Will I recover from the reverse culture shock?........................

March 14^th

 

Just assisted (well a few hours ago now) a woman in having a "normal" vaginal twin delivery (with no junior doctors or keen midwives wanting to conduct/do the delivery I am allowed to do this here- I enjoy this "hands-on" involvement although in all honesty I didn't really do anything other than be there in case there was a problem as the woman did it all herself).

She was a woman who had attended for antenatal care previously and thus we had diagnosed her twins some weeks ago. The news that it was twins didn't really surprise her as she has already delivered two sets of non-identical twins (predictably here one of the babies from her first delivery was stillborn but the other three are alive and well). The first baby was in a breech (bottom first) position and we also predicted (based on the position in the uterus) that the second twin would also deliver as a breech as well. When we saw her in clinic last week we recommended caesarean birth with tubal ligation to her- as this is recommended practice here the same as it would be in the UK although I have not been able to get a very concrete reason for this recommendation in view of the maternal morbidity attached to caesarean birth (both now and in future pregnancies) and the fact that the evidence from big studies suggests that there is actually only limited if any benefit for the babies in caesarean when they are breech in populations with a high perinatal mortality (which is definitely where we are here). However we do have difficultly in monitoring twins (most have continuous monitoring in the UK which is not an option her) and of course my resuscitation skills although now better honed than when I arrived are still not those of a neonatologist. So I decided that in spite of misgivings I would make the recommended recommendation!

Perhaps for the first time since I have been in Ethiopia the mother's response was to disagree with the recommendation and to say that she wanted to plan to deliver her babies vaginally- a long discussion with the clinic translator was roughly interpreted to us as "she says she delivered the other babies normally and two of them were bottom first , and  also she needs to get back to working on the farm soon after delivery"-in the circumstances this did not seem an unreasonable argument. So we persuaded her that she should come to Gimbi Hospital for the births (her other births were at home) and she agreed that she would do this. She was 37weeks at this point looked marvellous and had no complaints about anything at all (not even backache) - I have a photograph of this tiny woman with a huge bump smiling that wonderful Ethiopian smile (shame I can't attach pictures with email postings!).

She arrived in the early hours of this morning in labour and was happy with her plan for vaginal birth. The labour progressed normal but as is sometimes the way with third babies it was not quite as quick as her second labour. The midwife Sintaiyu, who was caring for her seemed u happy that the woman had "chosen" to deliver vaginally against the recommendation of the doctors (the idea of patient choice in most things is at best embryonic in Ethiopian practice and it is something I have spent a significant amount of time "banging" on about to try to increase the acceptance of involving women in decisions about their care) and muttered repeatedly that she didn't want caesarean section in a slightly disapproving way. I had assumed that she was repeating the conclusion of the clinic counselling but it transpired that she was asking the woman again repeatedly through her labour if she would agree to have a caesarean section. This fact became apparent when Sintaiyu came to me 10minutes after we had diagnosed full dilatation (i.e. it is getting very close to the birth of the babies normally) so say (very proudly) that she had now succeeded in getting the woman to agree to have a caesarean section.

At this point anyone reading who works with me will be smiling, knowing exactly what my response to such a request at this point in labour would be in the UK- a straight forward and categorical "No" . I'm not mean but on the balance of risks we are now at the stage where safe vaginal delivery has become very likely and at the same time the chances of complications from caesarean birth are much higher so that for a doctor who wants to do the best for their patient and particularly if they want to do the thing that is likely to involve least harm it is a very easy decision. In Ethiopia the decision was even easier as although our caesarean sections generally do fine, they definitely have more complications than the successful vaginal births. You can add to this the financial argument (which in the past we have had the luxury of ignoring in the UK although I suspect those days may soon be over) which is that in this hospital normal birth cost about 400burr (£20) and caesarean section about 1200burr (£60) - I don't know if this woman will require the safe birth fund but the fund will go a lot further if women are able to deliver vaginally.

Unfortunately poor Sintaiyu is now confused as she felt that she was doing as I would have wished her to do by involving the woman in choices about her care- more work needed for a complete understanding of difference between choice and brow-beating I think!

Anyway the woman seemed to cope with my refusal to agree to her "wish"  and 30-minutes later she delivered the first twin, a boy as a breech and 20-minutes after this  a girl who somersaulted into the pelvis and came out headfirst. Neither baby required any resuscitation, weighing in at 2.5kg each. This weight would be considered respectable here for a singleton and for 38week twins are very healthy weights. When I think that this means shat this 45kg woman was carrying 5kg of baby (plus at least 3kg of fluid and placenta), I can only marvel at the constitution that allowed her to smile and make no complaint in clinic less than a week ago-not to mention the fact that between that clinic appointment and delivery today she has been out working in the fields where she will almost certainly be again in a few days with breast-feeding twins in tow.

