LFAM in Monrovia, Liberia May 2014
Tracy Reynolds kept a diary of her working visit to Monrovia with Marie Lee. Read on to find out more about how dangerous it is to give birth in Monrovia and how difficult it is to be a midwife there.
Monday 5th May
Marie and I are going to Liberia to provide a workshop for sharing Midwifery Skills in Monrovia. We leave Heathrow at 13:30 and land in Liberia at 21:30 – here we encounter a 1 hour delay and have 1 stop at Freetown,Sierra Leone.
Abdul is there on our arrival with Usman (our driver), and we travel for about 45 minutes to our Hotel where we are sharing a basic but adequate double bedroom.
Tuesday 6th May
We are picked up at 08:30 sharp (very impressed) and taken to Abdul’s place of work LMHRA (Liberia Medicines Health Regulation Authority) which ensures safety, efficacy and quality of medicines and health products. The gloves we have provided are taken here to be checked over.
We then go to John F Kennedy Hospital (which is 50% government and 50% privately funded) and the main hospital of Monrovia. It has undergone extensive refurbishment in the past few years and we are very impressed with the facilities when Ujah, the head midwife, who is American and an administrator, shows us round. We arrange a date for our workshop (Saturday) and a day for us to come and observe routine practice (Friday). She informs us that 62 midwives work here and that there are between 300-450 deliveries a month. The main cause of maternal mortality is infection, but about 10% of pregnant women suffer from pre eclampsia and 5% end up with eclampsia. Here it costs women $25 (around £17) for a normal delivery and $200 for a Caesarean Section.
We are shown around the maternity unit and are taken to an early labour ward. From here, the labouring women go to the labour ward which is a run by an obstetrician and 2 midwives. There are no birth partners here and women labour silently by themselves – no pain relief is given. When the ladies are ready to deliver, they go to the 4 bedded delivery room, which is empty when we visited. A medicine cabinet holds all essential medication if urgently required, i.e. Magnesium Sulphate, Misoprostol etc. Following delivery, women go to a recovery ward (up to 2 hours postnatal) for closer observation, before going to the postnatal wards. Women remain in hospital for 24 hours following normal delivery, and 5 days following a Caesarean. These wards are busy, as they had a hectic night! Ujah informs us that, in the past two weeks, there were 2 cases of vaginal triplet delivery (multiple delivery rates are higher in Africa).
From here, we go and see the Deputy Minister of Health (John Harris) who warmly greets us and is keen for all of Liberian Midwives to attend Midwifery Skills workshops, as there is evidence that the Maternal and Infant Mortality rate is reducing in areas where these workshops have been provided.
I observe the poverty from our accommodation views and realise how very fortunate I am to be born in Britain. I see that water is available from wells and women are hand washing clothes in buckets. There is no electricity and at night time, torches are used.
Wednesday 7th May
We are again promptly picked up by Abdul who takes us to a very local privately funded Hospital,St Joseph Catholic Hospital. We are met by an administrator and Brother George, who provides information about maternity care at this hospital. A delivery here is cheaper at $15 dollars, and we are informed that many people travel far to deliver within Liberia where the maternal care here is better; (we meet one lady who has travelled from Guinea to have her baby here).
At this maternity hospital, there are about 100 deliveries a month and between 1-5 still births per month. Brother George takes us to the hospital supplies area, which is well stocked. We see enough Magnesium Sulphate but only 2 packets of Misoprostol. It is kept under lock and key and used carefully. We are shown around the maternity unit, which again is well equipped. There is a maternity theatre here but it is currently out of use as the theatre ceiling has had a leak – so any emergency or planned Caesarean Sections take place in the main general theatre, which is not close by. The delivery room has 2 beds and we are very pleased to observe that the 2 delivery beds have their backrests upright, which suggests that women here do not deliver flat on their backs. We go to a postnatal ward where there are 4 women and babies, and we present them each with one of Gemma’s hats. The beds have sheets and there are mosquito nets above each bed.
At another postnatal ward, we see three women who have had Caesareans and we see one of the babies with a cannula, as it requires IV antibiotics. In the labour room, there are only two beds – one in use, and we see a heart monitoring machine. A midwife tells us she uses it to listen to the baby’s heartbeat, but there is no paper in it and we see no partograms (charts which give an instant overview of labour i.e. pulse rate BP, temperature and the baby’s heart rate) in use. The lady who is present has had some IV fluids and a blood transfusion.
