From MIDWIFERY MATTERS, Issue No. 116 - Spring 2008
Anna Greco - student midwife
I am a student midwife undertaking a direct entry programme at the University of Nottingham. As part of this programme there is an optional placement element. I elected to go to Jimma Hospital in Ethiopia for two weeks in October 2007 as it is linked to the Nottingham City Hospital (NCH) where I train. Staff from the multi-professional team have been visiting Jimma for a number of years offering training and resources. In 2007, staff from Jimma visited NCH and experienced how care is provided in the UK including spending time in the transitional care unit.
Midwifery and obstetric staff have the opportunity to witness complications that have become rare in the UK including uterine ruptures, fistulas, severe eclampsia and complete uterine prolapse. Visiting Jimma Hospital provided an opportunity for me to experience Africa at first hand and compare this with the media portrayal and the experiences shared with me by African people I have met who are now living in England. I also wanted to gain an understanding of the reality behind the statistics:
• Maternal mortality rate Ethiopia 850 per 100,000
• Maternal mortality rate UK 11 per 100,000
• Neonatal mortality rate Ethiopia 51 per 1000 live births
• Neonatal mortality rate UK 4 per 1000 (1)
• Life expectancy at birth is 49 males, 51 females (2004) (1)
• Deaths from pregnancy related causes – 1 in 14 women (2)
• Density of midwives is 0.01 per 1000 i.e. 1 midwife per 100,000 people (2003) (3)
• Percentage of births attended by skilled birth attendant 1996-2004 - 6% (4)
• Population living below poverty line – 44% (5)
• People living with HIV age 15-49 – 4.4% of population (6)
• 5000 new adult HIV infections weekly (6)
I was part of a team comprising a consultant obstetrician, a consultant midwife, an emeritus consultant neonatologist and a senior house officer working in paediatrics. The plan was to run a training course in maternity emergencies. A former paediatric nurse would also be travelling to work in a Catholic mission hospital in Jimma and I able to spend two days working there also.
During the seven and a half hour flight I was introduced to the friendliness and warmth of the Ethiopian people which would continue throughout, when the person sitting next to me invited me to their wedding! From Addis Ababa we transferred to Jimma, a large town south west of the capital. From the air and then later when I spent two days in the capital at the end of my trip, I had a great view of the sprawling capital, rather shanty-like with the juxtaposition of the rich (Sheraton Hotel) and poor (around 60,000 women and children live permanently on the streets and in the city there are rotting corrugated iron houses). On the way to Jimma I could appreciate the trees, hills, rivers, herds of animals and traditional cylindrical houses with their conical thatched roofs. In contrast to the media portrayal of Ethiopia as a barren sandy desert, I was delighted to find it lush and green at the end of the rainy season.
Ethiopia was under Italian control during the 1930s and this influence is evident in some of the architecture of Jimma. Dirt roads, cows and sheep are herded through the centre of town and every now and then aromas of coffee and incense waft from the much practised coffee ceremonies. The town is busy with people walking, often bare foot, and with blue minibus/taxis. All types of music from Western to traditional can be heard bursting from the stalls and very early in the mornings from the churches and mosques. It is common to see men chewing chat, a leafy stimulant which is known to cause psychological problems for men and their families. The atmosphere of Jimma with its aromas, sounds, and bustle is something I will never forget. The climate in October was a perfect 28ºC, with a few short rains in the afternoon and very cool at night.
The bus trip from my hotel to the hospital cost around five pence. The university and hospital are neighbours and were both built during the Italian occupation. The maternity wards appear not to have changed since then. However, the good news is that the grounds are being developed and the maternity ward will be moving to new accommodation shortly.
In the grounds, families of in-patients sit with fires cooking or washing clothes which are sprawled all over the grass to dry in the sun. Women who give birth in the hospital usually do so because of a complication either antenatally or when in labour. All care provided, even down to the gloves the doctors and midwives wear, must be paid for by clients. Postnatal areas are split into a septic room and non-septic area and my first observation was that the five-bedded septic room was full but not one woman had a baby. These women had experienced complications such as a ruptured uterus and a fistula developed following an obstructed labour. Women without a live baby were also sporadically placed among women with babies and mattresses were put on the floor in the corridor when the labour ward was full.
HIV is at pandemic level in Ethiopia and all women are given a ‘rapid´ HIV test when they arrive at hospital if they have not been tested previously. Free anti-retroviral (ARV) drugs are available for all HIV positive women and babies. Women are counselled after labour and birth and accurate information regarding infant feeding is given in line with WHO recommendations which state that babies should be fed artificially only if it is “acceptable, feasible, affordable, sustainable and safe’ (7). For nearly all women in Ethiopia, formula milk is unaffordable and there is a lack of access to clean water. At the special care baby unit a formula-fed baby was admitted with vomiting and diarrhoea. The mother insisted she could afford the formula feed and perceived this as the best way to protect her baby from becoming infected with HIV through breast milk. Sadly, the reality is that babies are more likely to die from being formula fed with unsafe water.
