21st July 2012

This is my last blog as we are leaving on Saturday to journey back to the UK via Djibouti. It has been a very hectic couple of weeks as I have been trying to get all my project work done. I feel that I have largely achieved what I set out to do; I have seen over 900 women at the antenatal risk screening clinics and have included 423 in my study (women over 30 weeks gestation); I’ve followed up most of the 274 women identified as being at obstetric risk; and I’ve carried out 7 focus group discussions to understand why women deliver their babies at home, hospital or the health centre. I am now trying to get everything written up so that I can send off various papers to be reviewed for publication. What is clear is that the women here have a really tough life and are often left with little choice about their health care decisions. One in every 34 pregnant women die through pregnancy or childbirth. Around 10% of the women in my study had a previous stillbirth, with 3% having had 2 or more stillbirths. There are many possible reasons for these devastating figures; poor nutrition, lack of finances, difficulty in accessing services and lack of medication and equipment are just a few. Accessibility of health services is certainly an issue, with many women having to walk for over 2 or 3 hours before they can reach even fairly basic health care. Higher levels of health care are simply inaccessible for many as the cost of transport can be prohibitive.

Nevertheless, I am constantly astonished at the courage of these women when facing the difficulties surrounding childbirth. They will sell a coffee tree to pay for health care, they will deliver their baby on the side of the road when labour is too quick to make it to the health centre, their acceptance of possible death in childbirth will result in a home delivery which avoids ‘unnecessary’ costs, their desire for an ultrasound scan leads them to walk for 4 hours when 9 months pregnant, their need to continue to earn money leads to them daily carrying of 30Kg of wood on their back right up until the delivery day, their ability to deal with complete childbirth induced urinary incontinence without any underwear or pads, their ability to live with the knowledge that 1 in 17 children will die before the age of 1 year, their ability to work throughout the pregnancy despite an absence of iron supplements, their acceptance of enormous goitres through a lack of iodine in the diet, the absence of any painkillers during labour, the ability to walk the 2 or 3 hour journey home just 3 hours after delivery………..

I could go on and on and I am sure that when I look back on the time I have spent here, I will be constantly reminded of the bravery and the strength that the Ethiopian women face in their everyday lives. I have enormous admiration for them and it has been a privilege to have met them and hopefully provided some useful care. Possibly equally important, I hope that I have been able to show them some kindness and compassion; something that few women seem to experience. Indeed, one woman in my focus group discussion cried when she described the kindness that she had received and how this had made such a difference to her life. I wish I could do more for women like this but you can’t change the way things are. You can only hope to leave them with some hope that there are people out there that care about them and want to help them. 

I take with me the memories of the smiling faces of women who try to hide their amusement at my efforts to speak to them in Oromifa, their amazement when I show them the heart beat of their baby on the scan, their generosity when they offer me some corn from their field, their kind invitations to have coffee with them in their house, their desperate efforts to make sure that I am comfortable, their amusement when I show them a photo of their baby, their gratitude when I give them a photo of their baby or some baby clothes. I will also be taking back the many memories of Jaba, whose first birthday on October 21^st I will sadly miss. He continues to go from strength to strength and it is hard to think of those many weeks when he was in the ‘cheese counter’ fighting for his life. He has an extremely promising future and is very fortunate to have such a loving family to care for him. He is, of course, also very lucky to have such a large and caring extended and international family, who I am sure will want to be kept up-to-date with his progress. I think I will need to set him up on facebook so that people can follow his life.

Our last few weeks here are enriched by the company of Karen and Adam Lowton, who arrived last Monday despite BMI cancelling their flight the day before. Clearly, I am extremely happy to have them here and really hope that they enjoy their time here and in Djibouti. I have booked an amazing hotel in Djibouti. They have brought with them more luxury goods than I have seen in a very long time – dairy milk chocolate, chicken tikka in a bag, F&M champagne truffles, a bottle of pink Sancerre, and L’Oreal face cream, to mention just a few. So I think we shall be having some amazing meals and will probably be the envy of all of Gimbie. It’s Saturday film night tonight so we are going to share a chilli con carne (yes, with meat imported from Waitrose) with the ex-pats here and I might even open the Dairy milk. This is certainly a big event and will be the talk of the town for the next week. The Sancerre is definitely for personal consumption only.

