Maternal health beyond the hospital walls, a perspective from Senegal

Before going to Senegal I had looked up all of the health statistics in preparation for my work.  Maternal mortality is 370/100,000 compared to 20/100,000 live births in the United States.  For Senegal, this is quite an improvement from nearly double that rate in 1990.  Yet, there is still room for improvement and as an enthusiastic, young global health professional, I am trying to figure out my role in the effort.

The natural course would be to work on what I know – training physicians.  Surely there is a need to train more providers and improve the quality of that training, right? In Senegal, the ratio of physicians to population is 1:10,000 (versus 24:10,000) and although there has been an OB/GYN residency training program since 1968 there is still a lack of skilled surgical providers.  Yet in the hospital where I work on the outskirts of the capital, there are 6 part-time OB/GYNs who are all highly skilled and patients receive excellent care.  

We have access to reliable anesthesia, back-up surgeons, pharmacies stocked full of medications, a fairly consistent blood bank, and tertiary care hospitals to receive patients who require ICU level care.  Even more basic than this, but perhaps even more important, there is access to running water, electricity, paved roads, frequent taxis and even the occasional ambulance. These amenities are the norm for this hospital, but consider a rural district hospital a few hundred kilometers outside of the city.  If an OB/GYN is there, they are probably working alone.  They have little back-up.  They may not have anesthesia.  If they want blood, a family member must donate it for fresh whole transfusion.  Hospitals don’t stock medications and though pharmacies may have some of them, patients have to find the money to pay for them.  The referral hospitals are hundreds of kilometers away, and the journey to them is on deteriorating, dangerous roads in whatever vehicles can be found.  If there is electricity, a back-up generator is normally required to accommodate the frequent energy outages and any clean water, let alone running water is a luxury.  It is hard to understand how a physician can work effectively in such settings, let alone live there.

Given all of this as background, perhaps I was fortunate that during my rotation, my team has only lost one patient.  She had a normal delivery at a small community center that was complicated by a retained placenta.  The patient began to hemorrhage and was transferred to our hospital.  On arrival, her hemorrhage spiraled out of control and she showed signs of rapid decompensation.  She was taken to the operating room, her placenta was removed and a transfusion started, but unfortunately it was too late. 

Worldwide, 25% of maternal deaths are attributed to obstetric hemorrhage, making hemorrhage the leading cause of death for women in pregnancy.  Globally, we have seen declines in maternal mortality ratios and programs aimed at improving maternal mortality have taken on some great challenges – training skilled birth attendants, getting clean delivery kits into communities, mobilizing communities to promote prenatal care and delivery in healthcare facilities.  The truth about obstetric hemorrhage, however, and what makes it perhaps the greatest challenge, is that it is unpredictable.  There are few consistent risk factors for hemorrhage and most women who die from obstetric hemorrhage have no known risk factors.  When hemorrhage occurs, women need rapid resuscitation and capable providers with the capacity to intervene surgically.  Our patient had no risk factors, and at the first sign of danger, she needed a bloodbank and skilled, equipped providers at the facility where she delivered - or equally as good, a road and immediate access to an ambulance to get her to somewhere that did. 

While there is still a small piece of global health that I am trained to impact, global health is about so much more than training clinicians.  It is about socioeconomic development, distributive justice, infrastructure and access.  Perhaps it is time for us to take on the more complex systems that affect the health of the populations we seek to improve; to make friends in other areas of development so that governments and societies can create a coordinated approach to improving health.

Rebecca Luckett MD MPH

Taking it all in - obstetrics and gynecology in Senegal

This is my first time in Senegal and my first time providing clinical care outside of the United States.  I have made a fair number of rather long journeys to similar locals, but never in a clinical capacity.  In the past I had generally embarked on the journey expecting that I had an idea as to what my role would be, either in a school, a clinic, a public health project, but without an explicit job description. I had been comfortable with that. Coming fresh from a month of nights on a busy labor floor, I stepped off the plane in Senegal and I felt like I should enter back into constant movement and flurry of activities.  The first day at the hospital, I was relieved to find an awaiting cesarean section – I felt immediately useful.  And when down time followed, I found myself anxious about how I would maximize my time –how should I integrate into the resident team?  what should I do in my free time? should I join in a research project?  which presentations should I prepare for my colleagues? I was searching for ways to find the affirmation as an individual that I was accustomed to in residency. 

But I did not come to Senegal to simply be my American resident self, I was here to begin to learn how to be a doctor in a place where I don’t have every amenity and test at my fingertips.  I shifted my outlook over those first few days and paid attention, observed, listened, and asked questions, so that I could begin to understand the system I was going to be working in.  This is a glimpse of what I found.

The labor room.  Only for women ready to push.  As opposed to Boston’s spacious, private rooms with epidurals overflowing, there are three gynecology beds in a row, for three women to labor side-by-side, each to her own rhythm.  The only pain relief is delivery. 

