Zoe Vowles

It has been weeks now since I have been able to update my blog. I have had a series of frustrations with technology including problems with computer charging cables, generator and internet modems but am now back in the online world. It brought home to me how much I rely on the limited internet access we normally have here in Kamakwie to feel connected with friends, family and the wider world.

This year has flown by and I can’t believe I only have 5 weeks of my World of Difference Year left. Since writing last I have spent a week training midwives, nurses and doctors who work in faith based hospitals in Sierra Leone on emergency obstetric care. During October I was working with the hospital staff at Kamakwie to complete the work we have been doing on the maternity ward to improve documentation and clinical guidelines. During our final review meeting staff said although they were initially concerned about increased workload, the new system is helping them. They say it is especially useful having more comprehensive information about each woman and baby when shifts change and new staff take over and it makes it easier to detect problems earlier. Medical staff reported that improved recording of the condition of the mother and baby, including treatment and medications given make planning and evaluating care easier. One area that we are still working to improve is recording of care given to women during labour using a partograph – this is a tool used to record information about maternal and fetal wellbeing during labour, it also helps health staff identify prolonged labour. A colleague and I have spent some time teaching the Maternal and Child Health Aides to help them understand it.   

In 2008 in Sierra Leone almost half of women gave birth with Traditional Birth Attendants and in the remote communities we work with the number of women giving birth with TBAs is higher still. In a drive to reduce the high maternal and child mortality rates in Sierra Leone the Government launched free healthcare for pregnant women in April this year and is now urging all women to give birth in a health centre. The Government is advising TBAs to refer labouring women to a health centre to give birth instead of helping them to birth at home. At Health Poverty Action we try to take a grass roots approach to improving health of women and babies. We believe strengthening links between the community and the health care system, increasing knowledge of healthy practices at community level and supporting women to access available services are important if the expected results of the free healthcare initiative are to be realised.

We have been working to design a training course and toolkit for Traditional Birth Attendants to enable them to work as Maternal Health Promoters in their remote villages to share maternal health messages to promote healthy behaviour including, seeking of appropriate care during pregnancy, birth and the postnatal period, exclusive breastfeeding and use of family planning. These women are almost all illiterate so we have developed a toolkit of pictorial flashcards which they will use to promote discussion and share health messages. These women will work closely with the health workers in the rural health centres, they will mobilise women to access skilled care during birth and offer them additional support and encouragement during labour. Part of this project is to ensure women in the remotest areas have equal access to health services; we are planning to pilot birth waiting homes close to 8 of the rural health centres we work with. Women living long distances from the health centre will be able to come and stay in these rooms to be close to the centre when labour starts. The Maternal Health Promoters will also give support and health information to the women who stay in the home.

The training was incredibly fun but also quite challenging. Language was the biggest challenge. During this training the trainees spoke Loko, Temne and some also spoke Krio. There was lots of translation needed to be sure everyone understood. The fun part was the singing; I think we now have a song for every part of the training. The culture of song and dance is incredibly strong here. I was in awe of these women who can rustle up a song on any topic at the drop of hat. I also enjoyed immensely talking to these women and hearing about their work. Many of them although unable to read and write have kept meticulous records of the births they have attended by asking community members such as a teacher who can write to help them. I feel lucky to have the opportunity to work with these women, who hold so much information on the culture and history surrounding childbirth in Sierra Leone.

In Sierra Leone we are in the middle of the rainy season and the journey between Kamakwie and Freetown has begun to feel a little bit like an extreme sport. The journey which took around 6 hours in the dry season took us more than 8 hours yesterday and at times I wondered if we would manage to reach Kamakwie as some parts of the road were completely underwater because of the heavy rain.

I have spent another week working in Freetown with the Liverpool School of Tropical Medicine training midwives and doctors on Life Saving Skills for emergency obstetric and newborn care. After this we were straight back to Kamakwie to start 4 days training with the 27 Maternal and Child Health Aides working in our operational area. I thoroughly enjoyed the training. Having worked with many of them over the last six months it was great to see them all again. We included emergency skills and also the softer (but no less important) skills of making maternal health services more women friendly.

