Finally it is complete only 4 days before I leave Axum! The process to creating the neonatal unit as been a long one with many challenges along the way. This is how I did it for those that are interested:
Step 1: Find out that a neonatal unit is what the main objective of your placement is. It took me a little bit of time to do this as it wasn’t specifically mentioned in my initial placement objectives and when ever I asked people at the hospital I was told to ‘tell us what you think’. After I had come up with an action plan for improvements following feedback from the hospital and VSO it was apparent there was one priority – creating a neonatal intensive care unit!
Step 2: Write a proposal for funding. Initially I didn’t know that funding was available. (I found out about four months into my placement that I could get a VSO small grant.) Once you find out you write the proposal using an example provided and data gathered about neonatal admissions and mortality by painstakingly going through the ward admissions book to get figures. Ask the medical director for help with the costing’s for items (you find out later not always entirely accurate!)
Step 3: Experience sharing visit. You are told that you can’t submit the proposal as an experience sharing visit to a neonatal unit already established by previous VSO volunteers has been arranged and you need to go on that first. (See blog: Travelling and exploring – Part 2)
Step 4: Submit the proposal and receive feedback. The feedback doesn’t seem to take into account that hospitals in Ethiopia are similar and also that neonatal units all need to be to the same standard and contain the same equipment. Lots of e-mails and conversations partly resolve this issue.
Step 5: Get told that you have been granted the funding. The money doesn’t actually appear in your bank account until a few weeks later. A week after you have used your own money to run the 1st staff training course (see blog What do you do with free weekends?). The money comes in installments and you have to prove how you spent each section of the money before you get the next instalment.
Step 6: Start refurbishment works. Following instructions for painting and putting lino flooring in the rooms designated for the neonatal unit spend frantic weekend cleaning the rooms before the painting is done (see blog With a lot of help from my friends). Feel like everything may happen quite quickly (you’re wrong!).
Step 7: Start construction works. Medical director decides that you can change the bathroom into a nurse’s station and that a new bathroom can be built (using funds from the VSO grant which requires much discussion to get approval). Since you are creating a nurse’s station can now have viewing windows into neonatal rooms. Lots of mess created by making windows undoing all of the work that was done in cleaning and initial refurbishment! Construction of bathroom outside and work needed in neonatal unit itself takes a long, long time. Progress is made and then stops and then continues in an ongoing cycle. Repeated discussions with the hospital CEO take place about progress with multiple warnings given to the contractors.
Step 8: Get equipment. This requires a couple of afternoons with the head paediatric nurse and the pharmacy stores manager poking around in the three different storerooms at the hospital. Lots of good and unexpected things found which will be useful. The remainder of the equipment requires a trip to Addis with the pharmacy stores manager to purchase. Although some things are not available in the country you manage to get most of the vital equipment. (See blog The ongoing building work.)
Step 9: Re-start refurbishment works. Once you finally have the neonatal unit building works completed (work is still ongoing on the bathroom block) start refurbishment work again. Spend a day and a half cleaning – including scrapping years of encrusted dirt off tiles in the old bathroom/new nurse’s station. Keep asking for other refurbishment works to be done. Explain can’t run neonatal unit until the works are completed.
Step 10: Organise staffing. Get the hospital to assign four nurses for the neonatal unit (1 for each shift looking after 10 babies). Try to ensure that you get good nurses who will be willing to learn and deliver good nursing care. Arrange for extra training in currently operating local (8 hours away) neonatal unit. Once they arrive on paediatric ward try to get head paediatric nurse to understand that they need to be scheduled on separate shifts – it doesn’t work if they are all on the same shift. They should not be covering the paediatric ward only the neonatal unit as the whole point is the babies need specialist nursing care with extra observation and monitoring.
Step 11: Give multiple warnings that you are leaving so project needs to be completed. First warning given with a month to go following which multiple warnings are given on a weekly basis. After returning from annual leave with only 10 days until you finish have a frank discussion with CEO expressing concerns that the unit won’t be finished before you go. Then spend three days following people around and repeatedly going back to harass people to get the odd jobs done so the unit is in a state where you can do final cleaning and move equipment into place.