I realise that I am going to have to steel myself for a reverse culture shock experience when I come home and in particular force myself to dig deep to find my old sympathy for the women in my antenatal clinic who come complaining of minor aches and pains but who don't realise how lucky they are not to have to work in the fields when heavily pregnant.

Will I ever know what happened?....................

March 12^th

 

The saddest photograph that I have taken in Gimbi is one that shows a brown cardboard box sitting on top of a silver pedal bin. The box is one that previously had latex gloves for surgery packed in it and this old content is printed in large blue letters on the sides of the box. The box top is closed, in time honour fashion by folding the top edges inside on one another, as there is no tape or string available here. The only clues about the contents of the box are the letters "F1" written in black marker pen on the top.

F1 is a bed number (female ward-bed 1) and the box contains the body of the dead baby of the woman in this bed. Sadly even I can't remember why this particular baby died as the death of a baby occurs so frequently here. Looking at the statistics for February more than 1 in 7 babies were stillborn or died soon after delivery- as a result it is not uncommon to arrive in the morning and find one or more cardboard boxes packed and waiting for the parents to take when they leave the hospital.

Not surprisingly women protect themselves against the chances of pain of loss by an apparent refusal to become attached to their babies until it is born (when survival even if for only a short time are more guaranteed). When ultrasound scans are performed in clinic in is unusual for a woman to want to look at the screen or to know the sex of the baby. Telling a woman that her baby has died (something I have to give on an almost daily basis) is met with resignation- in my time here I have seen only three women cry although the majority of them do appear very sad at the death of their baby with fewer of the broad Ethiopian smiles and an introversion in speech and manner which is uncharacteristic. Women arrive with nothing in labour  for the newborn baby which is partly the fact that many of them own little but even the better off do not tempt providence by arriving with so much as a blanket before the baby is born.

The midwives also have what on first encounter can appear to be a shockingly casual attitude to the death of a baby- but this is just a way of getting through a daily event without becoming emotionally involved (as to do this would make coming to work very draining psychologically). Unfortunately this attitude from mothers and midwives leaves them where we were in the UK 20years ago, with a dead baby whisked away with no enquiry about whether the mother wants to see, let alone hold it. There is little discussion about what happened- and although there is often little to tell by way of medical explanation (due to the lack of any post-mortems or investigations) we can still offer advice about having more care next pregnancy but it sometimes is difficult even to get this information translated & relayed to the woman.

So why do so many babies die you might ask? In fact it is very hard to fathom even when you are "part"of their care- a significant number of babies die before the onset of labour (or arriving at the hospital for any care), further investigation if it were possible might reveal that the baby was not growing properly or that there was a congenital abnormality but the sheer numbers suggest that the poor nutritional status, chronic parasite infections and social deprivation in these women must also be contributing to this sad outcome of their pregnancy.  There are also a number of babies that die following prolonged labour at home where the women come too late for us to be able to save the baby who has become very short of oxygen and may also be infected. In addition there are a much smaller number of babies who die because of monitoring or care issues after delivery, which could have been avoided if things were done differently but the attitudes to the baby are such that it is difficult to get rapid changes in practice.

A small number of babies die in Gimbi hospital as a result of prematurity- these are babies that are born 6-8weeks early who struggle through for days or even weeks but finally succumb to feeding issues and infection. We don't see more extreme prematurity at the hospital, but as labour must happen in at least 10% of women before 32weeks I can only assume that the reason is that the families realise there is no hope for the baby at this gestation and so don't waste time, money & effort in coming to hospital, choosing instead to stay at home and let natural course of events occur. The hospital deaths due to mild prematurity feel particularly tragic, as I know that if these babies had been born in any developed country they would survive with only minimal intervention but unfortunately even that level of care is not available here and so survival is only possible if the baby is able to put up a fight against nature.

Thankfully some premature babies are amazingly strong- yesterday I saw a woman who came to outpatients with a tiny, 6-day old baby girl in her arms. (1.61kg on weighing her), she wanted the baby to be checked as she had been born prematurely. The mother had been attending outpatients regularly as she had a history of delivering four previous babies at about 28weeks (7 months) gestation (they talk in months which can be confusing) who as expected died soon after birth.  There was not a lot we could do to ensure a better outcome for this pregnancy but as there is evidence that regular antenatal care can prolong pregnancy in this sort of history, we encouraged her to attend regularly. Not sure it was anything to do with the clinic visits but this time she did get to 33weeks gestation (which was a date confirmed by ultrasound) before going into labour and had delivered her baby at home. Miraculously this baby was vigorous with no apparent breathing problem and a good suck/swallow reflex (witnessed by the fact that at 6 days of age it had no dehydration)- I contemplated whether we should admit mother and baby to the ward but the risks of hospital acquired infection (including TB) are not insignificant and the reality is that there is very little that the mother was not already providing that we could do so I explained about ensuring the baby was kept warm (we recommend "kangaroo care" with skin-skin for long periods) and recommended breast feeding every 2-hours if possible and she went home again-I just hope to see her in clinic again next week( this was suggested) as if she doesn't come I will never know if it is because the baby is doing well or has gone the same way as its siblings.

