Lead trustee: Dr Tei Sheraton
Since May 2008 MOA has had an ongoing program of educational support visiting Phebe Hospital, Bong County in Liberia three times per year. Phebe Hospital is based in rural Bong County with a population of 357,431. It is an important training centre for healthcare professionals and contributes to healthcare capacity across the country particularly in rural areas. Support from Mothers of Africa has involved the provision of training and updates and the development of a curriculum supported by e learning materials. This program of training is ongoing but we are now reaching a point where lack of facilities is also a major barrier to mothers and newborn babies receiving adequate care.
Whilst Liberia has now experienced 9 years of relative peace after the ceasefire in 2003, the country is still some way away from the development expected or required by the Liberian people. Difficulties in neighboring Ivory Coast in 2011 and then around elections in Liberia in the same year have led to the postponing of three visits in 2011 by the charity. This helps to highlight the importance of Training of people on the ground so that they can be as self sufficient as possible.
A Needs assessment was undertaken by Dr Tei Sheraton and Professor David Southall 24th February 2012 -1 st March 2012
With the help of Dr Meena Cherian, lead for the EESC (Emergency and Essential Surgical Care) programme at WHO in Geneva and Dr Lawrence Sherman Director of The Firestone Hospital in Liberia we produce below a summary of our findings.
Dr Cherian was able to visit the two hospitals in Bong County and a clinic. She also facilitated meetings with the MOHSW and with the WR of Liberia, Dr Nestor Ndayimirije.
Our assessment focused on Bong County, population 357,431. ABHB serves a population of about 500,000. Royal Gwent serves about 300,000 population so is comparable.
In 2011 there were 8216 deliveries in the county, 7135 undertaken in health facilities by skilled birth attendants. 471 CS were undertaken in 2011. 681 deliveries occurred at home without skilled assistance. There were 24 maternal deaths, 34 neonatal deaths, 38 infant deaths and 59 under 5 year deaths in 2011. The HIV rate in pregnancy is 4%. 116 pregnancies occurred in women under 18 years of age. The national caesarian section rate is 4%, which represents a lack of access to surgical intervention. We would expect a rate of around 10%. There is a dire shortage of trained healthcare workers. There are only 3 Liberian doctors serving Bong County and many of the distances are very large to get to a healthcare facility.
Following the needs assessment Mothers of Africa was ONE OF THREE UK MEDICAL CHARITIES AWARDED A THET/UKAID GRANT FOR A GROUNDBREAKING PROJECT TO IMPROVE MATERNAL AND NEONATAL MORTALITY IN LIBERIA
This groundbreaking project to improve maternal and neonatal survival in Liberia, lead by the Ministry of Health and Social Welfare of Liberia, has been awarded a £248,000 grant by the Tropical Health Education Trust (THET) and the UK Department For International Development (UKAID). The lead UK organization is Aneurin Bevan Health Board in South Wales (http://www.wales.nhs.uk/sitesplus/866/home). The project also involves The Royal Wolverhampton Hospital http://www.royalwolverhamptonhospitals.nhs.uk/), Maternal and Childhealth Advocacy International (MCAI) (http://www.mcai.org.uk/default.aspx), Advanced Life Support Group (ALSG) (http://www.alsg.org/uk/), The Association of Anaesthetists of Great Britain and Ireland (AAGBI) who feature opportunities for volunteering on their website (http://www.aagbi.org/international/volunteer-opportunities-overseas), the Royal College of Anaesthetists (RCoA) (http://www.rcoa.ac.uk/news-and-bulletin/rcoa-news-and-statements/mothers-of-africa-educational-initiative), The Royal College of Obstetricians and Gynaecologists (http://www.rcog.org.uk/international/working-and-volunteering-overseas/liberia-uk-obstetricians-required) and the World Health Organization (http://www.afro.who.int/en/liberia/who-country-office-liberia.html)
All partners will work together to train midwives, nurses and doctors in the emergency care of pregnant women and newborn babies, including the training of selected midwives (obstetric clinicians) to perform emergency obstetric surgery such as Caesarean sections, and of selected nurses (anaesthesia and critical care clinicians) to deliver anaesthesia and provide basic critical care for pregnant women and newborn babies. The three UK charities, Maternal and Childhealth Advocacy International (MCAI), The Advanced Life Support Group (ALSG), and Mothers of Africa (MOA), will work together to oversee the training of midwives who have been selected by the Liberian Ministry of Health. The Aneurin Bevan Health Board, the Royal Wolverhampton Hospital and the Royal College of Obstetricians and Gynaecologists will help to provide volunteer UK experts to support and mentor Liberian doctors who will train the midwives in obstetric surgery. The World Health Organization is leading the monitoring and evaluation of the project. However training is not the only issue and this is where you could help:
This is the main teaching hospital in the county. It has between 175 and 200 beds and there are 4 doctors based there: all perform obstetric emergency surgery including Caesarean section (CS) and obstetric hysterectomies. There are 5 nurse anaesthetists but no medically trained anesthetists in the country. Dr Sibley is the hospital director and Dr Garfee Williams is the regional director of healthcare in Bong County.
