you have here! Keep up the excellent work!

    Hands Free sink units