 

The test of acquired greeting skills...........................

March 8^th

The local language is called Oromifa and although I had not previously heard of it, it is the third most commonly spoken language in Africa after Swahili & Arabic. The official language of Ethiopia is Amharic, which is in reality only spoken by a minority of the country's population. In the past there have been political moves to make Oromifa the official language but as the Amharic speakers tend to be the most educated people (and hence often the" ruling" class) and as Amharic is a language that is particular to Ethiopia (Oromifa is spoken in Sudan, Uganda & Northern Kenya as well) these moves were unsuccessful. Amharic is a Semitic language whereas Ofomifa is a tribally derived language and thus there are absolutely no similarities between the two. Hence the few words of Oromifa that I have toiled to learn (languages were never my forte and it definitely gets harder as you get older) will be almost useless to me once I leave Gimbi to go travelling as the language of the North is Amharic and the South has other rare tribal languages & Amharic. Oromifa is spoken in Addis but as Ethiopians there also speak the best English (and like to practice) I am unlikely to use it much.

In Gimbi and the surrounding areas the majority of people speak Oromifa with only a small number speaking some Amharic as well. The nurses and midwives usually speak Oromifa & Amharic and in addition to this they will have a varying ability in English. Tekle (the Ethiopian Obstetrician) doesn't speak Oromifa only Amharic (see earlier comment about educated/ruling class) and so also requires translation.  As a result the ward round and clinic (if Tekle is there as well) require a 3-way translation-Oromifa to Amharic and Oromifa to English (or Tekle will do Amharic to English in a relay).

The translations in clinic can be bewildering-to start with one thing that I have learned not to question is the age that is written on the outpatient card. Often a woman will appear to be a older than the age that there cards states (and in case you wonder there are no sensitivities that mean that women beyond a certain age start to subtract years here) I used to ask about this but learned that the discrepancy is because people do not know how old they are as there is no birth notification, few people have calendars or anyway of recording dates as they don't read and write (apparently those with some education will write the dates of birth of their children in the family bible). So if I questioned the age of a patient I would sit through a protracted discussion between the clinic nurse and the patient that seemed to involve reminiscences about memorable events (droughts, bumper coffee harvests etc.) that allowed her to gauge her likely age- the summary of this would be along the lines of "yes-she might be a bit older" so I have learned to judge by appearances and only ask the question if it will make a material difference to my management (which is very rare). The other problem with translation is when as apparently simple question like "how many children does she have?" leads to a long and sometimes heated exchange between the nurse and the patient- the answer will come back eventually as "five" (or whatever) leaving me none the wiser about what was being discussed. for so long and so animatedly.

Greetings in Oromifa are one of the most amusing things, as they seem to involve a competition to see who will run out of possible greetings first. The most commonly used greetings are either "Nagada?" which literally means "is there enough?" or "Fayada?" which means is there health?" The responses are "Naga"-"there is enough" or "faya"-"there is health". These can be used as a response to either question (which given the questions does make sense). In addition to this there is "akkum" which sort of means "hello" and "Atembulteh" which is "good morning" - the response to either of these is also "faya" or "naga". So an exchange on arriving on the ward may go along the lines of "Akkum", "Naga-fayada", "Faya-Atembulteh", "Faya-Nagada", "Naga"-well this is the way it seems anyway and whether or not I start the exchange or am the respondent unsurprisingly it is always me who runs out of greetings. Greetings are common as you would greet or be greeted by strangers on the street with a"fayada""naga" exchange (thankfully it need go no further) and on meeting someone you know the full exchange is expected along with a minimum of a hand-shake (a very casual acquaintance) through to grasping hands in a hand shake and leaning forwards to "bump" shoulders right then left then right again (a bit like the movement to kiss on alternate cheeks without the cheek contact or air kissing) which you would do for someone you see regularly or know fairly well.

As if the extensive greetings are not enough the patients will often shake hands in clinic as well particularly the older ones-the very elderly will proffer their wrist rather than their hand, which is done as a sign of respect to you as a doctor (this practice is also used if you have dirty or wet hands when the hand shaking uses hand to wrist but does not cease).

The fact that you are a "faringe" makes it no less likely that you will be greeted where ever you go and in fact I suspect it may make it slightly more likely as seems to be used as a sort of test to see how much you have learned by judging in how many greetings physical and verbal you can string together before you run out!