Labour suite consists of a four-bedded room known as the first stage room where women are assessed on admission then if in labour, will stay here until second stage. There are no curtains around the beds so there is no privacy for intimate examinations. There is no electronic fetal monitoring, although they have an old ultrasound scanner. At the time of my visit there were no urinary catheters, so staff improvised by cutting down an IV giving set. I saw several women who would have received a blood transfusion in the UK, however this was not possible due to a lack of safe blood at Jimma.
The second stage room consists of two beds with lithotomy stirrups, again no curtains, a poorly maintained resuscitaire and vacuum apparatus for delivering babies. Women proceed to this room when they are fully dilated. I was amazed at how the women walked and then climbed on to these beds with no assistance. Lidocaine and pethidine are available as pain relief, however I did not see pethidine given as it is too expensive for the vast majority of women. Lidocaine is given sparingly before episiotomies, which are performed frequently as most women have had female genital mutilation (FGM). An oxytocic is given for active management of the third stage only if the woman can afford it. However, women who are deemed at high risk of post partum haemorrhage (PPH) will have it funded at the discretion of the hospital. After birth, women are transferred to the postnatal bay and will go home after a few hours if all is well.
There is a high incidence of uterine rupture because most women labour at home and will only attend the hospital when a complication becomes evident. With limited access to transport, women may have been labouring for a few days before reaching hospital (over 50% of the population live more than six miles from the nearest health facility (3)) the fetus has often died and the uterus ruptured. One woman with a cord prolapse arrived being carried in by four men holding the corners of a sheet. Caesarean sections are all carried out under general anaesthetic and there is a high risk of wound infection partly owing to the poor nutritional state of the women. Some doctors are trained in external cephalic version (ECV), although they sometimes do not see this as an option because of the lack of electronic fetal monitoring and access to tocolytic drugs.
The Catholic mission provides an out-patient and an in-patient service to people who cannot afford to go to the hospital. Often the in-patients are receiving palliative care for AIDS related illnesses. There is a room where babies who are abandoned or orphaned are nursed to health before being transferred to Addis Ababa for adoption. The mission is a wonderful place with a community atmosphere. Everyone who is well enough helps out; this could be cooking dabo (bread) or injera (Ethiopian sort of bread), looking after the animals or mending and cleaning the beds (which is done thoroughly every day). There are children everywhere and while their mothers receive treatment they are left to their own devices. However, a school teacher is employed to try and keep them busy! Everywhere I went I had crowds of little ones hanging on to my fingers or my clothing, and I was fooled by the little girl in a pretty dress who later turned out to be a boy! It was here that I learned that most babies are not named until they reach one year as there is a high chance they will not reach their first birthday (1in 10 die before their first birthday (8)). They are known as mimi (girls) and mamoosh (boys) until then.
Ethiopians are very proud people. Many asked me how their country is portrayed in the West and were keen for me to return home with a more balanced view. Ethiopia has a long and rich history dating back more than 25,000 years. Some of the oldest human remains have been found in Ethiopia, including the famous “Lucy” (over 5.9 million years old). They are the only country in Africa to have escaped colonisation until the 1930s and even then were never completely conquered thanks to fierce resistance fighters, many of whom were women. Ethiopia regained its independence in 1941. They have an amazing sporting tradition with great successes in distant running events and the Olympics. I witnessed athletes training in Addis Ababa each morning from 5am. However, with a massive World Bank debt, without a market to trade their resources fairly (coffee, livestock, gold, oil) and with food insecurity, the development of the country and the economy is hindered.
This elective placement provided me with a unique opportunity to see maternity issues from a different perspective. I felt privileged to be there and saw things which made me shudder with shock and feel humble with the strength and personality of the people. I can return to my high-tech environment and only remember the frustration of the doctors and midwives in Jimma trying to practise in facilities so lacking in the most basic of essential resources.
Anna Greco
(1) WHO Health status: mortality 2006 www.who.int/whosis/whostat2006_mortality.pdf
(2) Haile Sahlu (2004) special report: population, development and environment in Ethiopia ecsp issue 10 (43-51) www.wilsoncentre.org/topics/pubs/ecspr10_specialreport.pdf
(3) WHO 2006 World Health statistics www.afro.who.int/home/countries/fact_sheets/ethiopia.pdf
(4) UNICEF 2006 Ethiopia statistics www.unicef.org/infobycountry/ethiopia_statistics.html
(5) Ethiopian Economic Association (EEA) 2002 Second Annual Report on the Ethiopian Economy vol II 2000/2001 Addis Ababa: EEA cited in Haile Sahlu (2004) special report: population, development and environment in Ethiopia ecsp issue 10 (43-51) www.wilsoncentre.org/topics/pubs/ecspr10_specialreport.pdf
(6) World Health Organization (2006): World Health Organization, “Health Action in Crises.’ cited in Planned Parenthood Golden Gate www.ethiopia.ppgg.org
(7) WHO HIV and Infant Feeding consensus statement 2006
(8)World Bank (2005): “Ethiopia: A Country Status Report on Health and Poverty,’ Report No. 28963-ET (July 2005) cited in Planned Parenthood Golden Gate www.ethiopia.ppgg.org
This article was originally published in Midwifery Matters ISSUE 116 Spring 2008
AH updated 16 October 2008