Supporting midwives in Ethiopia

Gwent Healthcare NHS Trust lead midwife Melrose East describes the partnership between health professionals in South Wales and Southern Ethiopia.

The Southern Ethiopia Gwent Health Link (the Link) is a partnership between health professionals in South Wales and healthcare workers in Southern Ethiopia. Midwives from the Link have been visiting Southern Ethiopia for the past four years, during which time an annual five-day emergency midwifery skills workshop has been organised in Hwassa hospital for midwives and nurses working in remote health centres and hospitals in the region.

To date, 120 midwives and nurses have attended this course, with many travelling for several days to attend. Also, three rural health centres are supported by the Link, with midwives forming a major role in supplying essential midwifery equipment, on-site training and support. Each health centre serves a population of approximately 100,000 and has about 350 births per year, with care provided by two midwives, a health officer and six clinical nurses.

The Link is working towards the millennium development goals (MDGs) 4 and 5 in reducing child and maternal mortalities. The maternal mortality ratio in Ethiopia is 720 per 100,000 live births. Skilled attendants at birth are the key to improving outcomes, so continuing education of midwives and nurses is the main focus for midwives in the Link. This also fits with the Ethiopian government policy of aiming healthcare provision in rural communities.

Since providing on-site training to staff during the past three years, they have reported that they have found their new skills very useful especially, neonatal resuscitation, ventouse, breech and shoulder dystocia. The rate of episiotomy has been reduced at two of the health centres, but a higher incidence of female genital mutilation means that there is still a high incidence in the third centre.

Midwives in Ethiopia work in exceptionally difficult circumstances. They have very little equipment available to care for women in labour or to manage emergencies and what little they have is very precious, so they are sometimes reluctant to use it. Often there is no water to ensure cleanliness of women, babies, staff or equipment and certainly none to drink. Cleaning materials have consequently been provided by the Link. No refreshments are provided for women or staff. Electricity is also very unpredictable and generators provided by the Link have proved invaluable. The buildings themselves are often in a poor state of repair and, frequently, broken equipment is stored in rooms or health centre grounds. Sometimes two women could be giving birth in the same room, with no screen to provide privacy for each of them. This has been addressed in the three health centres supported by the Link, and now all have curtains at the windows and screens between beds.

In order to encourage women to attend health facilities to give birth, care during childbirth in Southern Ethiopia is free. However, local practices often mean that some women have to pay for ‘extras’, for example, ergometrine, IV fluids, suture materials, each costing about 14 Birr (just under £1). This can have the opposite effect by discouraging women from attending the health centres.

It is not the custom in the areas that I visited for the midwives and nurses to give ‘hands on’ care in the same way as would be the case in the UK. Usually female family members do this. There is no analgesia available for women in labour or birth in the health centres. Beds and cots do not have any sheets on them and women have to provide all clothes for the baby. All women breastfeed their babies.

One of my main objectives on this visit was to provide and train staff on the use of the partograph. One of the health centres I visited had documents provided by the ministry of health, but staff were confused on how to use it and, consequently, did not do so or, as I witnessed, recorded findings incorrectly. The partograph provides a very good way of recognising early complications in labour so that women can be transferred to the hospital in a timely fashion thus avoiding complications to mother and/or baby.

Interestingly, the partograph was devised for use in African countries but was not routinely used in the health centres I visited.

Tragedy is never very far away in Ethiopia and, during my visit to the first health centre, I met a woman who had just delivered a stillborn baby. The baby had died prior to the woman attending the health centre. There was little emotion shown by either staff or family – it being deemed to be God’s will.

During a visit to another health centre, I noted that a woman had been in labour for many hours, which is quite unusual, as most women arrive at health centres in the latter part of the first stage or often in the second stage of labour. After questioning the nurse caring for the woman I learnt that she had been admitted at 9am when the cervix was 6 cm dilated. At 4pm when I enquired about her, the cervix was only 7 cms dilated. I suggested to the nurse that she should be transferred to the hospital. It turned out that the woman and her family did not have the 100 Birr (over £6) necessary for an ambulance to go to the hospital. I quickly gave the family the money and the staff rang for an ambulance. I wonder what would have happened to that woman had I not given the money – it doesn’t bear thinking about!

The Link has donated a motor bike ambulance to each health centre it supports. These provide essential means of travel from rural villages to the health centre over very rough terrain and from health centre to the referral hospital free of charge. Priority is given to pregnant women with complications. While at the third health centre, a pregnant woman was admitted in labour. Her blood pressure was found to be 177/140 mmHg. She was unwell and needed urgent attention. The motor bike ambulance was called into action and soon had the young woman transferred to the local hospital some 25km away. Mother and baby were well. but the outcome could have been very different without quick access to the ambulance.

A very good, mutually beneficial, relationship has developed between staff at the three health centres and midwives in the Link. Support and advice is provided between the six monthly visits via email and telephone. The benefits to the Link midwives of such work is immense and includes improving communication and teaching skills, developing good leadership skills, experience in managing small projects, working within teams, conducting audits and evaluations, acknowledging and adapting to cultural differences, all of which are useful in our work as midwives in Wales and the UK.

Further information on the work of the Southern Ethiopia Health Link can be found at: www.ethiopiagwentlink.org