 

As if more threats to a mother's life are needed...........

March 7^th

 

Regardless of whether you feel termination of pregnancy for "choice" is ethically appropriate, the reality of the situation here in relation to induced abortion is such that it results in serious morbidity and mortality for women.

My (limited) understanding is that termination of pregnancy is legal in Ethiopia but only in the limited circumstances where the pregnancy is serious threat to the health of the mother or where the baby has an abnormality that is lethal or very severe (which is on paper much more limited than in the UK). However although not technically legal termination of pregnancy is undertaken in some "private" medical clinics and Marie Stoppes International also runs some clinics with the law apparently "turning a blind eye" if the procedure is undertaken very early-the problem is that the former charge high fees that many women can't afford and the latter although free or low cost are few and far between.

Unfortunately sex education in schools is at best rudimentary, culturally parents do not tell their children anything (I have heard stories of girl's who thought they were dying when their first menses occurred rather like in Victorian England) and free contraceptive advice although technically supported by the government is not well advertised or widely available. In a society where a "virgin" bride remains prized, falling pregnant outside wedlock is a social disaster with repercussions for mother and child for the rest of their lives. This background sets the scene for two very tangible types of problem for us at the hospital: one sad and difficult and the other tragic and life threatening.

The first issue is that a number of unmarried pregnant women (frequently teenagers) will come to the hospital to deliver each week and then want to have their babies adopted. Sadly adoption is not a common practice in Ethiopian society (men will divorce a woman who appears incapable of bearing children-even though it may be due to a male problem & remarry rather than consider giving a home to someone else's child) so that the only option for true orphans is usually an orphanage of some kind.  The maternal mortality rate & low life expectancy for both men and women means that there are plenty of orphans although many will be taken in by the extended family.

Gimbi has a number (about 20) of orphan street boys (from babies through to early teens) who are cared for by one of the big-hearted long-term Faringe (Monica) who has created an orphanage by renting a room for them in the town. She pays someone to ensure that they are fed and receive clothing & basic medical care- I did ask what happened to the girls and was told that they are "taken in" by families and basically become unpaid servants. You see these orphans around and about in the town when you go to the market-they are distinctive as they invariably wear the same T-shirt (donated in batches) and unlike other children they do not ask for money or food as they are taught not to beg. As you are walking down the street you will feel a sticky, grubby hand slip into yours if you leave it dangling free-it is heart rendering that all they want is to walk the street holding hands with a grown-up like other children do all the time and will eventually decide it is time to go their own way without asking for anything more than this human contact. These children all have mother's who died in childbirth at the hospital and have extended families who unusually were unable to support them- the nearest proper orphanage is in Addis but unfortunately there is now a lot of "red-tape" to prevent child trafficking (and underhand practices in procuring children for adoption abroad) which means that it is very difficult to arrange transfer of a child from Gimbi to Addis.

In Ethiopia abandoning a baby is a crime, which is fortunate as otherwise it would be hard to prevent women with social issues leaving their babies with us but they know that attempts to trace them by the police and that this will only make the situation worse. However hard it may seem, the hospital is not an orphanage so we are not able to take the babies from them but there is a system of basic social work to try to help them financially to keep the baby.

The second problem is that "back-street" abortion is very common. We saw a pregnant 17year old yesterday who came to the outpatient clinic bleeding, doubled over with severe abdominal pain and also with a high fever. Initially she claimed she was miscarrying spontaneously but on questioning admitted she had seen a village woman and had undergone a procedure to "bring on" the miscarriage- details beyond this are sketchy as the girl herself was not really sure what had been done.  Examination & a scan showed that she had not "miscarried" completely and suggested that there was either a serious infection in her abdomen or that the uterus had been perforated during whatever probably non-sterile "operation" had taken place.

We arranged for her to be admitted for high dose intravenous antibiotics and planned to open her abdomen later in the day to view & repair any damage that had been done (this could be done by a key-hole surgery procedure in the UK but here the only option is to do a large operation).  Unfortunately without the knowledge of any of the doctors, she was sent by the ward staff to pay a deposit for her treatment (these sort of procedures are classified as gynaecology and so does not technically get covered by the Safe Birth Fund). We don't know what happened but after a discussion with the cashier about the cost she left the hospital-it is possible that she is younger than 17 and unlikely that her parents know so she has no access to money. The chances that she will survive without medical treatment are slim and certainly if by some miracle she does pull through she will be unlikely to ever fall pregnant again (this is unlikely even if we had been able to treat her). Tracing patients here is very difficult and doing it quickly is almost impossible as we do not have a specific address for them with only the name of the Kebele they come from (a sort of village district) recorded, which for her is about 2-hours from here. Someone has been sent out to her Kebele on the hospital motorcycle this morning to try to find her and bring her back (we can worry about the funding later) but as yet there has been no word- as her condition is "sensitive" enquiry is going to be difficult anyway.

