Liberian midwives are being trained as surgeons to assume the role of maternal health doctors killed by Ebola.
Hannah Gibson, 36, first heard about Ebola when she arrived in Liberia in March 2014.
At the time she was stationed at C B Dunbar Maternity Hospital in rural Bong County, about 200km west of the Liberian capital Monrovia.
Gibson was also just six months into a pilot training programme teaching midwives advanced obstetrics, such as emergency Caesarean sections.
In July 2014, a patient with perceived malaria symptoms arrived at Phebe Hospital, a half-hour drive from C B Dunbar. The patient deteriorated despite treatment and the staff realised that this was the first Ebola case in the county.
Five nurses died as a result of the initial misdiagnosis and panic spread across the county’s healthcare services.
“There was a lot of fear in me and the other midwives regarding the disease and how it kills people very fast,” Gibson recalls.
She says most of the midwives at C B Dunbar fled, “leaving the hospital in the hands of the medical director and us, the trainees.
“Phebe Hospital had a lot [of] nurses die … but we took the challenge because C B Dunbar is a maternity hospital, the only maternity hospital in the county and all the referral counties – so we had to work. We stayed at the hospital working.”
Fear pervaded the small C B Dunbar team as they operated with very limited medical supplies, a lack of protective gear and no external support. They continued to manage maternity care for the county’s population of 330,000 people, while struggling to obtain further medical supplies.
“It was scary. Every time you go to work and you leave and go home, you start to worry. Have I come in contact with anybody? You have to tell your children to go away, not to come around you,” Gibson, a mother of three girls, recalls.
Patients showing symptoms of Ebola were turned away at the hospital gate and sent to the county’s Ebola treatment unit, which was set up in September that year and was the second to open in Liberia. Gibson says it was difficult to go against her instinct to help but acknowledges that the maternity hospital didn’t have the safety equipment or staff to admit Ebola patients.
Eventually, the risk became too high and the staff partially closed the hospital, only accepting cases involving emergency pregnancy complications. Gibson and some members of her team quarantined themselves for six months within the hospital walls. They worked overtime, eating and sleeping with the patients while continuing to deliver babies and perform Caesarean sections day and night. During this period, Gibson was able to see her family only on a few occasions.
In May 2015, when Liberia was first declared free of Ebola, fears were slightly allayed and C B Dunbar reopened.
The outbreak killed 184 Liberian health workers and, according to the Ministry of Health, only 117 doctors were available for a population of more than four million in February 2015.
Ebola damaged an already limping healthcare system.
Many doctors had fled when armed conflict ravaged the country between 1989 and 2003, and the temptation of better-paid positions overseas ensured an exodus of skilled healthcare professionals in the years that followed.
“The more education people get the more money people want. You also want your education to impact your life … and so we realised that we are training people that we do not have the market for,” says Dr Bernice Dahn, Liberia’s minister of health.
Dahn says Liberian medical schools follow a Western curriculum and standards, which enable doctors to transfer their skills over to healthcare systems in countries such as the United States, where the quality of life and pay are much higher.
“The rule is that you do at least two years of service,” Dahn says. “And right after those two years people find their way out of the country.”
According to estimates, more than three quarters of Liberia’s trained doctors emigrate to practise in other countries.
Maternal health is one of the areas which has been hardest hit by the shortfall in medical personnel.
find their way out of the country.”]
In 2011, President Ellen Johnson Sirleaf set out a five-year plan to dramatically reduce maternal mortality rates in Liberia.
But it remains high. It was around 990 deaths per 100,000 births in the period between 2012 to 2014, according to the World Health Organisation (WHO). Dahn says the rates are likely to have increased owing to the continuing brain drain and the impact of Ebola.
“At the moment in [the] country there are very few obstetrician gynaecologists,” Dahn says. “I think there are fewer than five.”
In other words, there are just a handful of specialists to manage more than 100,000 births in Liberia each year.
“If we were as a country to train obstetrician gynaecologists who have to go through medical school for five years first – for the basic training – and then an additional three years, and maybe another two years for fellowship, that’s 10 years. All our mothers would die,” Dahn says. “So there must be an innovative way of doing it.”
The innovation came when the British NGO Maternal and Childhealth Advocacy International (MCAI) initiated a task-shifting training programme in Liberia to teach midwives advanced obstetric skills in October 2013.
The goal was to bridge the obstetric skills gaps through a sustainable programme and relieve some of the pressures on the already overstretched and overworked doctors who would normally enter the operating room – particularly in rural areas. For the pilot, two experienced midwives were recruited to undergo a two-year training course followed by a year-long internship.
Gibson was one of these first trainees and MCAI paid her a salary throughout. During the Ebola outbreak, Gibson took classes in pelvic anatomy and basic ultrasound, learning how to identify malpresentations that would require a Caesarean section.
As the training became more practical, Gibson would assist the senior doctors in surgical procedures. By the end of the first year, while the country was in the midst of the Ebola crisis, Gibson was managing her own cases and performing surgeries in the operating theatre. It is a responsibility that she relishes.
“You no longer have to wait for a doctor. You can take action,” she says.
Despite the hurdles, Gibson has participated in hundreds of successful Caesarean sections. According to Dr Obed Dolo, master trainer at C B Dunbar for the task-shifting programme, the training has enabled doctors at the hospital to focus on other cases and has increased the capacity of the hospital to treat simple pregnancy complications, saving many mothers’ lives as a result.
Now in her third year, Gibson is currently stationed at Redemption Hospital in Monrovia with two new trainees.
She helps the senior doctors provide training and mentors the new recruits. But there, she has encountered a whole new set of challenges.
“It is difficult due to the lack of adequate working materials and limited doctors,” Gibson says.
Frequent power outages at the hospital mean that it is not unusual for her to deliver newborn infants using her mobile phone’s flashlight.
You no longer have to wait for a doctor. You can take action.
There are also difficulties presented by other colleagues.
“Some doctors feel that our training will be a threat to their jobs, making them give us the cold shoulder on the training ground. Despite this situation, I want to encourage the new trainees to keep focus on their calling,” Gibson says.
Liberia’s Ministry of Health has deemed the programme a success and with financial support from the WHO, the government late last year decided to roll out the programme to two more hospitals in Liberia and train nine new recruits with the aim of dramatically reducing maternal mortality rates across the country in the next five years.
As of May 2016, Gibson and the second initial trainee Naomi Lewis had between them participated in 422 Caesarean sections and saved the lives of hundreds of other mothers.
Gibson hopes to graduate in September and if successful, she will receive a five-year licence to practise as an obstetric clinician in public hospitals selected by the Liberian Ministry of Health.
While her new qualification is only recognised in Liberia, Gibson is adamant that she wouldn’t leave even if she had the opportunity.
“I will go where I’m needed,” she says defiantly. “This is my calling.”
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