Theory and practice

17.04, 2 November 2010

I’ve spent quite a lot of the last month training health workers in emergency obstetric care. In Bo, we were training midwives, doctors, nurses and maternal and child health aides who work in different faith-based hospitals across Sierra Leone. In a number of locations in Sierra Leone, mission hospitals such as Kamakwie Wesleyan Hospital may be the only referral hospital accessible to people living in remote areas where there is no government hospital. These hospitals are not yet incorporated into the free healthcare initiative for pregnant women (although the government is working on how to do this), which means user fees are still a potential barrier to women accessing life-saving treatment in these remote areas. Here in Kamakwie, a colleague and I have been running some informal refresher training sessions for hospital staff and student nurses on clinical placement.

In Bo, during the four-day training program, we had the use of a projector for lectures and expensive training models for practising skills. In Kamakwie, we are improvising – a teddy bear is our newborn (we have not been able to buy child’s doll anywhere in Kamakwie) and we spent the morning making a pelvis out of a cardboard box using inspiration from a fantastic book Helping health workers learn written by David Warner and Bill Bower, which has ideas for making low-cost teaching aids. In Kamakwie we have covered basic maternal and newborn resuscitation, management of shock and the unconscious patient, management of severe pre-eclampsia and eclampsia, and this afternoon we will be using our cardboard pelvis to practice management of shoulder dystocia and breech presentation. 

During training we teach a systematic approach to dealing with an emergency situation and attempt to make recommendations on appropriate actions as clear-cut as possible. This is easy in the classroom setting, but this weekend the complexities of midwifery in this remote part of Sierra Leone were evident. A woman was admitted at approximately 28-weeks gestation with severe pre-eclampsia. She presented with extremely high blood pressure, severe headache, visual disturbances, brisk reflexes and significant proteinuria. According to our guidelines, this woman should receive anti-hypertensive treatment, magnesium sulphate and have a plan made for delivery. The midwives were concerned that she was only 28-weeks gestation and initially reluctant to administer magnesium sulphate or make a plan to deliver the baby. Discussions with all the staff on the ward that day about the appropriate course of action for a good outcome for the mother and baby followed; these were truly multicultural as well as multidisciplinary, including medical and midwifery perspectives from Sierra Leone, Nigeria, the USA and the UK!

Midwives here work in challenging and extreme conditions and have also seen extraordinary outcomes. I find it hard to accept that a woman with this clinical condition, who appears to be on the verge of an eclamptic fit, can be effectively ‘cured’, go home and continue her pregnancy until term. But the midwives are confident they have seen this and it adds a new dimension to discussions on appropriate clinical management. In this situation, the mother’s wellbeing is our first consideration, but the prospect of managing a 28-week gestation newborn here is a daunting one where the most advanced care we can give is kangaroo care and support to establish and maintain feeding. It is not only the limited infrastructure that impacts upon decision-making, but cultural norms also need consideration. Although I develop a better understanding the longer I spend in Kamakwie, I still have a lot to learn about the customs and culture of life here. The role of the extended family is strong in decision-making. To decide to end a pregnancy and deliver a newborn, which is possibly too premature to survive (even if not taking this action could result in equally disastrous consequences), is not always a decision that one person can make and family elders may need to be consulted.

This story has a happy ending. The woman received magnesium sulphate, did not suffer an eclamptic fit and spontaneously went into labour the following day. I met a small but healthy baby on the ward on Monday morning and the mother and baby continue to do well. Reflecting on this situation makes me feel the training is useful as it gives clear guidelines on recommended best practice, but the reality of providing maternity care in this remote part of Africa means that clinical decisions will often feel much more complex than they appear on paper or in the classroom.

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