When I was out at the rural clinic in Muggi I took a photograph of a poster that I thought was rather macabre- it is a drawing depicting a young woman undergoing a "bloody" non-specific procedure in a village hut by a older woman in traditional dress with a skeleton "grim reaper" figure looking over her shoulder- the caption read "Backyard abortion-threatens lives". I now realise that such a stark warning is very necessary here.

 

Much better than a box of chocolates.......................

March 4th

 

Into my final month in Gimbi- I can hardly believe I have been here for 8 weeks and now have only 3 weeks until I go back to Addis to meet Mark for our holiday travelling in Ethiopia- There is so much to do here that sometimes the bit that I can do really does feel like a drop in the ocean (a phrase from my original fundraising statement)- so it is reassuring to have some confirmation that what you have done has made a difference to the life of a woman (as how ever much we feel we can soldier on regardless positive feedback always feels good).

In the future some epidemiologist is going to struggle to work out why there is a  localised popularity of the name "Leonie" in South London and the "Leonies" so often had premature or other  problem births  but it will create a bit of academic interest. You will be relieved to hear that so far no Ethiopian girls have been named after me here but I did get the opportunity to name a boy born in Gimbi this week.

It was the mother's first pregnancy and thankfully as she has a relative who works at the hospital she chose to come to hospital to give birth (this is unusual as the majority of women with apparently uncomplicated pregnancies will deliver at home with only a traditional birth attendant or a female relative to care for them) . I say thankfully as although she had a quick labour and a normal birth of her son (who was a healthy 3.9kg-huge by Ethiopian standards) she proceeded to have an unexpected and very severe post-partum haemorrhage (loosing almost 2lires of blood). In the UK about 5-10% of women have increased bleeding after delivery (but most of these are still much less than 2litres) and this was one area that I was expecting to be a big problem here due to the lack of transfusion and the fact that women have lots of babies (which increases the chances of a haemorrhage even more) but the rate of haemorrhage for reasons I cannot fathom is much lower than the UK in our hospital (I've wondered whether it is genetic that women have uteruses that contract better after delivery  due to "natural selection" or maybe that it is something to do with the altitude making blood "thicker"- neither theory has any foundation in medical fact that I am aware of but my resources fro research are non-existent at the moment).

The midwives here called me very promptly but by the time I arrived she had already lost a lot of blood. We worked quickly in stopping her bleeding (compressing the uterus to make it stop immediately & giving drugs to ensure it stayed contracted), resuscitated her and lined her relatives up to donate blood to transfuse to her. The midwives were fantastic and followed every direction I gave promptly, working together as a team. Throughout the woman herself appeared calm in spite of the fact that my limited vocabulary in Oromifa was definitely not sufficient to explain what was happening, to give her much reassurance. Or to apologise for the discomfort that treatment inevitably causes in such an urgent situation.

As things calmed down and came under control I asked the midwife to apologise if I had hurt her (any kind of apology is not typical behaviour amongst Ethiopian doctors and midwives but they have learned to humour the strange habits of foreign doctors) and I also suggested that we brought her baby to her and put him to the breast as this also helps the uterus to remain contracted preventing further bleeding. The midwives were not absolutely convinced that breast feeding was appropriate at this time as when there are problems with the mother the immediate response here is to put the baby to one side often for a number of hours but I persisted, explaining that it would be beneficial for both of them and they slightly reluctantly agreed to do as I suggested.

She was delighted to have her baby brought to her and my efforts were rewarded with that wonderful Ethiopian smile from her and a baby that latched on quickly and was equally contented.

In the UK we are perhaps a little complacent about blood loss as we know that we can get blood cross-matched easily and have a large selection of drugs to try to ensure the bleeding stops but in her case I decided to stay around a little while to ensure the bleeding really had stopped as I was still not certain we would get blood (we did get two units donated by her family) and I had given her both the drugs we possess to stop haemorrhage (the next sep here is hysterectomy as you can't afford to waste time and allow a woman to become seriously compromised).

After 20-minutes I was happy that all was going to be well - I communicated this to her and indicated that I would leave her in the care of the midwives. She responded by asking me a question in Oromifa which I asked the midwife to translate-"she is very grateful for your care and wishes you to name her baby" I was told. I smiled and declined, saying I didn't think I could do that as I didn't know Ethiopian names & their meanings well enough- "she doesn't mind & will call the baby by an English name in your honour" came the reply-it somehow didn't seem fair to call the baby Harold or Ernest or any of the other equally unsuitable names that flooded my mind at that moment as I realised that she was very serious about me naming the baby and also that she might be insulted if I declined the honour I had been offered. Fortunately I managed to remember that biblical names are popular here (& I knew that they are a Christian family) and so I suggested John as a boys name feeling it was unlikely to cause any offence now or in the future. She was very happy with the suggestion and so he was named Johannes, the Oromifa translation of John

Johannes and his mother were discharged home this morning both doing well- in the UK I might have received a card or a box of chocolates but the honour of naming a family's first born son will live on as a memory for me beyond any such material thank-you.

