With the lowest doctor to patient ratio in the world (1 for every 71,000 people) access to health care is a major barrier in Liberia.
Story by Sarah Newnham. Photos by Mark & Kelly Hewes and LuAnne Cadd.
Amongst those who suffer the most without the services they need are pregnant women and newborns in crisis. Poor working conditions, inadequate training and pay, progressively makes an already bad situation worse as doctors choose to leave in search of better opportunities outside of Liberia. There is little doubt that this human resource problem is a root cause of maternal and neonatal mortality.
Maternal & Child Advocacy International (in collaboration with WHO and the Liberian Ministry of Health) has been working to strengthen maternal and neonatal care in Liberia– with an innovative programme to upskill midwives.
‘MAF presence will help especially because the road condition here is very very ugly, right now’ Jonathan Lobo
Bringing hope through a new approach
Their solution is a hospital based approach where experienced midwives are trained in advanced obstetrics to carry out tasks that would normally be undertaken by doctors.
In September 2015, a two-year apprenticeship for nine trainee obstetric clinicians began in three hospitals under the supervision of master trainer in obstetrics, Dr Obed Dolo. The midwives were trained in basic surgical skills, pelvic anatomy and ultrasound scanning for obstetrics and taught to carry out major surgical procedures such as caesarean section and to manage serious complications such as major hemorrhage.
'In this remote county hospital, there is one doctor serving a population of 67,000.' Sarah Newnham
At the end of their apprenticeship midwife clinicians complete a one-year internship in a government hospital and a further five years working in a rural location. Here, they will be supervised by an experienced doctor. At the beginning of 2018, nine obstetric clinicians were qualified to begin their internship in three rural hospitals.
In November 2017, MAF was able to fly MCAI’s senior staff to assess the facilities of two rural hospitals in Fishtown and Zwedru to ensure they had the necessary equipment and facilities for advanced maternity care.
The flight from the capital Monrovia takes around an hour - but it would take one to two days by road saving the team much time and allowing them to visit two hospitals in one day!
I was accompanying Professor David Southall (MCAI director) and Dr Obed Dolo (obstetric trainer) and as the plane turned sharply, I spotted Fishtown airstrip nestled amongst the jungle in the remote village of Fishtown. In this remote county hospital, there is one doctor serving a population of 67,000. When you have pregnancy or child birth complications in rural Liberia, there are really very few options.
The doctor serving 67,000
The hospital staff were so excited at the prospect of more skilled practitioners coming to assist them. It dawned on me how unusual it was that Dr Dolo has chosen to remain in Liberia, practicing obstetrics and training future clinicians when most of his counterparts have moved to other countries or better paying jobs. I asked him with curiosity what makes him stay?
Full of enthusiasm he instantly replied, Because I love it. That great feeling when you know you have made a difference. Of course, there are times when you are frustrated and things don’t work out, especially when the loss of life is preventable. I chose obstetrics because it’s a field where even in a country like Liberia you can make a positive difference. By improving practice you can reduce mortality rates and see the positive outcome.
Saving lives one at a time
At the beginning of 2018 the new obstetric clinicians had been working hard to clean up and declutter the maternity department in Zwedru. The result was a more hygienic, organised and spacious area for medical staff to deliver babies and care for patients.
Grand Jedeh County has a population 127,000 covering served by one general doctor based in Zwedru’s Hospital. With an average of three or four babies being delivered each day, the need for these skilled clinicians is obvious.
Dr Obasi, medical director at the hospital tells us candidly, ‘the training program is great. I notice that the clinicians are competent in their jobs as midwives. They are able to do surgery, like cesarean section. This is great here in Liberia where you have few doctors, especially few specialty doctors. The difference for me is huge. Before they came I used to work 24 hours on the clock. I had little time for myself, little time to go anywhere as I was the only doctor available.’
Meeting the mothers
The three clinicians gave us a tour of the maternity department and introduced us to some of the mothers and babies that they had delivered. They have not yet noticed an increase in women coming to Zwedru to deliver babies but expect this to happen once word gets out that trained staff are available at the hospital.
The Clinicians spend some of their time travelling to rural clinics, ‘we tend to go to those facilities to call people together to tell them we are here to help them and so if anything complicated happens they should come to us’ shares Emmanuel. Training rural staff to make earlier diagnosis and refer women to hospital for necessary care is also crucial to improving safe delivery of babies.
In Zwedru, their skills in assisting deliveries and counselling mothers to successfully give birth naturally has already reduced the number of c-sections taking place. ‘I think with our being here, there will be hope for our patients because in a sense, now we are here, our presence has reduced the rate of Cesarean sections. We have been able to do other manipulations such as vacuum deliveries that we are trained for. So, it is a hope for the women, that they will be at less risk of future complications’ Jonathan.
Shuttle saves time
MAF is now flying to Zwedru on its weekly shuttle, enabling delivery of medical supplies and reliable transport for staff and patients to other referral hospitals.
Jonathan shares, ‘MAF presence will help especially because the road condition here is very very ugly, right now you can get to Monrovia but in the rainy season, it is very difficult to get there. Even to refer patients, from one point to another, is very difficult for us. So with these services in place, I think it will be a great relief to us’
‘We are hoping that the help will continue. It can be very difficult. The journey from Zwedru to Monrovia can take one week when the roads are bad. It’s a nightmare. So I'm only hoping that the help should continue through your organization’.Dr Obasi.
'I chose obstetrics because it’s a field where even in a country like Liberia you can make a positive difference. By improving practice you can reduce mortality rates and see the positive outcome.'