Elective report

Elective Report
Wendy Slee
Lady Willingdon Hospital,
Manali, India
World Medical Fund,
Malawi, Africa
Title of project: A comparison of the issues surrounding childbirth and care of the newborn between a
hospital in North India and a mobile clinic in South Africa and how these issues are addressed in the Aim of Project: To compare the issues surrounding childbirth and care of the newborn between a
hospital in North India and a mobile clinic in South Africa. Objectives of Project:
1. To observe the approaches to maternal and child healthcare in these cultures. 2. To learn how access to healthcare influences the care of patients in these two 3. To compare the delivery of healthcare in peripheral out-reach clinics in Africa, to 4. To learn about the diagnosis and management of maternal infections and the 5. To improve my communication and clinical skills within these different cultural Lady Willidgdon Hospital, Manali, India
The first month of my elective was spend in a small community in the foothills of the Himalayas, called Manali. Manali is a small town at the northern end of the Kullu valley, set at an altitude of over 6,500 feet. The hospital which I spent time in was called Lady Willingdon Hospital (LWH). This is a charitable institution, serving people of the Kullu valley as well as those from surrounding regions. The hospital provides primary and secondary level medical and surgical care to this population. It has 45 beds, roughly separated into the main specialities, surgery, medicine, paediatrics and obstetrics- The routine in LWH
Each day, ward rounds started at 7am. This involved joining the doctor, who had been on call the previous evening, visiting all of the wards in the hospital. This took between 2-3 hours, depending on how many new patients had arrived. The main aim of the round was to discharge patients, as each patient was required to pay a relatively large amount of money to stay for on the ward and so were limited to the amount of time that they were able to afford. In outpatients people would already be forming a queue outside the door to see a doctor whilst the ward round was continuing. In a morning we could easily see between 30-50 patients of all ages in the OPD. I was exposed to a huge variety of pathologies- in particular, those end-stage symptoms of weird and wonderful diseases which I had only previously learnt from textbooks for exams! Although the majority involved conditions related to TB. All of the doctors shared the same large consulting room and sat behind one of 5 desks. The patients either qued up outside the door, sat in the waiting room, or sat on one of the long benches in front of the doctors, if they were close enough to the head of the line. One of the visiting doctors would run gynae consultations at one end of the room, and was privileged enough to have a “private” examination room next to her, consisting of a bench, set high, on which the patient could lie with various speculums soaked in disinfectant next to it. Privacy was hard to find. All the gloves used in the examinations were socked in chlorine, washed, dried outside and then reused. Gloves are expensive for patients. On Tuesdays and Thursdays it was theatre day. This consisted of operations which had been listed in outpatients during the previous week (waiting lists were unheard of!) and usually included at least one c-section. All of the operations were carried out under spinal anaesthetic as the anaesthetists were not trained to give general anaesthetics. This turned out to be quite a problem during the longer operations, particularly hysterectomies, when the patient would often be in a lot of pain towards the end of the procedure, with copious amounts of diazepam on board. It certainly reduced the operating times and made my heart sink when it came to suturing the patient at the end of the operation! One of the c-sections. The indication for this c-section was deteriorating pre-eclampsia in the mother: Nurse showing mum the sex of her child- a baby girl The doctors at LWH tended to be “general” surgeons, furthering their education when a visiting surgeon came to the hospital, or on a trial-and-error basis. It was not unusual to find one of the doctors with an anatomy book open by their side as a navigation tool during the operation! During the afternoons I spent time on the labour ward or in antenatal clinics, run but both a nurse and the visiting doctor. Once my accommodation was moved into one of the rooms on the post-natal ward, the nurses knew exactly where I was for the majority of the day and were very keen to have me at In the evenings and during the night emergency surgery continued. As the roads leading to Manali, along the Himalayas, were very dangerous, and the buses often very much in need of and MOT, there were frequent road traffic accidents during the night. The night warden would come to wake me more than a few times during the week or at the weekend, asking me to come to theatre. I dreaded the sound of footsteps venturing towards my door, knowing that it would mean that there had been an accident. I think the poor warden saw me more in my pyjamas than out of them- I learnt very quickly to be cheerful when I was woken from sleep! The approach to maternal and child healthcare (1)
