Elective report: Obs & Gynae in Sierra Leone
Jonathan Nelson shares his elective experiences of working in Sierra Leone.
Eclamptic ward in Sierra Leone
When I told people I was going to Sierra Leone to do Obs & Gynae for my elective I got a variety of reactions ranging from, ‘What about the civil war?’ to, ‘Is that safe?” The second question was usually, ‘Obs & Gynae, are you sure about that?’.
Well, I wasn’t sure, but I really wanted to find something challenging in terms of medicine and as a personal experience. Sierra Leone certainly fitted the bill. The civil war in Sierra Leone ended in January 2002 and subsequently the political situation has become relatively stable, with the 17,000 UN peacekeeping forces beginning to withdraw. However, the scars of war are still present, in the bullet strewn buildings, in the beggars who have had limbs cut off during the violence, and in the stories and experiences of the people you speak to. Whilst crime in Sierra Leone, and in particular Freetown, remains a problem, I felt safe during my time there. The country has remained peaceful during the past 5 years, although it is struggling to free itself from the economic consequences of years of war, with the latest UN development index listing it 177th out of 177 countries worldwide.
My experiences in the healthcare system of Sierra Leone provided a window into the extreme poverty most people exist with. There is a government health care system, but this is running on a shoestring, and patients still have to pay for their care. It is a completely different way of thinking about healthcare, even from the doctors’ point of view. Everyone pays in cash before they see the doctor; antibiotics, blood transfusions and operations are not started until the patient’s family pays. There are no artificial ventilators that work in the whole country and virtually no investigative tests at all. The number of doctors per head of the population is staggeringly low. Freetown, the capital of Sierra Leone, has a population of 2 million people for whom there are half a dozen Obs & Gynae consultants. In the main government maternity and paediatric hospital there are 2 junior doctors. There is a medical school in Sierra Leone, but it has only just started up again following the war, and in 2006 there were only 7 graduates, 6 of whom left for Europe or the USA.
Despite this, the efforts of the doctors and nurses was remarkable. How they had time to even talk to me I don’t know, but they also made me feel so welcome. I divided my time between the Princess Christian Maternity Hospital (PCMH), a government hospital, and the Marie Stopes Hospital, a women’s hospital where foreign donations enable better healthcare to be provided to women at a reasonable price. My clinical experiences were similar to those that a U.K Obs & Gynae placement might involve: ward rounds, clinics, surgery and delivery suite. But being the only student and with hundreds of patients I was able to gain the sort of exposure that would not have been possible in the U.K. I made sure I did not put myself in situations that I was not qualified to cope with. But I was still able to examine many women, in clinic and during labour and I assisted with many caesarean sections and deliveries. Whilst assisting with a caesarean a situation arose that shows just one of the difficulties doctors face in Sierra Leone. The electricity supply rarely worked during my time there, and so the hospital was often running off a generator. If this failed during the daytime then the operating theatres would get very hot, but this could be managed. However, during one emergency caesarean late one night the generator failed completely. Fortunately the operation was almost finished, but it was not easy closing up in pitch black under mobile phone light!
Assisting in surgery in Sierra Leone
Sierra Leone also has the dubious honour of having the highest maternal mortality ratio in the world according to the WHO; around 2000 maternal deaths per 100,000 births. Another interpretation of this figure is that 1 in 7 women die by means of childbirth in Sierra Leone. This is often related to the late presentation of women during labour, often after 24-48 hours of an obstructed labour, by which time the foetus has died and the woman is extremely ill. During a week in the government maternity hospital I saw a complete cord prolapse presentation and a hand presentation. Both of these resulted in the delivery of dead babies via caesarean section, and one of these mothers died from a post-partum haemorrhage. Another case I saw was where I assisted with another caesarean, where there had been an intrauterine infection and the baby had died in utero. Unfortunately the mother developed septicaemia and with very few antibiotics and no intensive care she also died a few days post-op. Seeing these women die was extremely distressing. In the U.K., maternal deaths are extremely rare, and yet I saw 2 in a few days in Freetown. Most difficult to deal with is the fact that their deaths would have been avoided with slightly improved resources. Increased funding would help, but there are a number of factors that mean things may take decades to change: infrastructure, attracting doctors and keeping them, cultural issues and many others.
My experience in Freetown was not all hospital work. I stayed with a family I knew through my church in the UK during my trip as well as travelling on my own, and this was an excellent way to get to meet and know local people. The beaches around Freetown are fantastic, although not as enjoyable if you go during the rainy season (in Freetown it rains more in August as it does in a year in the U.K). It was useful being a football fan, as the Premier League really is taking over the world. I couldn’t walk 500 yards without finding another little hut where you could pay 20 pence to watch a match: I watched more English football in Freetown than I normally do at home! I also had the opportunity to attend the local church and the people here and in general were unbelievably friendly.
I am so glad that I took a chance and went to Sierra Leone for my elective. It was hard work, but an amazing experience that has really stirred me to consider returning to West Africa when I am qualified and can offer more than I did as a student. The efforts of the doctors I worked with were inspiring; some were still working long hours well into their 70s having dedicated their lives to treating their own people. Organising the elective was a long and sometimes frustrating experience as communication with the busy doctors in Freetown was difficult; I started to organise my trip about 18 months before going. If you can find a contact (or at least contact the medical school) then I would definitely recommend an elective in Sierra Leone or elsewhere in West Africa.
Jonathan Nelson
Final year medical student
Leeds University
jnelson@doctors.org.uk