In October 2016, I and three other midwives visited Freetown and some of its surrounding districts in Sierra Leone. We were volunteering for the charity, Life for African Mothers (LFAM), a charity based in Cardiff and established in 2005, whose aim is to make birth in sub-Sahara Africa safer by providing equipment to treat postpartum haemorrhage (PPH) and eclampsia. In addition, LFAM facilitates midwifery training in Burkina Faso, Liberia and Sierra Leone by providing training to midwives, maternity healthcare assistants and traditional birth assistants (TBAs). LFAM's message is clear and simple:
‘Saving a woman's life can cost less than the price of a postage stamp.’
Our itinerary for our 12-day trip was extremely challenging, with a mixture of workshops teaching normal birth and obstetric emergencies, alongside clinic or unit visits to distribute equipment and perform further training for those who were unable to attend the workshops. Our daily schedule was changeable, which sometimes made our obhectives harder to achieve, but definitely more fun. Among our group, I was the only one visiting Sierra Leone for the first time.
As we departed from a cold and rainy Heathrow Airport, I felt relief that finally I was on my way Africa—on my third attempt. In 2014, I was prevented from going due to the Ebola crisis, and in 2015 a military coup in Burkina Faso dashed my dreams of adventure. It has to be said that even though my colleagues told some fascinating stories of their African trips, I still didn't really know what to expect. The average life expectancy for women in Sierra Leone is 58.7 years (Countrymeters, 2017), and in 2015, Sierra Leone's maternal mortality rate was 1165 per 100 000 live births (World Health Organization (WHO), 2015). Sierra Leone was ranked 177 out of 187 countries by the United Nations' Human Development Index (2015). The standards of the maternity services vary a great deal depending on location, with city or township services offering significantly more than rural units.
My anxiety was totally unfounded. Sierra Leone's climate is not the only warmth I felt during my trip: the welcome we received was fantastic, and everyone was so kind and interested in what we were trying to achieve.
Plans for the trip
The itinerary was a mixture of two 2-day workshops and unit visits, some of which were 1-2 hours from our base in Freetown. Our trip was towards the end of the rainy season, which meant that we saw some breathtaking night-time thunderstorms, where the lightening turned darkness into daylight, and torrential rain bucketed down for hours. Any worries about how we would manage to travel to our planned destinations were unfounded: the roads were still passable, albeit very bumpy!
Unit visits
Our first task was to sort out the equipment and supplies for the units. LFAM supplied a resuscitation kit for every unit we visited, and in addition we had collected a considerable amount of supplies and donations from the UK.
Although resources were limited, the majority of the units we visited were well run. The units prided themselves in their use of visual aids that demonstrated different midwifery and obstetric practices: at the unit in Murray Town, we saw visual PPH guidelines and various statistics about the number of births and newborn vaccinations, and at many other units we also saw resources on baby vaccination programmes, breastfeeding, and healthy lifestyles.
At the Grey Bush unit we met a newborn baby, just minutes old, and I was very lucky to have a cuddle with the family. Mother and baby were both well, and even Grandma was present as a birthing partner, which was unusual, as many women in Sierra Leone labour alone. Some female family members do support labouring women, but it is still rare for the woman's partner to be present. During our workshops it became evident that the younger midwives and TBAs were keen to encourage birth partners to support women in labour, but many of the older midwives and TBAs still believed them to be more of a hindrance than a help.
The units we visited were in contrasting areas: some were rural, while others were in the built-up Freetown district. Birth rates varied considerably, from 30 births per month to more than 80. Two of the units we visited were situated within slums, and the first time we visited, I was lost for words. I had seen pictures of slums, but nothing prepares you for the experience. The conditions were astounding, but most people were kind and keen to greet us. I wondered what was it like living here with the rain deluging the area. I saw mothers breastfeeding their babies, and tried to consider how labouring women would find their way in the darkness to the small birthing unit situated up some steep steps on the outskirts. Giving birth in these conditions surely must be some of the most difficult that any women could face.
