So Much Happening

I have just been so busy with so many events that I have not had time to keep my blog up to date.
The internet is very patchy and I have had poor service from my Zain internet stick that I decided not to renew it.
Thank you to everyone who has contributed towards purchasing essential items and also those of you who have shipped out packages which have arrived here in Makeni via Freetown.
The students and staff have received the following:-
300 midwifery dictionaries – thank you to the good people of Somerset and my brother for organising this.
5 Myles text books – thank you to a good friend and midwife in my home town in Bury St Edmunds
A lap top for the ICT member of staff to assist the students in their studies – also some monies yet to be spent – thank you to a charity/school children in Hastings UK.
73 items of essential midwifery equipment for set 1 midwifery students. They will receive a Pinnard’s stethoscope, blood pressure machine and stethoscope when they return on 11th April – thanks to a very generous couple. I met a person in Freetown who very kindly supplied this equipment.
Thank you to a very kind friend from Bury St Edmunds who raised some monies to be spent on whatever I thought would be suitable. I have purchased a mobile phone and top up for the night security men at the school, CD’s to burn info onto, memory sticks, stationary, books and some further supplies which will be purchased before I leave.
Many of the items were transported free of charge by Dawnus – a construction company working here in Sierra Leone – without their help some of the items would not have reached the school.
A big thank you to all of you and anyone else I have not mentioned.
Things are changing here as the school is busy with students, tutors and teaching activities. The school has improved its facilities and can host other courses and this is used to make monies for the school.
The accommodation blocks are nearing completion for the student midwives and tutors.
Many staff from health posts and main hospitals in Sierra Leone have attended a Life Saving Skills Course run by Liverpool University. This will help increase the emergency skills of staff who work often alone in isolated health posts.
I have seen a little more of the country but travel is difficult due to poor infrastructure and lack of my own transport. However I have been very grateful to friends who have the use of a truck and Dawnus who share their days off with us.
I have been to Banana Island, River no 2 beach, Bo to a students’ wedding for a weekend. Most weekends are full even if I don’t leave Makeni and most evenings there are meals, a local hotel which is a meeting place not to mention a couple of other local haunts.
I go to the local Government Hospital on a regular basis, it is still looking after women who have often been in labour for far too long with grim consequences for mother, baby or both. There are plans to move to a new hospital soon but I have heard that ever since I have been here. The staff will be the same – just a clean environment. I do not know if that will improve the outcomes or not.
I am almost at the end of my year, so many mixed emotions. Some good some not so good and some feelings of frustration as I can only do so much within a limited period of time.
Well that is it for the moment – I hope to write more – internet willing.

Back from a short Christmas break

Just returned to Sierra Leone - Makeni - having had a short break back in the UK for Christmas.
The weather here in Makeni is wonderful! I left cold, frosty UK to return to 40oC.
I did however have difficulties getting back to UK just before Christmas due to the snow at Heathrow - but had a great time in Lungi airport Hotel waiting to hear when our flight was going to land! Only 2 days late - but just in time for the family celebrations.
Back to work! The students are all out on clinical placements and set 1 have just sat their second exams - so I am in the process of marking 73 scripts x 2.
The school accomodation building has grown since I have been away - which is great news as many of the students are struggling with finding suitable accomodation.
I have returned with Cliff my husband for the last 10 weeks of my placement which is great. He has adapted so quickly and is happy to ride motorbikes and eat local food even with his fingers (right hand of course).
Well thats it for now - more stories once I have settled back into work and life here.

Exams - everything is so last minute

The set 2 have just sat their end of first study block exams. They had 5 days of exams testing their knowledge on a variety of subjects - antenatal care, drug calculations, anatomy and physiology, fundamentals of midwifery, ICT to name but a few subjects.
All the 5 midwifery tutors who taught components of the training were required to set the exam paper based on the subject they had taught.
An exam chair was appointed and one other person to assist. The exam chair was another VSO - she had not set exams before and neither had the person who was appointed to assist the exam chair.
All the questions were given to the exam chair - all hand written - even though they were asked to send it by email. This was to make the exam question selection and formatting of the exam paper easier.
It turnes out that the tutors could not or where unable to send emails. This needs addressing - the students are having ICT lessons and many of them are learning fast!
The exam chair was given several reasons why emails could not be sent - including not knowing how the log off.
The exam chair felt really overwhelmed with having to choose exam questions and type and format into an exam paper for each subject.
I spent time together with the exam chair - the whole of the weekend just prior to the exam week typing up exam questions, choosing the questions from a selection the tutors had written and checking spellings, grammar before the final copy was approved.
The exam papers where shrouded in secrecy in case the questions were leaked. So much so the exam chair was asked to organise a trip to Freetown (not an easy journey) to get the papers photocopied. This was however done locally due to the practicalities.
The exams were due to start last Monday at 9.00. I was concerned that the photocopying would not be ready in time.
I was told by one of the tutors that when they sat some exams recently they had to sit and wait for the professor to arrive with the exam papers - he arrived so late they sat the exam that day in the dark - using torches!!!
I really wanted the Midwifery School in Makeni to do better than that!
I hope when set 1 come to sit their end of second block exams - many lessons will have been learn from this late preparation.
Amazingly - all the exams went smoothly and the correct exams where taken on the correct day at the correct time.
Then the marking had to be done - MCQ x 66, essay questions x 66 and for me an additional paper for an 'assessment' mark x 66!!!
They are all done and recorded - but how the questions were answered is another blog story!!!
The set 2 students are now out on their first clinical placement.