The free healthcare initiative has led to an increase in women using maternal health services across the country; this is brilliant but presents new challenges for the health workers coping with the increased workload whilst trying to deliver a quality service. Helping women develop a birth plan, which in this context includes preparing for the birth, discussing danger signs and developing a plan in case complications arise is an essential part of antenatal care but requires time. We had fun practising counselling women on birth preparedness using role play during the training.

Many of these frontline health workers are working in remote places and get little opportunity to collaborate and support each other. Giving them an opportunity to come together and share experiences, challenges and ideas for overcoming them is positive in itself. We incorporated sharing of skills and ideas into the training through using self assessment tools to identify problems and group exercises to develop plans for overcoming them.

In addition to these trainings other work at Health Poverty Action continues. We have been busy writing funding proposals, reports on our completed activities and we will soon start the mid term evaluation of our ‘kombra en pikin community welbodi project’ (mother and child community health project).  We are also working with our partners at the Kamakwie Wesleyan Hospital (KWH) and the Ministry of Health to advocate for the inclusion of Kamakwie Wesleyan Hospital in the free healthcare initiative. Currently only government hospitals are included in the initiative, this means in our remote operational area women are unable to access free treatment at hospital level, as the nearest government hospital takes hours to reach. The government are aware of the challenges this poses to women in remote communi

As I am writing this the sky outside is a steely grey and threatening rain at any moment. We had the first real storm of the year on Tuesday, spectacular thunder and lightening and rain so heavy one of my neighbour’s walls has collapsed. The rainy season is fast approaching which makes getting around in rural areas of Sierra Leone challenging. I am heading back up to Kamakwie on Sunday to begin work on our fistula project baseline survey and hoping that the weather will hold until we complete our 10 days of field work. We will be interviewing in all 5 chiefdoms which Health Poverty Action operates in and some of the villages are difficult to access even during the dry season.

The research is designed to give us baseline data on community (including Traditional Birth Attendants, Community Leaders and Health Workers) perception and knowledge of fistula alongside determining the quality and availability of maternal health care services prior to expansion of our fistula project. One of the most serious injuries of childbearing is obstetric fistula; a hole in the vagina or rectum caused by labour that is prolonged – often for days – without treatment. The baby usually dies and fistula leaves women leaking urine or faeces, or both, typically resulting in social isolation, depression and deepening poverty. If the woman does not seek treatment, it can lead to chronic medical problems. Fistula is a relatively hidden problem, largely because it affects the most marginalised members of society; young, poor and illiterate women in remote areas.

Our project aims to prevent fistula and reduce the stigmatisation suffered by women and girls living with fistula, and to ensure they receive repair surgery as soon as possible. This is done through training of ‘fistula advocates’ (women who have recovered from a surgical fistula repair and can demonstrate that treatment is possible) to share information on causes, prevention and treatment in villages throughout Northern Bombali, in addition to producing pictorial education materials and increasing awareness through the media. I have been working with an epidemiologist intern planning and designing the research and also a two day training course for the volunteers who will carry out the interviews and focus groups. We will also carry out interviews with health staff in the 27 rural health centres across the 5 chiefdoms and staff at Kamakwie Hospital. This is a good opportunity to visit some of the health centres I have not been to yet and meet some more of the Maternal and Child Health Aides before they all come for the 2 day workshop which I am planning for June, improving the quality of the healthcare that women receive is essential, not only reduce the number of deaths but also to prevent serious disability such as fistula.

In readiness for the launch of Free Healthcare for pregnant and lactating women and children under 5 and the anticipated increase in uptake and increased need for human resources especially midwives I spent another week this month working with the Liverpool School, this time training 30 retired midwives (who are returning to service to support the free healthcare initiative) on essential emergency obstetric and newborn care. It was a great week and considering the small numbers of qualified midwives currently in service in Sierra Leone, they will be a crucial addition to the number of skilled birth attendants which women can access. We are designated as the lead Non Government Organisation to support the implementation process of the Free Health Care Initiative for Bombali District and will provide support for dissemination of information, logistics and monitoring.