Tidying up & rethinking the location-specific implication of Down's syndrome...............

February 28^th

Believe it or not Friday was another public holiday in Ethiopia (3 in my stay so far & another on tuesday)-it was a Muslim holiday, most people seem to think that it was to celebrate the birth of Prophet Mohammed but no one is absolutely certain and my Bradt guide has failed me as for once this holiday is not listed. That a predominantly Orthodox Christian country should have Muslim public holidays is a testament to the apparent peaceful co-existence of Muslims and Christians here with no evidence of any  of the cultural tensions sadly so common in more developed countries.

This holiday meant that there was no outpatient clinic to occupy my time in the morning and there were no women in labour either so I decided it was time to force a tidying of the labour & delivery room (Mark knows to his cost that leaving me with unexpected time on my hands is likely to prompt me to embark on some sort of "clear out" exercise). The lack of resources results in a reluctance to throw anything away which is laudable until the place is so full of items saved for a "rainy day" that finding the things you actually need becomes difficult (and obviously in a hospital such items can become an infection hazard). There were a number of things that in spite of extensive enquiry no one could remember (if they ever knew) the function of, there were drugs & other packaged supplies that had expiry dates in the last century (in a country like Ethiopia there are reasons to be flexible in such matters but never with drugs that could become ineffective and even for other items there are limits!) and in addition to these things there were large numbers of stored empty boxes (just in case). I'm not absolutely sure what the midwives thought of the whole exercise (eccentric "Faringe" most likely) but they went along with it and only a few items that I threw away were retrieved from the bin!

Laundry is another area that was very chaotic in the delivery room and I felt a bit like Florence Nightingale must have, as I insisted that everything was pulled out of the cupboards prior to being sorted, folded and then being returned to the cupboards in orderly piles- allowing  things to be found more easily. Unfortunately this order also made it much more obvious what a severe shortage there is of linen there is as folded neatly it looks a lot less. I use the term linen very loosely- it compromises: 1) large plastic aprons (for the midwives and doctors to wear to save their scrubs or clothing during delivery- rarely with both neck band and ties but I have learned how to tie an apron very effectively with only a single string), 2) a very small number of gowns for women who require caesarean section (fortunately we rarely do more than 3 per day), 3) plastic aprons now devoid of any strings that will serve on for anything requiring a waterproof sheet (with a selection of other plastic "tarpaulins"), 4) pieces of sheeting (we might also use the term rags!) in a variety of sizes that are multi-purpose from wrapping babies after delivery, to cleaning mothers or surfaces or more rarely as a dignity cover for a mother- these are all carefully laundered in spite of the fact that some of them have more hole than cloth! and finally 5) rectangular pieces of thick plastic that are used to cover the delivery beds.  Describing this I realise how much I have moved on as when I first arrived the bleakness of these items was shocking but 2 months on I realise that although newer & less thread-bear items would be nicer, patients care is not materially affected by them as they are carefully, regularly and well cleaned  The stationary supply was also in chaos with a shortage of the items we use on all women and massive overstocking of items we use rarely (I can only conclude that someone enjoys photocopying). I was able to take 300 proformas for observation of women undergoing induction of labour to the Maternity Worldwide storeroom on the basis that we have induced no more than 10 women since I arrived at the hospital (5 years stock in circulation seems excessive).

So at the end of our efforts the delivery room is much more orderly with everything in an appropriate place- of course it now remains to be seen how long it will stay this way!

I was about to go for lunch when our first labouring woman of the day arrived. As is so often the case she had travelled from far and had been in labour since the previous evening. This was surprising (and immediately worrying) as it was her 6^th baby- with her five previous children having been born normally at home.  The baby was alive with a normal heart-beat (as ever against the odds) and on feeling her abdomen it was unusually difficult to tell which way around the baby was, so I immediately assessed her internally and for a moment thought that she had a breech (bottom first) baby in advanced labour. However it didn't feel quite right and I realised that it was not a foot but a hand and not buttocks but the shoulder of the baby that I could feel. I hope that even the non-medical readers will be able to appreciate that a baby trying to exit shoulder first is not good- it being technically impossible & possibly causing the uterus to rupture as the labour is obstructed but the contractions remain very strong trying to overcome the obstruction (a bit like squeezing a toothpaste tube hard with the top on). We moved quickly to do deliver the baby by a caesarean section- this proved to be one of the more difficult caesarean deliveries I have ever done as the baby was sort of folded in half (head and feet up and the arm & shoulder down- not a very comfortable position even for a flexible fetus) making it very difficult to effectively unfold in order to allow delivery through the incision. Anyway I managed to deliver a live girl with a bit of a struggle (happy to explain to the details at a future date to the initiated or interested), resuscitated her as she was very floppy at birth (not sure if I've mentioned that if the baby needs more help than the midwife is able to give I have to leave the operation mid-way and resuscitate the baby, returning to the mother when the baby is stable) and returned to the mother repairing a bigger uterine incision than is usual for a caesarean section but thankfully without further complication or excessive bleeding.