I have been very grateful for your company throughout this blog. It has been lovely to know that there are people who have been interested to hear about our lives here and it has been a great comfort to hear from you. If you have followed the entire blog, you have read 49,128 words. It’s not quite as much as my thesis but hopefully, a little more interesting.

We will be back in the UK on 8^th August and look forward to catching up with you over the weeks to come.  I leave you with a few of my favourite photos, some of which you may have seen before……..

At least I have a pair of shoes....

 Lalibella

 Colobus monkey

 Jeremy & Waishun

 Camels in the South of Ethiopia

 Waiting for a chance to get mangos

 By the pool in Djibouti

 Bonfire of bones (animal) at Green Bar

 My very first delivery

 Focus groups brought many happy women together

 Maybe at risk but all turned out well

 Hannah with Jaba

 Antenatal clinics create fascination for children

 My birthday chicken from Heidi & Andre

 Making Injera

 Jaba one month old

 Jaba 7 months old

 Birthday celebrations with Clara

 Scanning creates amusement

 Twins 5 months old

 Twins 1 week old

1st July 2012

My trip to the Boston spa was in parts enjoyable, although I didn’t manage to quite get the hair cut I envisaged. No layers, no shaping; just a simple straight cut all round. Oh well, at least they didn’t attack me quite so brutally as they did in the Hilton hairdressers.

Following my recovery from whatever feverish illness I had, we enjoyed a good few meals out in Addis and celebrated Jeremy’s birthday in an Indian restaurant. Thankfully, Clara is mega organised and brought some cake and candles along so we managed to do the whole ‘happy birthday’ thing and returned back to the hotel pretty stuffed. As you might imagine, we don’t need a great deal of food to become full up nowadays so we end up ordering for one less person than we have in the group. I’m sure that will all change on return to the ‘healthy’ UK portions.

Back in Gimbie, and I ran my very first focus group discussion to try and evaluate the work that I have been doing over the past 10 months. Well, two Ethiopians actually ran the group, on account of my not speaking good enough Oromifa. My biggest fear was that no-one would turn up and so I was pleasantly surprised to have a 50% turnout. Pretty impressive given that some of the women walked for 2 or 3 hours to come to the meeting. They were fairly quiet to begin with but eventually became confident to chat about their experiences of antenatal and intra-partum care.  So far, all seems very positive and women (and their families) do appear to take the advice to deliver in a health facility seriously. At the end of the discussion, they were asked what they would suggest could be done to improve the service and they responded by suggesting that I should come and live in the village, and even better still, live in the health centre houses. Clearly, that is not going to happen, but it’s nice to be valued.

One of the challenges now is getting the clothes dry in an environment of daily rain and minimal hanging area. So the clothes always smell a little musty and feel pretty damp. Mind you, I have got used to looking a little tatty, on account of having nothing that fits me. So smelling mouldy just adds to the effect. Very excited today though as a new order of clothes is arriving from the UK – Camilla went back home to renew her visa and so I ordered a few items of clothing from French Connection and she is bringing them back.

Jaba is here with us today and I have just noticed that he has ringworm on his head. We have some anti-fungal cream though so we will treat it before it gets too bad.

18th-24th June 2012

Morning tea was somewhat disturbed by the arrival of two men at the bottom of our garden, carrying that familiar cardboard box. I guess this means that the baby of the eclamptic woman, who has been sick over the past few days, didn’t survive. Indeed, there have been a few ‘boxes’ buried in the garden over the past couple of weeks, which, were we not leaving soon, would have caused me some concern as the cemetery gets closer and closer to the house.

The Wednesday clinic was busy as usual and we saw a total of 52 women. Luckily, Jeremy came with me and so we were able to set up 2 simultaneous clinics. We saw 3 women with twins, all of whom were rather shocked to hear the words ‘mucha lama’ , which simply means two babies. You will notice that my Oromifa hasn’t improved greatly, although I just about get by at the clinics, much to the amusement of all the women. It’s odd enough to see a white face in the village, let alone one that can speak some of the language.

I also saw a woman who claimed to be 9 months pregnant with her first baby, but clearly looked rather small for this. On examination, her abdomen was quite hard and when I scanned her, the 5 month-old baby was without a heart beat. Given that she was sure of her dates, it is likely that the baby had been dead for about 4 months. What makes this story even worse is that she had attended the health centre on 4 previous occasions and despite her small size, none of the nurses had thought to listen for a fetal heartbeat. Why? …you may well ask.