This has been a big week in Sierra Leone for two reasons, on Tuesday which was Sierra Leonean Independence Day; The President formally launched the free healthcare initiative. I really enjoyed attending the launch ceremony and hearing both the President and Vice President declare their commitment to improving the health of women and children in Sierra Leone. Yesterday was the launch of the Aberdeen Women’s Centre Maternity Unit, which will now not only provide surgical repair for women with fistula but also provide care for pregnant and birthing women, hearing the First and Second Ladies of Sierra Leone speak passionately about improving lives of women and children and tackling issues such as teenage pregnancy and prostitution was inspirational. I feel lucky to have been able to listen to the President, Vice President and their wives all speak about maternal healthcare in the same week.

I’m sorry for yet another update without photos but we currently do not have good enough internet to upload any.

I haven’t been doing much blogging over the last couple of weeks as I have been in Kamakwie with limited electricity and internet access. I did my first blog for the Royal College of Midwives website last week though, which you can see here. Two weeks ago was my first week teaching at the midwifery school. The students are community health nurses and the first ones in Sierra Leone to be trained as midwives, they are committed and motivated and I am enjoying my work with them. However, teaching a class of 73 students, making the session interactive, ensuring everyone can hear and not losing my voice is quite a challenge. I also learn a lot from the students who have an extensive knowledge and understanding of the challenges of health work in Sierra Leone.

Last week was spent on the maternity ward at Kamakwie Wesleyan Hospital. This first week was for me to get to know the staff, see how the ward works and talk to the midwives about what works well and what is problematic or needs further development. Health Unlimited has been working with the hospital since 2005, initially rehabilitating the hospital, which was damaged in the war. More recently HU is providing drugs for maternity cases and fuel for the ambulance. Over the last 5 years the number of women attending the hospital has increased and the maternal mortality rates within the hospital are going down. This is a good sign that the work that Health Unlimited has been doing so far to enable women to reach the hospital quickly by a four wheel drive ambulance, removing the financial barrier to healthcare through community loan fund schemes and keeping hospital costs down through provision of essential drugs is having an impact.

A new mother and grandmother

There is still a lot of work to do to reduce the numbers of women dying though, especially at community level. One woman on the ward had suffered a ruptured uterus, this is a serious and life threatening complication of obstructed labour. This had sadly meant her baby had died before she reached the hospital. Obstructed labour is one of the main causes of women dying during childbirth. This can be because women are unable or unwilling to go to a health facility or because of lack of appropriate referral and treatment by health staff. My work starting next month with health workers and community members in the villages will focus on addressing these issues. 

Sadly after our two success stories of these healthy babies we had the tragedy of a young pregnant woman, who was already a mother to two children, passing away later that day. She came to the hospital with severe pneumonia and sadly despite having all the treatment that we could offer did not survive. I have worked in Sierra Leone previously and I know that this is a reality here, but the death of a woman is incredibly upsetting. Being with a woman as she passes away is something as a midwife in the UK I would be thankfully unlikely to encounter. It is hard knowing she would have been unlikely to die at home. I am grateful to have the opportunity to be able to spend this year with working with HU to support their work to reduce these unnecessary deaths.

In the evening I had plenty of smiling faces to cheer me up. I am a source of endless fascination for the many children in the houses across the street from me. My house has no kitchen yet, I cook on my front step on a small gas stove. I normally have anywhere between 2 and 10 children and the occasional adult coming to greet me or sit on the steps and watch me cook, people walking past call out  that it is ‘chop time’ (food time) as they walk past. I wondered if I would get lonely in Kamakwie, not a chance!

I am in Freetown but we are having real problems with power and internet. I tried unsuccessfully to post this yesterday. I am going to try and include some photos but apologies if they are not in the post.

My placement has only just started but it’s great to be getting underway. I’m returning to Sierra Leone in January after a short period of time planning my placement at the Health Unlimited office in London.

Sierra Leone has extremely high maternal and infant mortality rates and many of these deaths are preventable. I’m excited to be able to work with Health Unlimited for the next year to try and improve health for women and children through training and supporting health workers.

I’ll be updating these pages regularly, so please come back to see how things are going and what a difference I’m helping to make.