Step 12: Buy floor for the neonatal unit. This actually takes the best part of the week even though it seems like a simple task. You go to the shop and see a good lino covering (thicker than the previous so less likely to tear hopefully). Then get told it will be brought later that day. Continue to go back to the administration/finance department to ask when it is coming. The following day get told that the price is above the market value (but also told it was the cheapest price and can’t get to the bottom of how the market value was reached). Get approval from the CEO for the extra cost. In the afternoon finally get collected and taken off across a muddy square to a different shop from the previous day. The lino is not the same and much thinner lino, which now is cheaper than the price you were told this morning. Go back to the hospital and speak to the CEO explaining the difference in quality and why the thicker flooring is better. Get the ok to buy the better material but told it will take another two days to go through the procurement progress again. Finally loose your temper. Get told they will speed the process if possible. Go on another trip with procurement people in tow to visit all three shops that sell the flooring you want. Get the costs for the correct type of flooring. (Out of interest the same price that you were told that morning). Back to the hospital as it’s the end of the day. Overnight awaiting the decision of the meeting to decide which of the quotes will be accepted. Ask in the morning when will get decision. Told would be two hours. Found by administrator to ask about the sample and if the floor brought could be different. Decided to go along to make sure the right floor brought. Taken back again to the same shop as yesterday and asked about buying the same poorer quality you were shown yesterday! Get pretty angry at this point. Convince them to go to the next cheapest quote shop. Find the flooring needed. Argument from hospital staff about the price with shopkeeper. Discover they’re arguing over 125 birr (£3.70). Offer to pay this to solve the issue but told no, just wait. Eventually the hospital gets the price they want and the floor is brought. In the afternoon fit the floor with the help of the nursing staff. Finally the worker who was meant to fit the floor turns up as you finish in time to glue the floor down. After three days the floor is complete!
Step 13: Final cleaning and organisation. Following the floor being laid co-opt nursing students, nursing staff and ward cleaner to do a final clean of walls and floor of unit (while the floor is still being glued down). Start to then move in equipment, which has been stored in various places around the ward. Make sure that equipment is cleaned before it is moved into nice clean neonatal unit first. Stick up posters of guidelines on the walls and try to remember what other equipment you may have that has been hidden so well you haven’t found it yet.
Step 14: Find leak into the critical care room. When you go in part way through the organisation of equipment find that there is another leak this time in the roof of the room which will house critical babies. (There had previously been a leak in the roof of the nurse’s station which required fixing.) Since this was found on Saturday have to wait over the weekend and public holiday for Eid before you can inform the hospital management and get it fixed. Surprisingly it’s fixed within two hours of you telling people about it.
Step 15: Open the neonatal unit for business! It’s taken over 10 months to get to this stage and so pleased that it has happened before I leave Ethiopia. This morning we moved babies and mothers into the neonatal unit. Hopefully with good nursing care, from enthusiastic nurses, the outcomes for babies at Axum St Mary hospital will improve. The next blog will contain photos of the functioning neonatal unit. Thank you to everyone that I know who has helped to make this happen through supporting me over the last year as well as donations of money and equipment.
What have I been spending three out of the last four weekend’s doing? I’ve been training 60 hospital staff (mainly nurses and midwives) on newborn resuscitation and care. Using many different resources I created a two day training course which was delivered with the help of the paediatric masters translating and my fellow volunteers, Romil and Claire, helping with the practical sessions.
The training course is part of the project I’m working on to improve neonatal health. The training on newborn resuscitation on the first day gave people the knowledge and skills needed to resuscitate a baby. Everyone was great at taking part in the sessions, which included resuscitation scenarios – something that was completely foreign to the staff as it is not a teaching method used here. In the UK no training is complete without practice scenarios! We even had proper resuscitation mannequins which moved their chests when effective ventilation breaths were given. These were a mixture of the types we use in the UK and also a special mannequin called a NeoNatalie. These great dolls are blow up resuscitation dolls! They are fabulous to use and a great solution for resuscitation training in many countries.
The second day was for teaching about universal newborn care practice, Kangaroo Mother Care (skin to skin with the mother wrapped in clothes and perfect for keeping babies warm), breastfeeding (everyone needs help and no matter where you are it doesn’t always come automatically to every mother and baby), neonatal sepsis, jaundice and the special care that preterm babies need.