In contrast to my time spent in Africa, my experience of healthcare in India was from a hospital- At LWH there was a well set-up antenatal programme for women to follow from the time they become pregnant to the birth of their child. HCG tests were available at LWH to all patients who had not had a period for over two months of their cycle. Those with a positive result were referred onto the ante- natal care programme and those with a negative result were referred to see the visiting gynaecologist. Each pregnant woman has an appointment to see the nurse every 4 weeks until week 28 and then every 3 weeks until week 34 and finally every week until week 40. If the woman continues the pregnancy beyond their expected due date they are admitted to the obstetric ward at the hospital for observation. At all of the nurse-run clinics, basic ante-natal checks are performed, including BP and examination to check the fundal height, lie and presentation of the baby. If any problems are found the women are then seen by the doctor, much like what happens in the UK. The antenatal checks are well organised at LWH, the main problem is the access to the hospital which is limited by both distance and money, particularly for women in the later stages of pregnancy who are less able to access this care when it is arguably more At 20 weeks the women are offered a routine ultrasound scan which is performed by a doctor who runs a special ultrasound outpatient clinic once every two weeks. You know when these clinics are going on as there are suddenly hundreds of women sitting on the ground outside the hospital awaiting their turn. The doctor has no formal training in using the ultrasound equipment which was donated to the hospital a few years ago by a Swiss charity. In India it is against the law to tell the parents the sex of the fetus due to the very high rates of illegal abortion of female foetuses. The scan only looks for major abnormalities, although, other than close monitoring of the pregnancy, very little can be done in the presence of any major abnormalities. As LWH is a Christian missionary hospital they do not perform abortions and also do not refer patients elsewhere for them to be carried out. All abortions are therefore carried out illegally or at the private Most women are encouraged to have a normal labour. Caesarean sections are reserved for emergencies and also for those who have had a previous caesarean section due to their concerns that a scarred uterus will not withstand the forces of labour. Instrumental deliveries are common practice and are carried out by the nurses when appropriate. The resus facilities in the hospital for the neonate are basic. After the delivery of the child the nurse shakes it upside down for a few minutes before suctioning any residual fluid out of its oropharynx. During one delivery the baby burnt its legs on the powerful light which is designed to provide a source of warmth for the neonate as the nurse turned it upside-down. Before taking the neonate away to the paediatric ward the nurse always shows the mother its genitalia. The rich families are always much more The hospital has a NICU unit with 2 intensive care beds. The doctors have no specific neonatology training and as facilities are basic, any babies they are worried about are transported to the nearest larger hospital in a town called Shimla, which is about a 6 hour drive away. Most families cannot afford transport costs and so decline this transfer. Access to healthcare (2 and 3)
Maternal and antenatal health within the hospital itself is well conducted and patient care is good. However, the hospital is only accessible to a very small catchment area, which includes patients coming from as far as Tibet to attend outpatient clinic. The majority of women therefore do not receive any form of healthcare during their pregnancy, unless one of the peripheral clinics which extends from the hospital reaches their village during their 9 months of pregnancy. As transport links to the hospital are cut off for up to 6 months of the year due to poor weather conditions, access to healthcare is made almost impossible for most during these months of the year. The villages are often not very receptive to receiving healthcare input from the hospital. In one of the peripheral clinics in Jibi during a previous visit, the doctor had performed an examination on one of the pregnant women to check the lie etc of the baby. A few days after the clinic had visited this particular village the woman had a spontaneous abortion. The village blamed the doctor who examined her for this, and now no women in the village will accept any antenatal care from any visiting practitioners, making outreach healthcare in the villages even more difficult. The delivery of maternal and child healthcare during these peripheral clinics is not demarcated from the normal peripheral outpatients clinics held there and not specific, it is more opportunistic. People from the peripheral villages tend to give birth at home. There is no community midwife, and women receive advice about pregnancy and labour from the older women of the village. The results of this is seen in gynae outpatients years later- young women in their 30’s presenting with uterine prolapses as during many previous labours, which have not been adequately managed, they push too soon during contractions. This is also a common reason for total abdominal hysterectomies at LWH. Maternal infection (4)
The commonest maternal infections seen at LWH are due to Trichomanis vaginalis. This is sexually transmitted and is a common cause of premature births and low birth weights within the hospital. Women tend not to seek help for this infection, particularly as it is seen as unacceptable for a pregnant woman to also be carrying a genital infection. If they do seek treatment, often they do not tell their partners about this and so reinfection almost always occurs as the partners are not treated. In LWH it is treated with a STAT dose of metronidazole. It is rare that pregnant women presents with a genital Communications (5)
To understand and be involved in the consultations I had to work on my Hindu fast! I was given a list of various symptoms and signs that the patients might describe to me and was taught some of the local etiquette and greetings by one of the doctors. Just trying to speak Hindu increased the patients trust in me and put them more at ease- although I still found hand gestures incredibly valuable too! When the consultations proved to be difficult I had to rely on my clinical examination skills to make sure I didn’t misinterpret what the patient was trying to tell me or miss anything out in the translation. In dealing with such end-stage diseases I also had to be thorough with my examination to cover all possible systemic The World Medical Fund, Malawi, Africa
