My weekly timetable - including The Government Hospital Makeni

There are now 2 sets of student midwives in the School of Midwifery Makeni. The first set started in January 2010 and the second set started in September 2010. Both groups are currently in school so the timetable currently doubles up - there are now twice as many classes to teach.
I teach Monday, Tuesday, Thursday and Friday. I have a non teaching day on Wednesday so I have taken it upon myself to attach myself to the Government Hospital Makeni. Partly because it helps me close the gap between teaching and clinical work so my teaching may reflect the context in which I am working. Some of the other reasons are that the hospital is within walking distance of the school and partly to try and set an example to the others who teach within the midwifery school - that to attach themselves to a hospital/peripheral health unit is beneficial to their knowledge and relationships with trained staff.
There are 2 other volunteers based at the government hospital. They have a very tough assignment and I join them on Wednesdays where the 3 of us do a ward round - I join the maternity department round.
When we arrive at the maternity department my experience has been that all the staff, patients, relatives and a few others who don't seem to be attached to anyone within the maternity department have plastic beach chairs lined up like a cinema and are watching a large television.
These televisions are new to the hospital - even though basic essential equipment is lacking.
The 3 of us announce that we are going to see all the patients - many people remove themselves very quickly from the ward, some staff appear annoyed with us for disturbing their television viewing, and some patients just look relieved that the noise of the load television has stopped. If you are lucky the plastic beach chairs are moved out of the way so the patients may be seen.
The type of clinical conditions I have seen here in Sierra Leone I have not seen in the UK.
Women with advanced HIV - because they were not tested during pregnancy. The test is offered to all pregnant women but many do not want it done for fear of stigmatisation and rejection by their families and communities. HIV is known as 'Slim's disease'. Therefore perhaps many women who die of HIV have 'Slim's disease' on their death certificates. So perhaps the AIDS problem is misdiagnosed and maybe a bigger problem than the statistics tell us. Apparently 2% of the Sierra Leonian population have HIV - these are official government statistics.
I have seen women transferred in from the peripheral health centres and health posts who have been in labour for 3-4 days. These mothers and babies often have very poor outcomes. Often the babies have died in utero and are either macerated or fresh stillbirths. Some babies have such elongated heads as a result of trying to pass through the birth canal. I have never seen such mishapen heads from birth until I came to Sierra Leone - but in the UK we do not allow women to labour (active labour) for 3-4 days.
There is such basic equipment here and the student midwives have informed me that in some of their units there is not enough equipment for the births. Sometimes the instruments are not sterilised between births. The equipment is rinsed under the tap - the water is not drinkable - it comes from a well source.
Women in labour are not offered or given any pain relief. I have not seen any Pethidine or Meptid let alone any entonox. There are however epidurals for c sections.
On the postnatal/antenatal ward there is a mix of all sorts of clinical conditions. Women who have birthed stillborn babies next to someone in the next bed with twins. I have witnessed a woman with severe eclampsia on Magnesium Sulphate - fitting - who was then put in an ambulance (no paramedics) with just a driver and a relative - to be sent to a hospital 3 hours away - I never managed to find out the outcome of this woman.
Immediate post operative women are put in the open ward with all the noise of babies, relatives, the television and the other patients. Many of these c section women have been transferred very late on in their labour, have travelled a long way to get to the government hospital with a very poor infastructure to even get there and they are exhausted.
Many of the women I have seen have severe eclampsia and c section is often not the first choice here in terms of care and management.
There is however a scanner - which was I understand until recently - stored in a cupboard. It was certainly good enough to confirm an intra uterine death at 26 weeks - classic Spalding's sign - the woman had not felt the baby move for 3 days. There are no induction of labour drugs - this woman will have to wait for nature to take its course - sometimes up to 2 weeks - many of these women abscond and their outcome is unknown as there is poor follow up. Bladder catheters are used to dilate the cervix in some instances - the balloon is filled up with water to stretch the cervix in the hope that labour will progress.
I can't help but feel shocked with what I see.
1:8 women die of childbirth 1:5 children do not reach their 5th birthday - there is now free health care for pregnant women, lactating women and children up to the age of 5. The demand now for free health care is higher than what can be provided. There is currently a lack of trained midwives and doctors - a poor infastructure and although traditional birth attendants are not to be encouraged to work in the provences - what choice do women in Sierra Leone really have.