Elective Report Wendy Slee 03/09/07-28/09/07 Lady Willingdon Hospital, Manali, India 07-21/10/07 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
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
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.
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.
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.
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.
All photos are my own, taken during my elective with the permission of the patients and people featured in them
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