The doctors, nurse anaesthetists, nurses and midwives are well motivated, but work long hours and in difficult conditions. .
The hospital needs renovation. The sewage system is poorly functioning. The Emergency Room is poorly equipped and needs renovation and basic emergency equipment. The obstetric unit also needs renovation and equipment. There is a near completed HDU next to the operating theatre, which needs renovating and a ventilator. It could soon be operational. Provided sufficient staff are available.
Renovation of 3 areas and provision of basic equipment for Phebe Hospital
a) The Emergency Room requires decoration, safer electricity and more reliable plumbing, decent lighting, an air conditioner, and essential medical equipment such as pulse oximeters, ECG monitors, electronic BP machines, electric suction equipment, portable screens for privacy, portable examination lights, better examination trolleys, two oxygen concentrators as well as properly mounted oxygen cylinders, an emergency trolley, nebulisers, pathways of emergency care on the walls. The existing ER needs to be re-designed to make more space.
b) The antenatal, postnatal, labour and neonatal wards all need decorating, improvements to electricity and plumbing, an air conditioner in the labour ward, decent lighting and more privacy. The neonatal unit needs an incubator, phototherapy, resuscitaire, pulse oximeters, electric suction machine and oxygen concentrators. The obstetric unit needs a high dependency area with pulse oximeter, electronic BP machine, electric suction unit and manually tilting bed.
c) The provisional high dependency unit (HDU) next to the operating room needs to be commissioned.
There are already high quality beds, 24 hour electricity and an air conditioner in this unit. Additional requirements are: power surge protectors and many more electric sockets, better plumbing, decoration, privacy screens, 2 pulse oximeters and 4 oxygen concentrators, oxygen cylinders in properly constructed supports, electronic BP machine, electric suction system, a basic, reliable ventilator suitable for adults and children, emergency trolley, drugs trolley, special HDU charts, ECG machine and AED.
Can we fund raise to help support these renovations for Phebe Hospital?
Partners in Liberia
Our activities focus on training and education. We only provide input at the invitation of local people and work alongside them to develop appropriate training for their own setting. One of our most inspiring “men on the ground” is Mr Wilmot Fassah. He is in his 60s and for many years was the only nurse anaesthetist in the main hospital in Bong County, Liberia serving a population of over 300,000. During the 15 years of civil war, which ended in 2003, the hospital came under attack three times. Each time Mr Fassah would take the training manikins and move them somewhere safe so that he could continue using them for training purposes. He had promised the medical anaesthetist who set up the school in Phebe (wife of the current Liberian minister of health Mr Gwenigale) that he would look after the school and continue training anaesthetists. Despite the obvious difficulties he managed to inspire young nurses to take up the training. One of these nurse anaesthetists Gogoe Augustine now runs the training school alongside Mr Fassah. See Fig 3 for more information about nurse anaesthesia training in Liberia.