We get taken to the antenatal clinic, where there are 3 obstetricians working. We are then shown into a room which is well equipped with brand new scanner and Brother George is keen for midwives to be trained in its use. On the way to Abdul’s office, he tells us he is one of 11 and his mother died in childbirth. Usman also informs us his sister died in childbirth. It certainly seems like a common occurrence! Abdul informs us about the civil war (1989-2005) and the repercussions. There is still extreme poverty here; 35% of the population are not educated and live in squalor. They live in small tin roofed shacks with no electricity or running water. Fortunately, aid has been coming and we see plenty of wells which seem to be always in use and hope there will be more put into place.
After lunch, we head off to Redemption Hospital which is a free hospital for the poorest people. It is here where The Toughest Place to Be a Midwife was filmed! We travel through miles of extreme poverty through New Kroo Town before we get there, and it is very noisy, chaotic and busy when we arrive. Even as we get out of the car, we are surrounded by people who need help and aid. We are introduced to the head midwife, Yamma and she shows us around her unit. We are visibly shocked by what we see. There is an ante/postnatal ward with 10 beds each side, full of women – sometimes up to 4 women are sharing a bed. The ward next door has a similar layout and we are informed that 2 midwives and 2 carers have to look after each ward. This 2nd ward is for the higher risk women, i.e. following caesarean, anaemia and women suffering from malaria. There is a very high delivery rate here, about 20 per day, with sometimes up to 10 Caesareans performed in one day. She shows us her well-kept statistics and we can see that there have been 3 maternal deaths here from January to March, from Sepsis, eclampsia and haemorrhage. They gladly receive our donations. We are shown around the children’s ward, where we see very sick children and babies suffering from a variety of illnesses. We talk to a couple of ladies with their babies, one baby is suffering from severe malnutrition and another Abraham has had a bad chest infection and is on oxygen and IV medication. They are sharing a cot – it is truly depressing to see. In another ward, we see women providing kangaroo care (babies inside their mothers clothing and between their breasts), there are not enough incubators and 2 women we speak to have both had their babies 7 months into the pregnancy and have been here for the past 2 weeks. The babies are tiny but appear to be thriving and are being breast fed. We look into the busy neonatal ward which is full up with a variety of different size babies. Here there are open incubators, but there are no babies needing life support. The delivery suite is too busy for us to see, so we arrange to work here tomorrow to offer our services and they gladly agree to this.
We feel quite depressed as we travel to our 3rd hospital of the day,James Davies Memorial Hospital; another free hospital in this extremely poor part of Monrovia. Again, it is a very busy unit with about 10 deliveries per day. Here, however, the midwives work 12 hour shifts – one day, one night, followed by 2 days off continuously. We again have to meet the administrator before being shown to the neonatal ward, a very small room crammed with at least 10 cots. It makes us realise how very lucky we are in the UK with all our facilities and equipment etc. It is exhausting taking it all in.
Marie and Tracy with Liberian Midwives at the workshop
Thursday 8th May
We are picked up at 8:30 and taken to Redemption Hospital. We are dressed in scrubs as we are going to observe the labour room and the delivery room. Yamma, the head midwife, meets us about 09:15 and we can see that it is clearly very, very busy! We go into the labour room, which consists of 5 beds and a small area which acts as an office. The room is packed – there are at least 2 to 3 women on a bed. No relatives are allowed to be present. There is a doctors round going on, so we tag on to hear what is being said. All the women present are in the early stages of labour, except for one lady who is postnatal. She apparently delivered at home two days ago and then came to Redemption Hospital following seizures. She was suffering from eclampsia. One of the doctors informs us that this woman had not been treated for 4 hours, from admission until they arrived. She was treated with a bolus dose of Magnesium Sulphate, followed by 4 hourly injections. This poor woman was apparently fitting all day yesterday until 10 PM! Today, her blood pressure was checked and it was 150/100; she is still clearly agitated on the bed.
Amber, a consultant obstetrician from America spent 4 days here, she told us about her experience with 2 ladies suffering from a ruptured uterus. One lady was having her second baby and was labouring for more than 24 hours. A stillborn infant was delivered and the woman had a hysterectomy. The second lady was having her first baby also in labour more than a day. It was a very difficult case that they managed to save the uterus and the baby. Apparently women here are worthless if they can’t have children!
Amber informs us that a maternal death has occurred here today! Last night, a woman had to have an emergency Caesarean for her eighth child at 4 am because the baby was breech and was performed under spinal anaesthesia. The surgery was routine and she went following delivery to the postnatal ward with a healthy 3.5 kg a male infant. She was discovered dead at 07:30. She still felt warm but her pupils were fixed and dilated there were no attempts to resuscitate her! No one seems to want to take responsibility. The apparent cause of her death was too high a spinal block! Another maternal death had occurred 2 weeks previously from a similar cause!