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.

Weekend in Kabala

I have only been to Freetown from my base in Makeni about 3 times. Mainly this is due to transport and more recently - accomodation.
Last weekend 4 of us went to Kabala which is north of Freetown - about 200 miles although it takes about 6 hours to travel from Freetown to Kabala.
One of the 4 of us managed to arrange transport via a works truck - of course we had to pay for fuel and for the drivers time.
It took 2 and a half hours to travel from Makeni to Kabala - about 135 miles.
The road was rough and bumpy but was not as bad as I thought it would be. The tarmac was very pot holed in places and the edges of the road were non existant. Often we drove on the wrong side of the road to avoid pot holes that were filled with water and so the driver would not have known how deep the holes were.
We arrived at another colleagues house in Kabala - she had booked the 4 of us into a guest house - the best one in Kabala!! Bed but no breakfast. It was basic and had 2 double beds in 2 bedrooms, a small sitting room and a toilet, sink and wet room style shower. When I brushed my teeth I did not notice that there was no goose neck attached to the sink - so my spit that went into the sink sprayed out onto my feet! We slept 2 to a bed - I wondered how clean the bed was. The pillow case had black mildew on it and the sheets smelt sweaty not to mention moist - but that could have been from my sweat. There was electricity from 7pm - midnight - so we put the fan on that was in the room.
We went for a walk in Kabala the afternoon we arrived. It was a beautiful day - bright, sunny and certainly a lot cooler than what we have come to expect in Makeni. We stopped at a small cafe and had groundnut soup - a very typical meal made with goat meat and loads of rice. We also had some bottled fanta.
We walked to the town - a lot more airy and spacious than Makeni - if you think of Makeni as a diluted Freetown and Kabala a diluted version of Makeni. There was certainly less traffic and very few houses had compounds.
It was great to get out and have some really fresh air.
Some of the group went to the cafe for some drinks later - but I went to bed early - I was shattered!
The next day the 4 of us and our 2 colleagues plus a local guide all walked up the big hill - Wara Wara - I think that is what it is called - I've left my guide book at home! It was a steep climb and the others walked up it like mountain goats. Our guide made us some walking sticks - this helped with getting past the rubble as the incline was steep.
I did not make it to the summit and neither did one other - we chose to wait just at the base of the summit - it would not have been too far to have completed the journey - but I was flagging. We waited for the others to complete the climb then they returned so we all walked down together.
We met a family who live on the hill. Apparently during the civil war many people took to the hill to escape from the rebels. There was evidence of crops/managed land for growing produce. The house was just so basic with no electricity and water other than what was collected from a stream.
I spoke with one of the boys who lived there - he travels up and down the hill to get to and from school every day. I asked him about the last baby that was born in the family - he told me that a local traditional birth attendant came to the house to help his mother as she could not walk down the hill in labour. She was lucky and so too was the baby - but this type of midwifery is common as the infastructure is one of the problems, not to mention lack of trained staff and midwifery 'waiting houses'.
We walked down the hill but my hips were showing signs of strain - one of our colleagues walked with me - and I was very grateful for that - I could not hold on with my feet and the steep angle - I was fine once we had reached the bottom.
We went back to our colleagues house and I poured water on my feet - the best feeling in the world! I also had no socks - which did not help - only a few blisters!!
We had a cab ordered for us to take us back to Makeni - a 9 seater Renault estate car. We paid for 7 seats so we had comfort in the 2 back seats between the 4 of us. The boot was full and the driver picked up 2 passengers who both sat in the front seat. One of the other passengers had a live chicken in a bag and by the time we arrived to Makeni - it had pecked its way out of the bag. I was sitting in front of the chicken and every now and then I could hear it rustling - but it was squashed in by a suitcase.
That day we also visited the maternity hospital in Kabala - it was I understand run by Dutch personal - but 2 years ago they pulled out and left it to be managed by locals - overseen by the government.
I was impressed as the hospital was clean - it smelt of cleaning fluids, the women looked well cared for, the beds were not covered in blood and there were 2 wards - one for newly birthed and one for c. section women. The operating theatre and birth room also looked cared for - this was certainly a surprise - not what I was expecting. The grounds of the hospital were spotless - well done to them.
More about the Government Hospital Makeni in my next blog.

