Collaboration to improve women’s health in Gondar region, Ethiopia

Gondar is the most populous and geographically largest part of the Amhara region in Ethiopia. The topography is characterized by difficult terrain, making access to modern means of transportation challenging. Preg-nant women face difficulty in ac-cessing good quality obstetric care. Anecdotal evidence and everyday observation show that most cases of maternal mortality and severe acute maternal morbidity reported at Gondar University Hospital (GUH) (uterine rupture, obstetric fistula, haemorrhage, puerperal infec-tion, complications of abortion and cases of intrapartum fetal death and birth asphyxia) are reported in women who arrived from hard to reach areas. Inability to get quality care on time is usually the result of unavailability of services, inac-cessibility due to distance, limited transportation facilities or high costs. Even after reaching a clinic in good condition, casualties still happen as a result of inadequate or actually harmful care.

Much effort has been made by the government of Ethiopia as well as by non-governmental organizations to improve the situation. The number of health professionals at all levels has increased significantly; health care accessibility has also increased due to road construction, construction of new health facilities and upgrading of the existing ones. Below we describe the col-laboration between Gondar University (GU), World Vision (WV), the Liverpool School of Tropical Medicine (LSTM) and the Working Party International Safe Motherhood and Reproductive Health (WP), an example of such effort. In June 2015, a team from WV, the LSTM and the WP spent a busy and fruitful week in Gondar University Hospital. This resulted in an agreement between all four parties and a Memo-randum of Understanding (MoU) was signed. In this MoU, different activi-ties to be undertaken were described: rolling out the Life Saving Skills in Emergency Obstetric and Neonatal Care Course, research activities and develop-ment of subspecialty programmes.

Liverpool life saving skills-emergency obstetric and neonatal care training (lss-emonc)

Rolling out the LSS-EmONC course, as developed by LSTM, is the core of the collaboration. A first training was conducted in June 2015. Health care pro-viders from different levels participated in the training: consultant obstetricians and gynaecologists (5), residents (5) and midwifes (20) from GUH as well as from local health centres. Three months later a team from GUH, the WP and WV made follow-up visits to four participat-ing health centres. Concurrently, a two-day training of the trainer course (ToT) was provided to the GUH team to facili-tate the LSS training. A third visit by the WP was organised in February 2016, which brought a LSS-training to another 27 participants and a new follow-up visit to four participating health centres. The scheduled visits in September 2016 and February 2017 were cancelled because of the political unrest in Gondar.

As noticed during training sessions and field visits, the training package is ideal for the Ethiopian situation. Leading causes of morbidity and mortality in the Ethiopian setting are covered, more emphasis is placed on the practical part of training, and this very intensive LSS-training is done in only four days compared to the extended BEmONC training being given in Ethiopia (21 days). During our field visits, we ob-served trainees using knowledge and skills achieved during the training. Furthermore, supportive supervisions scheduled three months after the train-ing helped local health care providers to implement new information and good practices on the ground. More follow-up visits and mentorship are scheduled to be implemented in the programme.

Research activities

Since the MoU was signed, many re-search ideas were raised and there were efforts to implement them. So far, only two student projects have been conduct-ed. Departure of some staff members from the GUH side, concentration only on issues related to LSS-training, and difficulties in understanding each other’s working culture, together with the political unrest in Gondar, might be some of the reasons for the sub-optimal achievement in this area. Since research is a potential area for scaling up the col-laboration to a national level or beyond, all parties committed to the MoU need to analyse the shortcomings in this area and find the way forward. Joint research projects could be a catalyser in the remaining period of the collaboration.

Subspecialty programme support

Another area of collaboration was assisting the obstetrics & gynaecol-ogy (Obs & Gyn) department of GUH in the newly established subspecialty fields, gynaecological oncology and urogynaecology. During the visit in June 2015, a gynaecologic oncologist, a member of the visiting team, operated on some cases of ovarian and cervi-cal cancer and shared her experience with the team at GUH. Eventually, the WP identified and contacted a Dutch professor in urogynaecology to visit GUH in the autumn of 2017 to assess the specific needs in further developing the subspecialty programme.

Future of collaboration

Even though the political situation in Gondar was not ideal during the last year for international collaborations, some opportunities have de-veloped in favour of our collaboration. New hospitals have opened in the districts where the collaboration project is being implemented and are staffed with medical doctors, anaesthetists and emergency surgical officers. Enabling these hospitals to become a CEmONC centre is a top priority for the Regional Health Office. GUH is also eager to empower selected hospitals to become affiliation sites for resident and medi-cal student-training. These are ideal opportunities to implement better supervision of the staff, which will be beneficial for the long-term results of the LSS-training. Research will be done on all locations to increase the data and get more medical staff involved in research activities. Subspe-cialty training will continue in GUH, focusing on urogynaecology, oncol-ogy and possibly laparoscopy. Hands-on training under close supervision combined with data-collection will be base of this long-term training.

Conclusion

Our collaboration has created a close relationship between the parties at a personal and institutional level. We have taken important steps. A number of professionals from GUH as well as midwives from the sur-rounding health centres have been familiarized with the LSS training. Basic LSS-training materials have been provided to the Obs & Gyn de-partment. Key officials at the Ministry of Health are informed about the advantages of the LSS-training versus the BEmONC training, which may have implications for the future. Further development of the col-laboration requires more face-to-face meetings between the leaders of the programme, which will also help to find the way forward to collabo-ration in research and building the subspecialty training programmes. Provided the political situation in Ethiopia stays stable and funding for sustained collaboration after the initial phase can be found, the perspec-tives for further development of the collaboration are promising.
Acknowledgement: many thanks to Prof. J. Stekelenburg for his contribution to this article.