On Amber’s second shift, she was involved in five emergency Caesarean sections. They ran out of spinal needles and went to 3 pharmacies to try and find spinal needles but to no avail, so two of the Caesarean sections had to be performed using minimal pain relief! We go into the delivery room and see there are 3 delivery beds all in use. One lady delivers as soon as we arrive, and all is well. It is her seventh baby (although only 3 have survived) and is 35 years old. She had a normal delivery of a girl weighing 3.5 kg. The midwife stresses the importance of the use of family-planning and urges her to go there before leaving the hospital.
The delivery beds are always in use, they were very quickly wiped down and a clean plastic white sheet was put down. One lady is about to deliver; it is her second baby and then another lady arrives ready to give birth. A slipper bedpan is placed under both the ladies’ bottoms. They both deliver at the same time; one has a girl one has a boy. They both deliver at 10:40! The newborn baby boy is not breathing when he is delivered. The midwife clears the airways. He still does not cry; after it seems like a couple of minutes, I put on gloves to provide stimulation. There is a heartbeat and it is less than 100. We ask where the resuscitation mask is but no one can find it! Fortunately, by this time, the baby responds to our treatment. The three babies are checked and left on the couch unlabelled, not given to the mothers! One of the ladies requires suturing. I give the midwife my glasses to use, as she has mislaid hers and a medical student has to hold his telephone as a torch to provide light so she can suture!
Three midwives work in the delivery/ labour room with 2 helpers, and the same amount on the postnatal wards! The delivery room is very poorly equipped with no air or air conditioning. There are 4 large buckets which are being used to sterilise equipment. The lighting is very poor. The delivery beds are very well worn and threadbare; however, we were very pleased to see that the backrests were upright.
We go for a short break and when we return, the labour room has two different women in it. One is a lady called Saybah who is expecting her third baby and her cervix fully dilated. She is clearly tired and pushes ineffectively when the midwife tells her to do so. After about half an hour and nothing visible, Marie encourages her to move about. She tries squatting and she tries sitting on a birthing chair and on all fours, but to no avail. After about an hour, the midwife goes to get medication and whilst she is gone, the woman pushes more effectively and I end up delivering her by default!
She had a normal delivery of a boy. The baby weighed 3.7 kg and rotated just before delivery! The baby is born with an extra digit which is tied off. The other lady, Promise, has been in labour with her second baby since last night. An Oxytocin drip (after we purchase a cannual for her because patients need to buy their own) has been put up to speed up the delivery. Her progress is very slow and Marie encourages her to move, so she tries standing and sitting on a commode. Marie provides back rubbing and talks to her. Unfortunately, we have to go before she delivers, but happily her cervix is 8 cm dilated when we left! The woman pleads with Marie to stay, but we have to go! Before we leave the delivery room, another lady is seen who is not progressing in labour. The doctors are trying to persuade the lady to have a Caesarean. The lady is not keen because she has no money to pay for this. The doctors tell the patient to find a blood donor from family members and tell her that she may die if she does not consent and her 2 living children will have no mother. We leave before we hear the outcome. We are both mentally exhausted by what we’ve seen!
We go back to Redemption Hospital. Surely it cannot be as bad as yesterday! We enter their labour room and it certainly looks quieter, only 2 to a bed instead of 3 to 4. We go straight into the delivery suite and immediately we see Promise, Marie’s lady from yesterday, still pregnant, and are informed that her baby has died. We are absolutely horrified and very upset! Promise is desperate for water, so we give her some of ours just to sip, as she has probably had no water since yesterday when we were looking after her. Other labouring women open their mouths so we can pour some of our drinking water into their parched mouths; it is distressing to see. There is nowhere here where drinking water is freely available. Amber, the American doctor, tells us what has happened to Promise. There was still a foetal heart at 5 PM but when they listened in at 10 PM it was absent. There was talk then of taking her to the theatre, as she had started to bleed and they were worried about uterine rupture. However, as her condition did not deteriorate, they left her. When we saw her at 9:15 in the morning, she was waiting for a Caesarean section, she had no drip up (it had fallen out!) and the American doctors had to buy a cannula. I end up putting it in as the other midwife had tried a few times with no success. There is no water for us to wash our hands, but fortunately we have sterile gloves with us! The doctors had to go to 3 pharmacies before any tubing could be found, as this was necessary for her to go to theatre. At 11:10, Marie goes with Promise to the temporary theatre (at present, the theatres are being renovated) – the theatre is tiny, at about 8ft x 8ft, and there is no running water in the hospital at all today. When the baby is born (11:15), it is found to be severe hydrocephalus (water on the brain), which is why she never delivered. The baby was a good sized baby at about 3 kg. The doctors had to wash their hands in a bucket prior to putting on sterile gowns and gloves!