At the end of the course we had practical and written tests. Some difficulties were created as not everyone can read English well and unfortunately I didn’t have a Tigreyan translation. Everyone did well on the practical section of the test and successfully resuscitated a NeoNatalie! The enthusiasm and active participation from everyone involved was fabulous to see. Hopefully the information and skills learnt will be taken back the wards around the hospital and put to good use. As one of the participants commented – “the babies born after this course will have a great advantage.”
I saw an article recently in the British press about the high under five child mortality rate of the UK (www.theguardian.com/society/2014/may/02/uk-child-death-rate-western-europe-health). It caused me to reflect on the differences between child death in the UK and Ethiopia. The UK under five child mortality rate in 2012 was 4.8 per 1000 (30th in the world). This is high compared to other western European countries (Norway’s rate is 2.8 per 1000) and I agree needs to be improved. However for other countries, like Ethiopia, this rate is something to aim for. In 2012 the under five mortality rate in Ethiopia was 68.3 per 1000 (156th in the world). The rate in Ethiopia has fallen dramatically from 204 per 1000 in 1990. A child mortality rate of less than 5 per 1000 is just a dream currently for health professionals working in Ethiopia and other countries round the world.
It is a tragedy when any child dies anywhere in the world. The aim should always be to reduce the number of children dying and examine the causes of deaths so action can be taken. The lower the child mortality rate gets though the more difficult it is to affect it. Ethiopia has taken significant action to try to reduce the under five mortality rate and meet the Millennium Development Goal to reduce the under five mortality by two thirds. It was announced in September last year, not long after I arrived in the country, that the MDG for under five mortality had been achieved. This is fantastic as it makes Ethiopia one of only a handful of countries currently to achieve this MDG.
Behind the headline figures is another story though. Ethiopia is a federation of 9 regions and 2 city administrations. The rate of child mortality varies considerably between each region with some still having an under five mortality rate as high as 169 per 1000 in 2011, while others have a rate as low as 53 per 1000. You also have to look at the age under five of the child when the death occurs. The rate of neonatal deaths is still high. Although child mortality decreased rapidly, neonatal mortality (death in the first month after birth) has not decreased as rapidly. The neonatal mortality rate was 3 per 1000 in the UK in 2012 (34th in the world) compared to 29 per 1000 in Ethiopia (168th in the world). In comparison to the under five mortality rate as a whole the neonatal mortality rate in Ethiopia has decreased by less than half from 54.2 per 1000 in 1990.
Death is more common here but there is always sadness when a child dies. Families mourn their children no matter how old the child is (newborn or older). Just because families often have many children doesn’t meant that life is seen as cheap or not as important because they are only children. It is particularly hard for me when a child dies who I feel that if they had been in the UK I could have done more to save the child’s life.
Events around a death in hospital follow a different pattern here. In the UK resuscitation attempts are prolonged with the family present and kept informed throughout. I found when I arrived that resuscitation was not always attempted for babies and children, although this has improved since my arrival with nurses now attempting resuscitation even if there is no doctor present. The family is often in a different part of the ward and do not always want to be present with the child. After the child dies they are wrapped in white clothes and given to the family for burial. Usually the male relatives will leave the ward with the child and the shovel and pick axe that are kept on the ward. After the child has been buried they return the tools and the family will leave to mourn in private.
There is still plenty to do in Ethiopia that will affect the child mortality rate. Reducing the neonatal mortality rate is a major part of the challenge and one of the reasons that I am working here in Ethiopia is with the aim of establishing a neonatal unit here at Axum St Mary Hospital. The neonatal deaths here occur mainly due to infection or prematurity and low birth weight. Basic care can help a lot of the babies who currently die. Keeping preterm babies warm, making sure they get the right amount of feed to gain weight and supporting their breathing can save a lot of babies who otherwise wouldn’t survive. For infection it is about recognizing a child is sick and starting antibiotics early. Stopping some traditional practices (uvulectomies and use of traditional medicine) that often lead to infection would also help. Education of mothers and families is essential.
Through improving nursing care, giving guidelines for neonatal care, training staff in newborn resuscitation and care, creating a neonatal unit with the equipment needed we hope to help to reduce the neonatal mortality rate here in this small corner of Ethiopia.