The charity which I went to work with for the last month for my elective was called the World medical Fund (WMF)- “giving children a better chance of life.” This small NGO is based in a very small
town called Nkhotakota, along the shore of Lake Malawi. The charity runs mobile children’s clinics to remote villages, reaching out to a total of 15 in Malawi, some over 75km away from Nkhotakota. It gives children a chance of healthcare which they would otherwise be unable to access nor afford. The majority of the villages live by subsistence farming and so money does not have a place in their culture. Each clinic can comprise of between 50-200 children who come from miles around with their mothers to where the clinic is based. There were 4 main programmes which I was involved with during my time spent with the WMF. These were the children’s mobile clinic, anti-retroviral programme, PMTCT (prevention of mother to child transmission of HIV) Within the WMF there are a few administrative staff, 2 clinical officers (no doctors), 2 nurses, a pharmacist, one counsellors and 2 jeep drivers. For each clinic they send out a clinical officer, a nurse, a A typical day in Malawi
Each morning the jeep left the compound at 7.30am and drove for about an hour on the main/only road in Malawi and then upto an hour (depending on which driver came with us!) on very bumpy dirt tracks, which was an experience in itself! When we reached the clinic, usually a bamboo shelter in the middle of the African landscape, there were always lots of mothers and their children gathered outside Each clinic started with an education session which was run by one of the nurses. The nurses teach the women songs about family planning or HIV prevention and then go on to give a short talk on either HIV transmission, malaria or TB to raise awareness of these conditions for the benefit of both the The clinics then begin with the weighing of the children and measurement of their upper arm circumference. This is added to their “health passports” as a form of monitoring growth and screening for malnutrition, before they go onto to see a clinical officer. After being seen, they then go onto pharmacy to collect their prescribed medications from the nurses. These tended to be albendazole (worms), PZQ (bilharzia), SP (malaria), amoxicillin syrup (chest The WMF have also recently started a programme to prevent mother to child transmission of HIV (PMTCT). Mother to child transmission constitutes roughly 30% of all HIV infection in Malawi. Whilst with the WMF I spent time going to all of the villages in the surrounding areas to see each chief to brief them about the proposed programme. The chief has a huge amount of influence in each village and so the WMF needs to get them all to work in partnership with them. They do this by involving the chiefs in the programme through these briefings, and paying them for their time as a kind of “bribe.” The chief forms the opinions of the villagers and determines how receptive the women are to the education given by the WMF. They then run teaching sessions for the traditional birth attendants (TBAs) of the villages, all of whom seem to be elected by being the oldest women in the village! The teaching focuses on the prevention of HIV transmission of already infected pregnant women, but also takes the opportunity to explain childbirth, care of the mother and of the newborn. TBAs have no other formal teaching and so currently rely on a mixture of witchcraft and personal experience! As they had just started the programme, it was uncertain how receptive the TBAs would be to this input. Currently, the infant mortality rate in the villages is so high that the mothers often do not want to see their babies for hours after birth in case they die, so they wish to remain detached. The approach to maternal and child healthcare (1)
In contrast to my time spent in India, my experience of maternal and child healthcare in Malawi was form a community based approach, dictated by the TBAs within each village. The TBA sees each pregnant woman regularly to examine the lie and presentation of the baby and to give her herbal medicines to help keep the baby in the correct position and to prevent the woman miscarrying. She is also present during the birth. The WMF visits the TBAs to see how many pregnant women there are in each village and to provide education for the TBAs and to give advice. For example, they encourage HIV positive mothers to only breastfeed their baby’s upto 6 weeks after birth. The main problem is that the mothers cannot afford to buy any other milk for their children, and so if they are unable to find another mother in the village who would be able to act as a wet nurse for them, they have no choice but to The WMF also runs a VCT (voluntary testing and counselling) programme at their clinics. The mothers of any children who come to clinic with symptoms or signs of HIV infection are invited to go onto receive counselling about HIV testing at the government hospital. The major problem with this is that often the women do not have the transport to get to the hospital for this 30 minutes test, even though they are often keen to get this done in order to receive treatment for either themselves or their children. Family planning is not used in the villages. Condoms are not widely available, nor are commonly accepted due to propaganda scares. Whilst I was in Malawi there was a damaging report about a catholic minister in Europe who had allegedly infected all the condoms sent to Africa with HIV to wipe out all the Africans! There are also widespread rumours amongst the males in the villages that they need to have intercourse with an “innocent” to be cured of HIV. It is so difficult to educate the villages and dispel these rumours as villagers are not very receptive to outside input. Although the WMF are starting to reach out to the male populations and encourage them to come along to clinics and bring their children themselves, giving them priority in the queues if the children come with their fathers, to try and build up a relationship and trust with them for possible future programmes. Access to healthcare (2 and 3)