Whilst Marie goes to theatre with Promise, I do a quick walk around with Amber the American doctor. On one bed is a lady who had a stillbirth. On another bed is the lady still pregnant, with a baby that died because it was shoulder presentation. There is a lady who has been labouring all night with a breech presentation and will be going to for a caesarean after Promise and there is a lady with her first baby with dangerously high blood pressure, plus other labouring lower risk women. I go back to the delivery suite where I end up helping look after a lady called Grace, who is expecting her second baby and has had no antenatal care. If she delivers, the baby will be six weeks premature. She is desperate for water, so we give her some of ours and I help her walk around. The doctor says to leave her but after all we have seen, Amber is keen to deliver Grace and asks for a Ventouse kit (gentle suction using a cap which is applied to the baby’s head. The baby is then lifted out.) I rush around, asking 3 different midwives where the Ventouse kit is kept but no one knew! We waited for them to look for it, but by this time, Grace had got herself onto the couch and was in the fours position and a small baby boy was born who looked stillborn on arrival. We immediately took the baby to the resuscitation area and, following suction and vigorous tactile stimulation, the baby responded well! The baby weighed 2.350 kg. I check the baby over. We check the delivery records and realise that one of the deliveries we had witnessed yesterday wasn’t even recorded. I ask them if they know about Grace’s delivery this morning and they say they have all the information, despite not even being present in the delivery room! The woman with eclampsia indicates that her back is hurting and we find her drip has gone wrong. Fortunately she has brought another cannula, so I end up inserting it. Her blood pressure is high so the doctor prescribes Magnesium Sulphate which eventually she is given. There is no urgency here from the staff, which is terrible to witness. This appears to be the norm here.
Tracy and Amber with Gracy’s baby
We arrive at the hospital in good time, in readiness for our workshop. Typically, the room where we should have had the workshop is locked. A replacement is found so we set up the projector for the PowerPoint and videos. 26 midwives arrive, which is good. We start with a quick teaching session on hand washing, then move onto Normal Labour, Shoulder Dystocia and Care of the Newborn, including neonatal resuscitation, breech presentation and post-partum haemorrhage. The girls really enjoy the hands-on practical sessions and they all promise to try and do an all fours delivery! At one point, they get up and do a quick song and dance for a 5 minute break. Some of the midwives have been on the night shift and others are going to go on shift straight after the workshop.
Abdul arrives early, so we walk around the local area which is very poor. We see snails being sold at the markets; they are huge! We also see little Angela Alice, who is now a toddler whose mother was saved during childbirth, following the use of Misoprostol. She is about two or three years old and named after Angela Gorman! We look around before being driven to a local church, which is Remedy Church International. It is jam packed and we go upstairs, fortunately sitting under a fan! The pastor is shouting/screaming so loudly we can’t understand, so after a short while we leave, not quite the church experience we were anticipating! When we get back to our room we spend some time chasing after a mouse that has taken up residence!
We go to Soniwein, a small midwifery led unit in Central Monrovia. Here, there about 40 deliveries a month! There are always 2 midwives on duty, working 8 hour shifts. There is no running water here (the well has been out of use for 3 years, so birth partners go nearby to collect safe, clean water) and electricity is temperamental! We get shown into the tiny delivery room, where there are 3 beds. A woman has just delivered and 2 women appear to be in established labour. The equipment is very basic but, looking at the records here, there is a success story! All medicines are strictly monitored and accounted for. They have had no maternal deaths since 1998, as there is early referral and a very well attended and run antenatal clinic. They are in need of basic equipment such as gloves, baby clothes, a resuscitation bag, BP cuffs, weighing scales and maternal height calculators. There is also a well attended postnatal clinic and we see babies arriving to have their vaccinations! Leadership and organisation are obviously very good here! Marie is keen to do a workshop here and Irene, the Officer in Charge, is pleased for her to do this.
We set the alarm for 02:30 and are ready to leave by 03:00. Unfortunately, Usman and Abdul are doing African time and don’t arrive until 03:45! At the airport, we are kept outside for about 30 minutes, which appears to be normal practice here. The airport lounge is very basic and cold. I get talking to our pilot during this time and I inform him of our 8 day stay. When we get on the plane the air stewards want to talk about our trip and when we are airborne we are moved up to Business Class, courtesy of the air crew. What a lovely gesture and a fitting end to our African adventure!