I hadn't really had chance to look at the baby in closely during the resuscitation as I was keen to get back to her mother as quickly as possible but immediately after I finished the operation the midwife asked me to look at her again. She had a hugely swollen arm (easy to explain as that had been the front bit that was being pushed down the birth canal) and swollen legs and one side of her face (less easy to explain but I think the result of being folded and squeezed for a number of hours). However these were not what was concerning the midwife- who had noticed a typical facial appearance. I examined her and agreed that she has features strongly suggestive of Down's syndrome. Thankfully her heart appears to be normal, she also rapidly established breastfeeding suggesting she doesn't have any of the bowel abnormalities and the initial floppiness (which can be a feature of Down's syndrome) seems not to be very severe. I was worried about the future for a child with such a significant handicap in an environment where even normal children seem to struggle to survive.

On the ward round next morning I asked the midwife if anyone had explained to the mother that I thought that her baby has Down's syndrome (no blood tests available to confirm here- so clinical suspicions have to be acted on). The midwife shrugged and said what did I want to tell her as there is no Oromifa word for Down's (not absolutely sure even the midwife knew what we were talking about although there is a Down's syndrome orphan in Gimbi town). In the end we agreed she would tell her that this child would be different to her other children, that would require everyone in the family to encourage her by playing with her and helping her to learn to walk and talk. The mother accepted this without question and it made me realise that I must not to make assumptions based on my views of the world as a citizen of a developed country: in a society where few people can read or write, where the majority of people will do manual work and the extended family is very strong- being born with Down's syndrome is not the same handicap as is in the UK.

I won't be switching to General Practice in the foreseeable future......................

February 25^th

Back from my clinic trip to Muggi and am now able to appreciate what a thriving metropolis Gimbi is by comparison. Also enjoying the feeling of knowing what I am doing in clinic and of having what now feels like a large diagnostic and therapeutic armamentarium in the hospital compared to a remote clinic.

Muggi is a very small town about 40km (as the crow flies much longer by road) from the border with Sudan and about 120km from Gimbi. Unfortunately only the first 15km are asphalt road and the rest is "gravel" so the journey there takes 5 hours. The countryside on the way is stunningly beautiful with rolling hillsides, traditional thatched circular hut villages (& one refugee tarpaulin camp with migrants from Sudan) and a lot of vegetation as it is at a slightly lower altitude than Gimbi. The lower elevation also means that this is the heart of coffee growing country and the clinic was held shortly after coffee harvest meaning that the local population were feeling relatively affluent and hence potentially keen to see to lingering health needs. The nearest large town to Muggi is called Dembi Dollo and this has a small government hospital but this is still an hours drive away. There is a very large town called Gambella about three hours drive further along the road towards the Sudanese border (which is not technically open fro crossing). Gamebella & the immediate surrounding area is the only part of Ethiopia that was a protectorate of anyone, as the British managed to make a stand there. This was because there is river access in the wet season that allows boats to pass all the way through to the Mediterranean and thus it was important for coffee supply (information courtesy of my knowledgeable husband). The boats ceased going some time ago and there is now a National Park in the area unfortunately if you look at the Foreign Office website Gambella is also the only area in Ethiopia with an advisory notice not to travel there so I was happy to stay three hours away.

Muggi is one of 6 out-reach clinics that the Adventist hospital runs- each clinic has a small staff (2 nurses, a guard/caretaker, a lab technician and a cleaner). This allows local people who live very far from a hospital to have some access to basic healthcare as the clinics carry basic drugs (for example painkillers, antibiotics, TB & malaria treatment). As there are limits to the things that the nurses feel able to manage, the hospital tries to send doctors out to the clinics every few months with the trips advertised in advance so that the patients can attend for review if the wish. Unfortunately it is often difficult to find doctors to go as they are needed at the hospital so on this trip it was myself (theoretically advertised in advance as someone coming to see obstetric and gynaecology patients) and Daisy who is a very competent final year medical student from Edinburgh doing an elective in Gimbi. Daisy had an advantage over me in that she has had the opportunity to spend some time in the medical outpatients at the hospital and so knows how to manage some of the common problems found in Gimbi and the surrounding areas.