Workshops
During our unit visits, the staff were very keen and enthusiastic about attending the LFAM workshops. However, it was a challenge to monitor who attended the workshops, as staff were encouraged to move around units, making it difficult keep track, and to assess skill levels. Some staff wanted to attend more than once, but this was not possible. During our workshops we were expecting 30 attendees each day, and hoped to concentrate on normal birth and baby resuscitation. The venues for the workshops could not have been more different: the first was in the middle of bustling Freetown, covering some of the busiest units in the city, whereas our second, in Waterloo, was in a very rural setting, 2 hours from our base.
I found myself really looking forward for an opportunity to learn more about how African midwives work. On our first workshop in Freetown, there should have been 30 midwives and TBAs, but a total of 43 arrived. We did not want to send people home, so funds were found to buy extra food and cover travel costs, to allow everyone to stay. My colleagues and I were relieved that we could continue, but we needed to make up time, without reducing the workshop's contents. With temperatures above 38 degrees, and no air conditioning, the training environment was not conducive to learning.
There was a mixture of midwives, TBAs, maternity assistants, registered nurses and one practice manager, and the majority seemed enthusiastic about attending. We decided on some ground rules, then discussed infection control, antenatal care, normal labour and neonatal resuscitation.
We tried to make the day interactive, and covered hand washing, bouncing on birthing balls and hands-on neonatal resuscitation. My group had a mixture of attendees, and included two TBAs, which some of the maternity assistants seemed to disapprove of. There appeared to be a definite hierarchical structure amongst the TBAs and maternity assistants, but I believe I was successful at sharing information, irrespective of job title.
The group session on resuscitation went well. Differences in practice were described, such as giving steroids to women who are transferred to the main obstetric unit in Sierra Leone (regardless of gestation) to improve outcome. Attendees were keen to practise with the resusciation dolls and to perfect their techniques within a controlled and safe environment.
The second day of the workshop ran more smoothly. Once again, there were 43 attendees, but I felt a real sense of pride that they had all enjoyed the first day enough to return. Visual aids, such as PowerPoints, film clips and role play were all well received, and encouraged audience participation. In addition to neonatal resuscitation, we covered obstructed labour, breech, PPH, pre-eclampsia, shoulder dystocia, and cord prolapse. My colleagues and I tried to emphasise that we encouraged two-way learning, so we were constantly asking groups about their practice. When discussing abdominal palpations, one group explained how a ‘saucer shaped’ abdomen may slow labour, and one midwife, Elizabeth, told us the meaning of this particular complication. This visual description was much simpler than the term we used, occiput posterior.
Two of the team role-played a shoulder dystocia delivery. This was repeated several times and the women were involved so that they could practice the McRoberts position, applying suprapubic pressure and the all fours position. This was great fun and many of the women filmed our performance to show in their units.
After the workshop, we took photos before having a certificate ceremony. We also donated two birthing balls to enthusiastic attendees who wanted to take them to their units to encourage women to keep more upright in labour, instead of the traditional supine position. Attendees were asked to complete evaluation sheets, which reported high levels of satisfaction with the course content and its delivery, although participants for both workshops requested that the workshops be longer and cover more specialised subjects such as anaemia and diabetes.
Planning for the future
On journey home, we drafted some recommendations as to how future groups could follow-up on previous workshop attendees to see if they are cascading their learning to others. During our 12-day trip, we had 78 attendees to our workshops and visited nine units, so interacted with approximately 100 maternity staff of various job titles. However, there are still hundreds of individuals that want to attend workshops, and many units still need to receive the basic LFAM resuscitation pack.
This was a life changing experience, and I would encourage anyone to take on the challenge. I am hoping to return to Sierra Leone later in 2017, to see for myself the progress being made. I would like to thank LFAM, and I hope I can repay the charity with more work on their behalf.