Access to healthcare is one of the major limiting factors to healthcare in Malawi. The government hospital in Nkhotakota, which I also spent time in, runs a relatively comprehensive obstetric and gynaecology programme for women, but is not used to its full potential as so few women in the area have access to transport to get to it and are able to take time away from working to travel here. The WMF is more successful in delivering peripheral healthcare than the hospital in India. This is because it focuses on specific villages which it regularly visits once a month to provide some continuity of care, rather than opportunistic intervention. The charity uses local nurses and clinical officers who already have a standing within the community and are well respected within the villages, which helps to maintain the relationship between them and makes the villages more receptive to intervention by them. During the clinics they also take the opportunity to appoint members from the village as “volunteers” to help both set up and run the clinics, making them involved as part of the team. Maternal infection (4)
The commonest maternal infection which I saw both in the hospital and within the peripheral clinics in Malawi was by far HIV. 1 in 3 people are affected here, and it is sadly too much a part of their culture. It is a disease which everyone fears, and it is commonly talked about. The villages are accepting of people with HIV within their community and are supportive. There are many HIV orphans in the villages. These children are well looked after by either a family member, or another mother within the village. The WMF also runs a programme to provide regular monitoring, and anti-retroviral treatment (AVRs) for these children. Unless the HIV positive mothers are able to access VCT at the hospital and have a high enough CD4 count to receive ARVs, there is very little, beyond educational opportunities that Communications (5)
Like in India, I had to learn my Chichewa fast. I thought I was doing really well with this, until we reached even more peripheral clinics, where the women would speak in different dialects and I had to resort back to sign language and gestures again! The women at the clinics would laugh at me and get their friends to come and listen to me when I started speaking in their own language. I presumed that this was because my grasp of the language was so poor. I was later told by one of the volunteers that it was because they were just shocked to hear me speaking and could not believe it and so had to get one of their friends to verify! I leaned heavily on my examination skills again, although these were relatively limited due to the absence of any equipment, other than my trusty stethoscope and the Hb monitoring kit which consisted of a needle and a piece of litmus paper on which you placed a spot of blood before deciding whether it was unacceptably pale of not! Often my clinical skills were relatively obsolete as many women would come to clinic and tell me their child has got “malungo” (malaria)- they had seen it so many times and were always right. Conclusions
The issues surrounding childbirth and care of the newborn in LWH in India, and the peripheral clinics run by the WMF in Africa were very different. The healthcare in India within the hospital was very well organised and there were many similarities between LWH and the UK. Very little of their work involved education or outreach to members of the community, and it relied on the women being able to, and choosing to access healthcare at the appropriate time. They had a variety of monitoring equipment within the hospital, including ultrasound and CTG machines, to enable them to foresee any problems and guide appropriate interventions, which often meant transferring women to one of the main hospitals in The healthcare of both mother and child in Africa was centred on an educational approach. With so few interventions available to them, it was more important to focus on the prevention of disease. The issues surrounding childbirth were centred within the community, with relatively little outside input. The women relied heavily on experience, and with such a high infant mortality rate, had many children, at least 6 in each family in a village was normal. Care of the newborn only took place when the clinic visited the village once each month, and any treatment which could be given to them was very limited. Access to healthcare here was the major limiting factor for women to seek help, and so any concerns raised during pregnancy were dealt with by the often relatively inexperienced TBA of the village. The education programmes were well received within the village, and the women understood the risk of HIV, although without access to family planning methods they could do relatively little about this. Reflections
My elective was truly a life-changing experience. It was amazing to be exposed to such a wide variety of diseases which I would never normally think about when seeing a patient in the UK and to work within such generalised medicine, where you really have to have a wide breadth of knowledge. I have met some amazing people who work under alot of pressure in very difficult circumstances. In Africa it was so frustrating to work with so little resources, to know the ideal management options in a situation, but not have the tools or medicines to treat often very sick patients. I found it so difficult realising that if the patient was in the UK they would have every chance of receiving good and effective treatment, but having to leave them in their village in Africa without adequate treatment. The people in the villages were so grateful of any help you could offer, even when you knew that it was relatively so little. I realised the importance of local input within the WMF programme, and how valuable this is to provide healthcare for these enclosed communities. In India I learnt a great respect for other people’s cultures, with their values