This weekend’s plans were unexpectedly changed at the last minute. We had planned to go and visit friends in Adigrat but that trip was postponed and cleaning of what will be the new neonatal unit at Axum St Mary hospital took place!
After we found out on Friday morning that the painting was due to start that afternoon we had a discussions about how nice it would be if we could clean the rooms first instead of just painting over the dirt – this was deemed to be a good idea. So on Friday both the ward cleaners cleaned a room each and today myself and the other two VSO volunteers working at the hospital went in to do a second scrub down of the walls and floor. We were helped by the two nurses on shift and the head paediatric nurse (wearing his best clothes). It was a great effort by all involved with lots of bleach, scrubbing, and water splashed around.
Below are some pictures of all the activities featuring some of the people who helped out. Also featured is the new sink installed this week at the entrance of the unit for everyone to wash their hands and yes it does work!
The reward at the end of a hard morning’s work – a chocolate covered doughnut from the local pastry shop of course.
I’m now half way through my time in Ethiopia with only 6 months left before I return back to the UK and paediatrics in Yorkshire. The range of cases that I’ve seen since I started working in Axum is very different to what I would normally see in the UK. Some of the cases are the same as the UK, for example gastroenteritis and pneumonia, but others are very different. I’ve learnt a lot about managing different tropical diseases as well as other conditions which are a lot more common here compared to the UK like acute glomerulonephritis. I have become experienced in dealing with children with malnutrition. I know how to clinically diagnose and treat acute rheumatic fever. Children with a haemoglobin of 1.6 g/dL (the normal is about 12) no longer make me panic even when it takes us 3 days to get blood to transfuse the child. I’ve seen too many cases to count of malaria and visceral leishmaniasis. I’ve seen a handful of cases with cutaneous anthrax too (make sure you wear gloves when you examine the lesion is one of the important lessons here). TB and HIV also occur although not as frequently as in other countries. Neonates (babies) make up many of the admission here. The main problem is infection but there is also a lot of premature and low birth weight babies under 2.5kg who get admitted. Without folic acid supplementation of food I have also seen many more cases of spina bifida and encephaloceles in the last 6 months than I saw in 6 years in the UK.
Diagnosis are made using very few tests. We have FBC, urine microscopy and dipsick, blood films and stool exams, some serology tests for some of the infections. Cultures are not available and the only radiology is x-ray and basic ultrasound scans. We don’t have any biochemistry tests for electrolytes or kidney and liver function tests as they are currently non-functional due to a lack of distilled water I’ve been told. Even when results are given often they are repeated as the results from the laboratory are not always accurate. Diagnoses are made based on the history and examination findings with pattern recognition and knowing the epidemiology of, for example, where the malaria and visceral leishmaniasis endemic areas are. It’s frustrating when full histories of patient’s illness and examination aren’t done or recorded by staff as it’s assumed what the problem is from the presenting complaint.
Treatments are limited and everybody gets antibiotics. This depends on what antibiotics are available as there has been a shortage of some of them. There are limits to what can be done in Axum and some cases need to be referred to Mekelle, a town 8 hours away with a large referral hospital, or even to Addis Ababa, the capital. What is difficult is when parents cannot afford this and so a child’s treatment is limited by the cost. Patients have to pay for each nights stay in hospital, any investigations done and any medications needed. A hospital stay can cost families a large proportion of their income. Neonates, HIV related illnesses and malnutrition feeds receive free care at the hospital at least.
Care on the ward is very different. Out of hours there is only 1 doctor for the whole hospital and sadly paediatrics often gets neglected. Nursing staff do not provide the same level as care and monitoring – children get observations done once every 24 hours instead of every 4 hours as in the UK. Even when done abnormal observations are not acted on often. It is upsetting to think that with more regular observations and if action was taken when they are abnormal more children may survive.
I have learnt a lot working with a lot fewer resources than I’m used to in what can be a very difficult environment. My clinical knowledge has increased and I don’t feel the lack of all the extensive tests that I could do in the UK apart from on a few occasions. There are frustrations when I know that with the care and resources available in the UK that a patient could have survived but here they do not. Although there are faults with the NHS we are lucky in the UK to have access to free at the point of care healthcare where you get whatever tests and treatments you need no matter what the cost with round the clock care from dedicated doctors and nurses.