The government struggle to increase the proportion of women attending for antenatal care and put considerable resources into new health centres and health posts and even increase the numbers of health care staff by at least fourfold. However, what they haven’t managed to do – and we all struggle with this – is to motivate staff to provide a high quality service. This seems to be a particular feature of the male dominated health centres. So when a woman comes to the health centre, she often gets a cursory check-up, with little more than a few questions being asked about why she has turned up. Yet, they are supposed to be delivering what is termed ‘focused antenatal care’, where the woman receives fairly prescriptive, but effective care. So the challenge for all of us is to find a way to alter attitudes – not an easy task. Yes, you can offer financial incentives; and this is what many people seem to want but this just spirals and quickly becomes the norm. Interestingly, many NGOs (non-government organisations) have fallen into this trap and have been paying health staff considerable sums of money to attend training sessions. Now, of course, you can’t get someone to attend a training session unless you pay them. This is certainly a ridiculous situation, especially when you consider that in the UK, we all have to pay to receive any form of training. So it’s easy to make mistakes and find yourself in a worse situation than when you started.

I don’t have the answer – I would be a very cleverperson if I did – but I do think that there is a need to introduce some form of accountability into the health system. So if we take the scenario of the woman with the intra uterine fetal death that I just mentioned, you would have some kind of mechanism whereby this is followed up. Clearly, the woman received inadequate care. What can she do about this? Who does she report this to? What kind of complaints system is there? Well, you won’t be surprised to hear that there is nothing she can do about it. There is no-one to complain to. Indeed, you would be lucky to find anything written in her notes about her 4 visits to the health centre.

I could write a whole book about all of the difficulties (don’t worry, I won’t post this here) as it really is a fascinating and incredibly complex situation. On a positive note, one of the nurses (female) at a health centre managed to deliver twins in a woman who had a previous caesarean section. The woman turned up in the night, having been driven for the past 2 hours on her way to hospital. She was not able to complete the next 2 hours of the journey as she was having rapid contractions – indeed, when the nurse looked, she was fully dilated and the head was popping out. So she delivered one baby and then started to deliver the placenta, only to find another baby emerging. The woman had no idea that she was pregnant with twins. Both babies and the woman survived the whole ordeal and although the nurse was a little shaken by it all, she performed extremely well.

We heard that the government had banned the use of Skype here, which you might appreciate, is rather troubling for us as it is one of our few communication channels. Apparently, they were worried that ETC, which by the way, is the only telecommunications organisation, were losing vital revenue because people were using Skype. The response was to ban Skype and try to pass a law that stated you would get 15 years in prison for using it. I am told today that, due to international pressure, the decision has been reversed.

I’ve been a bit unwell over the past couple of days, with what I am mildly concerned might be malaria. This is now the 3^rd time that I have had a sudden onset of high temperature, headache, neck stiffness and feeling generally rough. I had my blood tested last time this happened and it came back as negative but I’m not so sure that the tests are that sensitive. Anyway, I think I will have a check up when I get back to the UK to see if any amoebic rogues are lurking around. It’s a bit of a nuisance though as we are now in Addis and I want to enjoy the food. It’s Jeremy’s birthday and so we felt that we needed a treat – some food. Actually, I have had to go out and buy some new clothes as I am now a size 8!! I am a little sad, however, that my new jeans have just lost a button. Such small things are upsetting when you haven’t had any new clothes for at least 8 months.

Booked in to have a hair cut and a facial at the Boston Spa – hoping to look a little better than I did after the last hair cut. I don’t think that the concept of ‘layers’ and ‘shaping hair to fit the face’ has arrived here yet though.

 Women get to do much of the heavy labour - carrying wood for the fire

 Men, however, also have to do some heavy work - carrying a woman to the health centre on the 'foot ambulance'

Waiting for antenatal check-up 

Kids at the local school.



17th June 2012

Most mornings now we start the day with ‘no light’. It seems that the electricity cables or posts are just not strong enough to withstand the nightly rain storms. I have, however, managed to get out to the health posts and the health centres and so the work continues, which is just as well as the women keep flooding in. I saw 49 women at Ganjii and many of these women had never had any antenatal care in the whole of their pregnancy. I’m not quite sure why so many new women turned up but suspect that my conversations with the Health Extension Workers (health workers who are based within the villages) last week provoked further discussions with women in the far away villages. Some women had walked 2 ½ hours to come and see me. I hope they were happy with the service they got. The exhausting day ended on a bit of a low as a woman in her first pregnancy was found to have an intra-uterine fetal death. I was really sad for her and thankfully had a very kind Ethiopian with me who translated the news sympathetically.