The nursery.  You may have noticed the “nursery” in the picture above.  After birth the babes are cleaned, swaddled and placed in a row on an open table, under regular lamps to keep them warm.  Spooning babies is surprisingly effective soothing while mom is recovering after her delivery.  

The Pinard.  My co-resident pictured above is expert and I am always wishing that I had smuggled a bedside Doppler into my luggage to find each babies’ heartbeat. 

The operating room.  No bells and whistles, but with everything we need.  After scrubbing and prior to opening the sterile box of instruments, it is always a mystery as to which instruments you will find.  It is typically no more than 15 instruments, many of which are different from the last kit used.   We return to surgical basics and make instruments work for us.

Anesthesia.  General is rarely needed though available with manual ventilation as pictured below.  Nearly all gynecologic procedures are performed under regional anesthesia.  Fortunately, both the gynecologists and general surgeons do extremely challenging surgeries within the time constraints of regional anesthesia.  

Indications for surgery.  Fibroids were by far the most common reason for gynecologic surgeries.  These are typical specimens from one patient - every last one comes out.  

Operating with general surgeons.  I have not assisted a general surgeon, let alone had a male patient on the operating table since my third year of medical school. Yet the general surgeons here do a fair amount of gynecologic surgery and thus are incredibly valuable teachers. 

Fortunately, despite some of the contrasts highlighted here, the human body and gynecologic pathology are fairly constant whether you are in Boston or Senegal.  That keeps me breathing easy while I continue on this incredible and humbling journey.

Rebecca Luckett MD MPH

Learning about Task Shifting

Pictured above: Sangath, Goa

Neuropsychiatric diseases like unipolar depressive disorders, addictions, bipolar disorder and schizophrenia make up 28% of the global burden of disease among noncommunicable diseases and are economically more disabling than cardiovascular disease or cancer. When you add infectious diseases, neuropsychiatric disorders make up 14% of the entire global burden of disease. While access to mental health is essential to improving quality of life among people and economies of the world, there is a dearth of resources. How do we address the need? Vikram Patel MD, a psychiatrist at the London School of Hygiene and Tropical Medicine is doing fascinating research in task shifting, the idea of training community health workers to handle psychiatric interventions with supervision, as an answer to the need. I was lucky to get a chance to visit his clinical trial center in Goa, India.

With India's population of over 1 billion people, they require at least 150,000 psychiatrists. Currently, they have around 3000 psychiatrists meeting about 2% of the country's need.  The idea of task shifting is to train community health workers to carry out psychosocial interventions. Chosen community health workers are those who are dedicated to their community's psychological health and understand the cultural contexts within which mental illness exists in their society. I got a chance to meet these wonderful women at Sangath, Goa. They go out to primary care centers to do prescribed therapies that have shown to be helpful in addiction and depression.

For the trial Sangath recently did (MANAS trial), the community health workers use depression and addiction scales to screen and triage patients in primary care centers who are having trouble with depression and alcohol abuse. Those who screened positive would either be assigned to the control group or see a community health worker for 6-8 cognitive behavioral therapy sessions to treat depression or addiction. In the picture below, you will see the packets the community health workers use to do the therapy and assess improvement behind them.

The community health workers get supervision weekly with more senior counselors on difficult cases and meet with a psychiatrists at least once a month. They are connected to referral services for urgent and more medically complicated cases. These trials have shown a significant impact to improving depression and addiction in this community.

It was a wonderful experience for me to see people trying creative solutions to major problems to accessing mental health care. It's a great way to involve the community, to help create sustainable resources, build capacity in a health system, and reduce the stigma of mental health.

Jhilam Biswas, MD

Pediatric Medical Education in Mbarara, Uganda

Before my arrival in Uganda I had read numerous articles on commonly seen conditions, spoken with residents and attendings who had previously worked at Mbarara Regional Referral Hospital (MRRH), and did my best to familiarize myself with cultural practices.  However, nothing could have prepared me for the reality of working at MRRH.  I am privileged to train in a country and hospital where essentially no resource or specialist is more than a phone call away.  There is almost always another test or procedure which can be performed to try to reach a diagnosis, and many third (or fourth or fifth) line treatments available before we tell a patient or their family that there are no further options.  At MRRH, the residents and students practice in an environment where they are never certain what resources might be available that day – do we have patient files or order forms, oxygen available for those in respiratory distress, or appropriate antibiotics for any of the numerous infectious processes encountered daily?  The answer is dynamic, changing from one hour to the next.  Too few nurses leads to the residents and students checking vital signs on rounds and family members administering most oral medications and alerting care providers to changes in a patient’s condition.  There are limited diagnostic tests available, and the providers learn to live with a high level of uncertainty.