and traditions. In respecting these it immediately builds a better relationship up with the patient, engaging them and gaining their trust. Communication was more difficult in India, as I found Hindu a more challenging language to learn, but as this was such an important part of the consultation, I realised that it was much better to have With few investigations available in both India, and more so, in Africa, I had to heavily rely on my history and examination skills. I gained much more self-confidence during these few months. Towards the end I was much more receptive to patterns of signs and symptoms I had seen within the clinics, linking them to previous patients, and treatments which had worked for them, to the patient sitting in front of me with a similar condition. My clinical skills have improved, and particularly my recognition of common tropical diseases, especially TB, AIDS and malaria. In my future practice I will now always be on the lookout for the unusual and unexpected during consultations! In working with such limited resources I have also learned that education and lifestyle advice given to patients can be just as important and effective as medical treatment. I will not be so quick to think about medical and surgical options for patients, but to consider more conservative management too. This experience has made me realise that we are very fortunate to have access to such advanced investigations and tests for patients in the UK to aid our diagnosis, however it has also shown me that the investigations are only as good as their interpreter and that taking a good history and examination are The assessment and management of risks during my elective
Before venturing off on my elective, to asses any risks I used elective reports from previous students who have been to the same area/hospital and looked at any problems which they encountered during their elective. I used this alongside information I gained from the WHO website for guidance on infectious diseases and the university’s guidance on contagious diseases and universal precautions. On my elective I was not exposed to high-risk incidents as I closely followed health and safety advice given to me regarding hygiene whilst working in the hospitals, taking care at all times to protect myself. I found this most difficult to follow whilst in Malawi during the peripheral clinic as there were no hand-washing facilities and so I had to rely on using alcohol gel between patients and also checking that the gloves which I used were intact. Ethical issues
In India one of the main ethical concerns raised was that of consent. I had to make sure that I received appropriate consent from patients before carrying out any procedures. The language barrier often made this a long and difficult task, particularly when I was trying to explain my role within the hospital, but often the nurses helped me to do this. At all times I had to make sure that I was appropriately supervised by other doctors or members of staff. This often involved explaining to them the differences between a 5th year medical student in the UK compared to one from India, being honest about my limitations to put the care of the patient as my first concern. Confidentiality was also quite a challenge with the lack of privacy within the consultation room. I had to make sure that I appropriately covered up the patient to preserve their dignity whilst I was examining them and also not to discuss patients I had seen with the doctor sitting next to me when they were dealing with another patient, which often happened between the doctors. In Africa one of the main difficulties I had within the clinics was that the WMF had strict rules not to treat anyone over 15 years old as they did not have the funding for this. I found this very difficult to do, as often a 15 year old girl would come in with either their child or a younger sibling and would obviously have malaria which needed treating too. I had to try and urge them to go to hospital to get treatment too, knowing that most of them would be unable to afford the journey, but this advice was the best I was able to do. After each clinic we would have possibly two spaces in the land rover to take sick children back to hospital with us. This was often a huge decision as quite a few children needed hospital care, for example, to receive IV quinine, but the WMF would only take those children who had a higher chance of surviving, rather than those who may die with or without hospital care. Some of the African women did not want to take their children to hospital, when advised to. This was also really difficult to deal with, as I had to respect their decision, even though I would have chosen differently myself. The other ethical issue which I encountered in Africa was that the women would often come to clinic with healthy children and make up symptoms to receive medicines as they knew that they would not see a doctor for a very long time. To maintain trust between the patient and the WMF we were encouraged to give the mothers paracetamol for their children, rather than sending them away empty handed. I felt that it would have been better to explain to the mothers that we could find no problems with their child and to be honest, but I also realise that this would probably not be well received, as some of the mothers were quite demanding of their medication. It was difficult to deal with ethical issues in a different cultural setting, where they have their own defined rules of what is acceptable. They have their own values and priorities which we need to Thank you I would also like to say a huge thank you to the RCOG/WellBeing of Women Research
Advisory Committee for awarding me with a student elective bursary to enable me to go on my elective. References
All photos are my own, taken during my elective with the permission of the patients and people featured in them

Source: http://www.wellbeingofwomen.org.uk/downloads/file/02_research/pdf/2007%20Elective%20Reports/Slee%20Repor%20web.pdf

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