Death - Part of Everyday in Sierra Leone

Death seems to be part of everyday here in Sierra Leone - over the past couple of weeks there seem to be accounts of people dying perhaps uneccessarily.
We had some plumbing done recently in our house in Sierra Leone - the plumber had lost his 26 year old daughter 3 weeks ago. She had a dental extraction done by a dental quack. She apparently was unwell 5 days later and died from chest pain. There are no dentists here in Makeni and only a few in Freetown. I cant recall the exact number but I can remember being very surprised at how few there were.
At the local government hospital an aneasthetic nurses wife complained of a headache last Sunday whilst preparing vegetables for her 3 children. Her husband the aneasthetic nurse went to watch the football at a local bar and returned to find his wife dead. She was 36 years old. Apparently at the funeral last week - her father said he had now buried 6 out of his 9 children.
Recently I was given an account of a child being admitted to the children's ward. This child had been admitted very late on with whatever the condition was - but there was no cannula to insert the necessary treatment - although treatment was administered via an alternative route - there was also a lack of the appropriate drugs required. This child died.
There was a death due to Lasser fever recently in one of the local hospitals - the staff involved in the patients care required specialist monitoring incase they had contracted this fatal disease. One person I believe had tested positive but has been able to recieve appropriate treatment - but others are still being monitored closely.
At the government hospital last week - another VSOer and myself came across a woman who was 34 weeks pregnant. She had had 2 fits and was on a recognised pre-eclampsia treatment. But there was no surgeon working on that Friday when we saw her - and unlikely to be one available on the Saturday or Sunday. The fetal heart was 140 bpm and the mother's own pulse was 100 bpm. She was potentially going to have another fit - perhaps with a poor outcome for either the baby, herself or indeed both. I was with another VSOer and a referal to another hospital was made - however the receiving hospital have a policy of patients paying - I will follow up the outcome next week.
One of the student midwives lost her daughter in childbirth on the second day of her midwifery course. Her daughter died of a post partum heamorrhage. The child survived. The student midwife continues with her studies - this is how it is here in Sierra Leone.

Things are Improving

Since I have returned from UK last month I have noticed several improvements within the School of Midwifery Makeni.
Despite the obvious lack of money - we have a new generator at the school this means the electricity supply is much more powerful even though it needs to be cut off at lunch time to rest it. The internet although dial up is still working reliably. The 16 computers in the library are for the student midwives - only 2 of the new student midwives have ever touched a computer before - but they are all willing to learn.
The 3 returned Sierra Leonian midwifery tutors have just completed their tutor training in Nigeria. Also we have another VSO midwifery tutor. This brings the department up to 5 tutors plus the Head of School - she can now concentrate on some of her administrative duties.
There are some changes regarding student welfare, storage of lesson plans, twice monthly academic meetings, curriculum development meetings,weekly all staff meetings, use of printed student and staff information which is now posted in strategic places.
This is just a small part of the sustainable organisation of the new school that is happening.
The school now has a motorbike and a truck - which makes life easier for transporting students, although a larger veichle or small minibus is also required considering the numbers of students.
Some student midwives are receiving sponsorships and this helps with funding their education and clinical placements. Much more of this initiative is required.
We still struggle without a photocopier as the engineer who came to fix it did not know what the problem was.
Printing notes for lessons is sometimes slow and currently due to the size of class -the use of powerpoint presentations is prohibitive.
A decision was made to open up the internet in the library to the general public as a means of income generation. However it was pointed out that without specific anti virus protection the computers would almost certainly be open to abuse - even if not deliberately. This has been highlighted and hopefully a sustainable solution will be found. The staff at the school were not aware of the possible issues around contamination from the use of memory sticks, accessing porn, corruption and violent websites.
The library is currently being catalogued by one of the staff into subject headings with a system of identifying each book so that book loans will be a possibility soon.
When I think back to April when I first started - things have improved and will I hope continue so as to provide the midwives Sierra Leone needs to reduce the unacceptable high maternal and infant death rates.