New-born mortality rates in Ethiopia down by 40% thanks to VSO volunteers

In Ethiopia, the first 28 days of a baby’s life can be a matter of life or death. Since 2013, international development charity VSO has increased the number of neonatal intensive care units in Ethiopia from three to 16. According to VSO’s latest Annual Report, volunteers such as British obstetrician and gynaecologist, Alexa Vardy, have improved the healthcare of over 33,000 babies and women in the last year. Alexa reflects on her experience…

As a doctor, I’ve always been keen to share my skills by volunteering abroad. Leading international development charity VSO believe in putting people at the heart of development and sharing skills to change lives. This ethos is important to me. Thanks to the Royal College of Obstetricians and Gynaecologists / VSO Fellowship, it was easy to sign up and volunteer. I had been working in obstetrics and gynaecology for over five years, performing operations such as caesarean sections and instrumental deliveries. This meant I was eligible for the ‘Out of Programme’ experience, which ensured I had a job to return to after my placement.

I spent a year working as an obstetrician and gynaecologist at Abi Adi Hospital in Tigray, Northern Ethiopia. This is a rural hospital with approximately 1000 deliveries a year. It has a patient population of around 400,000, with some travelling up to 50km – often by foot – to reach the hospital. Sadly, only 10 per cent of women have a skilled birth attendant present at delivery and only 34 per cent of women receive antenatal care. The maternal mortality rate in Ethiopia in 2012 was 676 per 100,000 live births, compared with 10 per 100,000 in the UK.

My placement was part of the Maternal, Newborn and Child Health initiative, aligned with the UN’s Global Goals, which aim to eradicate poverty and make the world a fairer place. My role was to improve the delivery of services and arrange training to reduce maternal mortality. In reality, I did a lot more hands-on work, delivering around 100 babies by caesarean, vacuum (power permitting!) or with forceps.

When I first arrived, I was impressed with the general lay out of the hospital. The wards were single storey connected by external covered walkways, but the delivery room had three beds with no privacy, and hygiene left something to be desired. My main Ethiopian colleague was a health officer with a Masters in Obs, Gynae and Emergency Surgery. It was a big surprise to me – and all of the doctors who came out to volunteer with VSO – that we wouldn’t actually be working with doctors! My colleague was the only person to cover these specialties and he was on-call 24 hours a day, seven days a week, 365 days a year.

It’s amazing how quickly I got used to things that seemed very unusual at first. There’s no real sense of urgency. During my first emergency, I was stopped! Power cuts and water shortages are the norm. There’s a reliance on traditional healers as patients tend to pay for investigations and treatment here. Occasionally, this results in a delay in receiving the right treatment, eg, a young woman with eclampsia was brought to hospital very late as it was assumed that she had a bad spirit inside of her. The traditional healers had tied her hands and feet together and burnt her soles in order to release the spirit.

Three mornings a week, there would be a ward-round. The rest of the day would be taken up with antenatal or gynaecological patient reviews, performing ultrasounds or attending emergencies. Partograms were rarely completed. This would lead to the late diagnosis of obstructed labour which would sometimes lead to stillbirth or obstetric fistula. Maternal and foetal mortality were simply accepted without the need for review to see if any improvements in care could be made.

As neonatal mortality is particularly poor in the Tigray region of Ethiopia, my priorities for the first training session revolved around partograms and neonatal resuscitation. After intervening in neonatal resuscitation during several deliveries, the paediatrics master asked me to arrange appropriate training for the midwives. Resuscitation usually consisted of bulb suction and back slapping whilst holding the newborn upside down. Inflation breaths – though part of the resuscitation protocol – were frequently omitted. This was often all that was needed.  Thankfully, VSO has had great success with the 16 neonatal units which they have helped open across the country, reducing newborn mortality rates by 40 per cent. I had the opportunity to visit the neonatal unit at Arbaminch Hospital, set up by previous VSO volunteers. The great work which goes on there helped me write the NICU proposal for Abi Adi Hospital.

Besides providing training, my main achievements were reducing the rate of caesarean section at full dilation, by encouraging the use of instrumental delivery. This is much safer for a woman who may not be able to return to the hospital in her next pregnancy and with a one night versus eight-day hospital stay postpartum. I also encouraged the use of opportunistic ultrasound in any pregnant woman who presented to hospital for any reason during her pregnancy. This helped ensure that molar pregnancies and congenital abnormalities were picked up, as well as providing a better estimate of gestation.

In Ethiopia, over 80 dialects are spoken and the language barrier was certainly a challenge. I often wondered how much was lost in translation. Whilst the medical notes were in English, few staff was conversant in it and would usually use the Fidel alphabet. Few girls in rural areas can read and write, as they often leave school early to help with housework or to get married. In a bid to reduce the number of child brides, virginity tests are often carried out, consisting of a wrist X-ray to estimate age and to see if the hymen is intact. I had an ethical issue with this practice.

The thing that I found distressing was performing destructive deliveries. This is done to aid delivery where the baby has died in-utero, normally during labour, and involves a number of procedures to reduce the foetal size. Thankfully, there is no need for this in the UK. The lack of facilities such as high dependency care and a lack of drugs also meant that we couldn’t manage people how we wanted to.

Patients and their families were usually very grateful for my assistance and would kiss my feet. There was some suspicion about my knowledge and experience when I first arrived as I am ‘young’ and female. I was the only “ferengi” (foreigner) based at the hospital and thus a source of fascination and amusement! The highlight of the job was undoubtedly delivering healthy babies and the feeling that I had truly made a difference.

Overall, the year was fantastic, but heart-breaking at times. I would thoroughly recommend gaining experience in global health as it’s useful and enriches your career. It was fascinating to encounter so many different problems to those that I usually see, including tropical diseases and unusual pathology which would normally be picked up at a much earlier stage in the UK. I have more confidence in my abilities now and I’m undoubtedly a better communicator since my return. I’ve learnt so much and met so many wonderful people.

For more information about VSO and volunteering oppoertunies, please visit: https://www.vsointernational.org/healthroles

Staff Writer