Fig 1: Mr Fassah: Head of the nurse anaesthesia school in Phebe stands outside thaeatre. He is committed to rejuvenating nurse anaesthesia training in Liberia to be the best in West Africa.
Fig 2: Mr Gogoe Augustine wins a prize at a MOA sponsored Liberian Association of Nurse anaesthetists (LANA) conference in 2009. He is now one of the three nurse anaesthesia trainers in Phebe Hopsital, Bong County Liberia and current secretary of LANA.
We believe that success of our projects is dependant on reliable personal contacts on the ground in the countries that we visit and excellent skills of our volunteers to both teach and to teach in country teachers. We work with others to achieve our aims. Our partners have included Gwent Link , Maternal and Childhealth Advocacy International (MCAI), and Association of Anaesthetists of Great Britain and Ireland (AAGBI) International Relations Committee .
We do not set up supply chains for drugs or equipment; or dump unwanted/second hand/inappropriate medical equipment or unwanted educational resources.
Fig 4: Map of Liberia: Liberia is situated in West Africa, bordering the North Atlantic Ocean to the country’s southwest. It lies between latitudes 4° and 9°N, and longitudes 7° and 12°W. The landscape is characterized by mostly flat to rolling coastal plains that contain mangroves and swamps, which rise to a rolling plateau and low mountains in the northeast.
Providing training and support
Following a needs assessment in Bong County, Liberia in February 2012 (figures 5,6) Mothers of Africa are seeking up to 8 experienced (ST5 or above or consultant) anaesthetic volunteers to be resident in Liberia for a minimum of 3.5 months. The program will start in January 2013 and there will be time included for handover to the next volunteer. Volunteers would be supporting nurse anaesthesia training as well as monitoring and evaluation of that training in collaboration with the Ministry of Health in Liberia and the World Health Organization (Liberia and Geneva). Volunteers would be working alongside an experienced UK Obstetrician who will be undertaking an equivalent role in obstetrics training 8 nurse midwives to undertake emergency obstetric surgery over a period of two years.
This program is part of comprehensive Emergency Obstetric Care (EmOC) program, and if successful it will mean that areas of Bong County where there is no access to emergency obstetric surgery will have this provided by pairs of nurse anaesthetists and nurse midwife surgeons. There is potential for the program to be rolled out in other countries where there is a dire shortage of trained personnel.
Dr Samson Arzuquio, experienced Liberian GP surgeon was interviewed as part of the needs assessment at the newly opened CB Dunbar hospital in Gbange. This hospital is one of the three in the county that can provide comprehensive EmOC and one of two that the volunteers would teach in. During the interview he explains how a woman dies in childbirth despite her family’s best efforts to get her to his team. The long distances and dire shortage of skilled healthcare workers mean women die unnecessarily in childbirth. . He also told of a midwifery colleague who lost her newborn baby despite their best efforts and the need for more training in basic neonatal care.
Introducing Critical Care
In addition to supporting training of the extra 8 nurse anaesthetists the long term volunteers would support the current two year nurse anaesthesia training (approximately 6 students per year) and oversee the introduction of context appropriate critical care for adults and new-borns into the curriculum. Dr Paul Fenton reported in the BMJ in 2003 that 80% of maternal deaths in 25 hospitals in Malawi occurred on the ward in the post-operative period . Dr Ray Towey (Consultant Anaesthetist) recently presented at a World Anaesthesia Society Seminar held at the AAGBI. He has more than 10 years of experience from a critical care unit in rural Uganda and collected data from July 2005 to date representing 2,314 critical care admissions. The unit has usually 1 trained nurse to 4 patients and offers basic critical care including sedation, ventilation, and good fluid management. ICU mortality ranged between 27 and 31% over a six-year period. It is likely that most of the IPPV and many of the HDU patients would have died without this facility. Dr Towey’s experience suggests that even in remote rural African areas an effective ICU/HDU facility is possible with modest funds.