It must be strange for a woman to see her baby on the screen when she probably doesn't have access to a mirror and so doesn't even see herself on a regular basis.

There are always children trying to peep through the clinic window

 The road back to Gimbie from the health centres

Jaba continues to be well, which is something of a relief given that 1 in 17 children here die before the age of 1. We took him to the police station to register him as ‘abandoned’ – something the hospital are supposed to do when the event actually occurs. This is the second time I have had the need to visit Gimbie police station (previously had to go when Makabe was robbed) and it was just as amusing this time. There were quite a few people waiting to tell their troubles to the 2 policeman in the hut and so we waited amongst the bare necked chickens for our turn.  The necessary information about Jaba was entered into an A4 lined notebook and various signatures were obtained before we were sent on our way to the office of women’s and children’s affairs. Here we again told our story and registered him as abandoned and gave them a letter from the hospital confirming the story. Now all we have to do is apply to the court for a hearing, bring three witnesses along with us and he is legally ‘abandoned’.

And boy does it rain.....

No, the dog isn't ours..... 

Colobus monkeys playing on the roof of our veranda 

8th June 2012

Another week of heavy rain and the roads are now becoming very slippery indeed. Yesterday, I tried to get to the Ganjii antenatal clinic but when we got to Haru, just 30 minutes out of Gimbie, there was a huge lorry with a trailer stuck in the ditch and unfortunately blocking the road. Since it was still raining, the driver had relocated himself to a dry place, leaving us and the bus waiting for………..what?? Nevertheless, in good Ethiopian style, we did wait – for an hour – and then we decided to find the traffic police as they should be dealing with the situation. We brought the rather unperturbed policeman to the scene of the road block but by the time we arrived, the driver had returned to his vehicle. The policeman also returned to his post, leaving a team of locals helping to dig out the lorry. After about 30 minutes, however, all ‘tools’ were downed on the basis that nothing could be done but to wait for the sun to dry out the mud. Well, this was clearly going to take a very long time as the sun was firmly hidden by numerous rain clouds. So after 2 hours of waiting, we decided to return to Gimbie, having achieved nothing other than got cold and wet and a bit muddy. I clearly felt bad about the women who will have walked to the antenatal clinic and so was relieved to hear from the head of the health centre that it was also pouring with rain in Ganjii and that very few women had turned up to the clinic. He also added that there was another lorry blocking the road there, making any form of access impossible. What happens in an emergency, I wonder? They are totally cut off from any hospital care.

Positive aspects of the rain: 1) it provides lots of water for washing and drinking; 2) the crops will grow well, providing essential food for the country and animals; 3) the roads are no longer dusty; 4) it provides a new source of amusement for children who play in the puddles.

Negative aspects of the rain: 1) it wakes me up most nights as it falls on the corrugated iron roof; 2) The roads are muddy and often impassable, leading to relative isolation; 3) the power lines fall down, leaving us in darkness and without a fridge; 4) all clothes remain damp after washing.

I guess that on balance, the lifeline that the rain provides for many outweighs the inconvenience it causes.

Once the rain had settled, after getting various bits of paper signed and stamped by health officials, the hospital staff made a big bonfire to burn all of the expired drugs. The task was considerable as the hospital get many drugs donated from the government – only one catch though; they have just 3 months of use before expiring, which means their disposal becomes a task for the hospital rather than the government. Not such a generous gesture after all.

Having heard that there was a sick baby on the ward, I spent the morning in the hospital. The 2-day old baby had been fitting on and off over the past 36 hours, having presumably been pretty hypoxic during the delivery. He also had pretty rapid breathing and a high temperature, which suggests meconium aspiration. He had been started on the usual 2 antibiotics available here and had received one dose of phenobarbitone 36 hours ago. Despite being directed into his eye rather than his nose he was on around 30-40% oxygen, delivered through an oxygen concentrating machine (oxygen cylinders are too expensive to get refilled and have to come from Addis). Since he was still fitting, I asked whether he could have some more phenobarbitone and perhaps some phenytoin as these drugs are generally available here. So we stood there watching the baby continue to fit whilst the relatives went to get the prescription of drugs. Drugs have to be collected form the pharmacy on the next floor, where the relatives will need to queue and pay for them. After an hour, the relatives returned with exasperated expressions explaining that the drugs were not available anywhere in Gimbie. One of the nurses asked if we had any ‘in your house’ and so I had to explain that although it sometimes appeared like we ran a pharmacy – or indeed an entire hospital supplies unit - anti-convulsion medicines wasn’t something we ran to. Eventually, we managed to find two tablets on the male ward, which I then had to take home to crush and mix into a solution. No pestle and mortar sitting in any drug cupboard here. Actually, no drug cupboard here.