In spite of the "advertising" there were few obstetric and gynaecology patients came to clinic over the two days. This was a great disappointment to me as there must be lots of pregnant women in Muggi and the surrounding area (people travelled from significant distances to the clinic) and it seems unlikely that they are all well, low risk and experiencing no pregnancy complications! As one of the important strategies in reducing maternal mortality is to try to identify risk and recommend delivery in hospital (this would have been Dembi Dollo Government hospital rather than Gimbi) I had hoped in some small way to help- but it was not to be the case on this occasion. Instead I became a "bush" GP- I'm afraid I wimped out and declined to see men (22years of specialisation means that there are some things that are just too foreign to me now and the first man I was offered had "swollen testicle"- "to Daisy " was my response.), so I saw all the women (and children although there were remarkably few of these) and Daisy did a male clinic.  Goitre (swelling of the thyroid) gland is endemic in the area due to the lack of iodine in the soil and about a third of consultations were for this problem. The remainder were a mixture of joint pains, abdominal symptoms and the occasional lump and bump. I sat with my Oxford textbook of Tropical medicine to hand but no one seemed to have TB and although I requested a few blood films for malaria all were negative. I will always wonder if I missed some other rare and fascinating tropical disease but if I did the presentation was subtle.

One good point is that the women here & especially in Muggi (it would be different in Addis) never smoke or drink. However the bad point is that many of the problems I saw are largely intractable as they are related to poor nutrition (constipation due to poor fibre, headaches due to the lack of fluid) and to the field work that women do here carrying heavy loads from dawn until dusk resulting in knee & back pain. This can also create difficulties as there is a great desire for investigations and prescriptions amongst the patients regardless of their problem and the administration of basic "life-style" advice can leave them dissatisfied with their clinic visit.  One consultation exemplified this well- a 17year old came in and declared that she has swollen and painful feet. In order to examine her feet, I asked that she remove her shoes (in Ethiopia the majority of people do wear shoes usually made of single piece of moulded plastic, rather than flip-flops or going barefoot as is the case in many other poor countries). As she struggled to remove her shoes it was clear that they were not only about three sizes too small (perfect imprint of the shoe remained on her foot after removal) but they were also ridiculously pointed (like the ones I wear albeit in the correct size for reasons of female vanity for brief periods when I will not be required to walk far) and although slim she had broad feet. I naively asked whether she had other shoes fully knowing the answer without a real need for a response. I gently explained that her problems were because she had outgrown her shoes and that these were an unsuitable shape for her feet.  This was translated was followed by an exchange of some length between her and the interpreter. Eventually I interrupted & enquired as to the nature of the conversation and was told, "she wanted me to prescribe something to cure her tight shoes". I tried to point out that the cost of any prescription (if I were to have an Alice in Wonderland "drink-me" solution to shrink her growing feet) would be more than the cost of going to the market and purchasing new, bigger and broader shoes.

We stayed in a small hotel opposite the clinic which was basic (and this is not English understatement) but then it only cost 20burr (£1) for the room that I shared with Daisy so it would seem unreasonable to expect more than a double bed, relative cleanliness (no roaches seen) and a plastic wash bowl with water from a canister in the communal wash cubicle (the toilet is best left without description but suffice to say I have used worse in French railway stations). Any way it was sufficient to clean up after the journey (very dusty) and for a good nights rest (braying donkey and 5am prayer call aside). We had brought sleeping bags and didn't inspect the sheets too closely but it seems unlikely the room rate included regular laundry. The room also had a bare electric light bulb and a candle but we made more use of the latter as there was only electricity for 3 hours of our 48hours in Muggi- some towns are not more atmospheric by candle light. Anyway the fact that I survived my two nights in this hotel should stop Illona (our travel agent at Steppes Travel who is arranging our trip at the end of my time in Gimbi) worrying about whether we are tough enough to cope with the two star hotels we will be staying in for some of the trip.

We returned to Gimbi (along the same beautiful but bumpy road) slightly earlier than originally planned as the initial torrent of patients dried up by lunchtime on the second day and the symptoms were becoming less serious (if you have a genuine problem you come as soon as possible on the first day) and also more bizarre (my interpreter declined to translate to me when amongst an array of other symptoms one women said "she believed that she was being nibbled by cats" suggesting instead that I might break my non-prescribing rule just to get her out of the clinic room). In total I saw 64 patient- the four O&G cases I was well qualified to deal with and thankfully on reflection I don't feel I missed anything serious or did anything too harmful to the other 60 who technically I am less qualified to deal with.

I always have had an enormous respect for GPs, as doing a good job is stressful and difficult. So my experience in Muggi has consolidated this opinion and made me absolutely certain that I made the right career choice!