After an hour or so, the baby looked a bit better and the convulsions lessened. He’s still a pretty sick baby but perhaps he has a chance……

I have just looked outside our veranda to find an enormous hole just inches away from the house. It seems that the old cesspit used to be here and the heavy rain has shifted the corrugated iron covering, leaving the earth on top to cave in. I am told that someone will come to fill the hole and rather hope that this will happen before the veranda – and house – slides into the crater. 

30th May 2012

The entire Ethiopian phone network – yes, there is only one network – has been switched off for 48 hours in a desperate attempt to stop cheating in the grade 10 exams. Apparently, everyone has been passing the exams as they have all had the answers texted to them. I am told that it is not the students who initiated the cheating but rather the teachers. As soon as the exam scripts are opened, a teacher passes a copy to another teacher, who then completes the paper and sends the answers around by phone to some syndicate of teachers who then somehow inform the students in the exam rooms.  So for 3 million Birr, the government are able to buy ETC silence and we are yet further dislocated from the world. As it happens, and I don’t know if this is linked, the internet has also been off for the past 24 hours, making any form of communication rather difficult.

I am beginning to dread Wednesdays as this is the day I visit the largest health centre to provide antenatal care and it is really busy. 68 women turned up, all of whom wanted to have an ultrasound scan. Who said women do not want antenatal care?? The latest figures released form the government state that only 46% of women in Ethiopia have any form of antenatal care. Well, I can safely say that we have managed to improve on that in this area. Many women come back two or three times, having walked some 2 or 3 hours to get there and often having to wait most of the day to be seen. It is just impossible to see everyone in one day and so I have told 30 of them to come back on Friday, when I will do an extra clinic. We try to see those who have travelled the furthest first, but the system breaks down as women push their way to the front, having no concern about their queue jumping.

The husband of a woman who had a C-section in the hospital last week, came to see me, asking for help for his wife who was apparently at home with a gaping wound and unable to move from the bed. He said that her wound had burst open and that she couldn’t be moved. Well, what was I suppose to do? Given the torrential rain over the past few weeks and the increasing difficulty driving on the ‘main’ road to the health centres, I asked them where they lived. Having only just got the car back from the garage, I was not in the mood to find myself sliding off the road and into some ditch. ‘Oh it’s OK, they are just 5-10 minutes on the main road’ I was told. Being considerably experienced in Ethiopian inability to tell you the truth, I checked this information at least 3 times. Yes, I was told, it is definitely on the main road and yes, her wound is gaping open and yes she is unable to travel.

In order for me to get back to Gimbie before dark, I need to leave the health centre at 4pm. You really don’t want to travel in the dark as there are no street lights and assorted animals belligerently lying on the road. If you kill a cow, you have to pay 10,000 Birr (£375.00). A sheep is 4,000, a goat is 3,000 and a donkey is 3-4000. If you kill a person, you get 17 years in prison – not a nice thought at all. So I closed the clinic at 3pm and we set off to see the woman in her home. You probably won’t be surprised to hear that; 1) the road was anything but ‘main’ and due to the rain, it was rather muddy/flooded; 2) it was a 25-30 minute drive to the house; and 3) the wound was not gaping but rather, there was a slight infection causing minor breakdown of the edges. Having placed a dry dressing over the wound to stop the dozen or so flies getting to it and prescribing some Amoxycillin, we left the house as quick as possible to get back to the health centre, where a pregnant woman and her husband were waiting to be taken to the hospital.

We made it back just before nightfall and I vowed, once again, never to believe the story I am told. Whilst frustrating, I am beginning to see the funny side of the things that happen – probably because I know that in a short while, I will be walking away form all this. If this is your life, however, you must totally despair. Perhaps that explains some of the attitudes here?

I often wonder how this little chap will turn out. He is going to have to deal with a lot of frustration over his lifetime. At least for now, he’s happy……..