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The Obstetric and Gynaecology Experience at Kisiizi Hospital, Kabale, Uganda by Alice Webb

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The Obstetric and Gynaecology Experience at Kisiizi Hospital, Kabale, Uganda by Alice Webb The Obstetric and Gynaecology Experience at Kisiizi Hospital, Kabale, Uganda by Alice Webb My time at Kisiizi Hospital was shocking, interesting, frustrating and very educational all at the same time. I feel I must set a backdrop for my experiences and to do so must write a bit about Kisiizi Hospital itself initially: Kisiizi hospital is a Non-Governmental Organization under the umbrella of the Church of Uganda. It is situated deep in the mountains of North Kigezi in the Rukungiri district of southwest Uganda about 20 miles off the nearest tarmac/paved road. It is a private, not-for-profit hospital, partially funded by the Church of Uganda. This site was chosen for Kisiizi Hospital because of its close proximity to a waterfall hydroelectric power source. Kisiizi's mission is “to bring high standard, holistic healthcare to patients/clients and life in all its fullness to them and the whole community within and beyond the hospital.” The hospital serves an area that stretches for hundreds of kilometres and often sees patients that travel from beyond the regional town Mbarara 80 miles away. Inpatients have a relative to attend to their basic needs. I spent the majority of my time there with the obstetrics team on the ward and occasionally in the community. On my first day at Kisiizi Hospital I went straight to the maternity ward after 8 am chapel to introduce myself to the staff. The labour ward was quiet so I was asked to perform the ward round with a midwife. As it was my first day and I had no idea of the services and pharmacy available I requested to just assist in my first ward round and to my surprise the midwife lead it instead. If an intern doctor finished his work on the surgical ward he would often come and lead the round but this was often not the case. The ward was grossly overcrowded with 2 mothers in some beds, whilst others were on the floor in between or under beds on blankets. During the busy ward round I was shocked when I stood on a bed of blankets on the floor and realised I almost stood on a newborn wrapped up in said blankets, the mother absent. Most of the ward round consisted of post C- section mothers and a few complicated obstetric cases such as pre- eclampsia and antepartum haemorrhages. I was shocked to hear that the pharmacy often ran out of medication leaving, for example, a 37-year-old mother at 34 weeks gestation with an uncontrolled blood pressure of 165/110. The next obvious difference noticed was the parity of women and the significant extremes of age. I met a G11P10 patient as well as an expecting 12 year old and 56 year old. There is some public health underway in the area of continuous reproduction with many posters around explaining the harm in having many pregnancies close together and the benefits of having a smaller number of children, however these messages are sadly not being heard and there is a very large bay dedicated to purely malnutrition on the paediatric ward. Efforts are also being made to educate patients on the dangers of pregnancy at a young age, as there is a high rate of vesico-vaginal fistulas in the area. The only senior doctor in obstetrics and gynaecology was absent for training in this very specific area for a lot of my time at Kisiizi and I saw a case first hand after a 15 year old patient had been in obstructed labour for 12 hours and then unfortunately had a still born delivered by C- section when she eventually reached the hospital. Sadly, intra uterine fetal death is not uncommon in Uganda and I saw many cases, it was additionally heartbreaking to watch these ladies give birth on the labour ward surrounded by successful new mothers and newborn babies. The perinatal mortality rate per 1000 total deliveries in 2007 was 50. Many patients choose to give birth at their homes often miles and miles from the hospital, even if they can afford the fare it is often far too late by the time they are seen at Kisiizi Hospital to treat complications. The deprived state of the hospital means there are no CTG machines and USS are pricey and not standardly requested. Fetal distress is based on pinnard monitoring of heart rate and meconium staining and I wondered very early if the rate of c-sections seemed significantly higher than in the UK and discovered the rate was in fact 24.9% in 2007 (the last report written) compared to 23.8% in England in 2008 (Ref 1). I spent a lot of time on the labour ward - so much so that I made a strong friendship with a midwife there and have been asked to be a bridesmaid for her wedding next year! The delivery experience at Kisiizi was hugely different to the experience in the UK. A labouring mother commonly has to walk miles in labour to reach the hospital, they are asked to bring plastic bin liners and when a bed becomes free is taken to the labour ward where they sit on these bin bags on an examination couch. There are torn curtains between the 4 beds in the one room. The patients are attended to by relatives and are only allowed to drink tea that the relatives must bring if they can afford it. Catheterisation is very uncommon and patients mainly squat over a bucket on the floor to urinate. Unfortunately for the women of Uganda no pain relief is offered during delivery whatsoever and only now can I truly appreciate the pain of childbirth. Some local anaesthetic is given when repairing perineal tears and codeine or paracetamol is commonly given after delivery. I was very grateful to have the opportunity to deliver many babies and below is a baby boy I delivered independently that presented with his cord around his neck. I also gained a lot of experience in fetal heart rate monitoring with pinnard and Doppler and determining the position of a fetus through examination, all of which I felt I (and I'm sure many other medical students) have previously hoped a good guess at would prevent me looking incompetent in front of consultants. These skills will be very valuable when I start my obstetrics and gynaecology rotation as an FY2. Despite the lack of equipment there I was amazed to see very few complications during my time at Kisiizi and it makes one wonder if the natural process of childbirth is sometimes complicated by our efforts to make it more efficient and safe. There is a good antenatal clinic ran at the hospital and I thoroughly enjoyed visiting the community with the antenatal team on several occasions to assist with their work. Gynaecology was based on the surgical ward and for the majority consisted of malignancies of the female reproductive system. Sadly, every case I saw simply received palliative care. There were few cases of much else as menorrhagia and dysmenorrhoea are the least worrying of many of these woman's afflictions. As predicted there is a high prevalence of HIV in Uganda and I spent many mornings with the HIV clinic team. Every pregnant mother is screened for HIV for free and anti-retrovirals are one of the only medications free of charge to the patients. I also spent some time on the isolation ward and learnt a lot about the diseases HIV can predispose one to. There was also a very high rate of sexually transmitted infections due to the common occurrence of adultery and serious lack of barrier contraception use. There is an unacceptably low rate of contraceptive use and there are efforts going in to public health in contraception, IUDs are fitted for very cheap but it is not the traditional way of life in Uganda and the messages mainly fall on deaf ears. My time at Kisiizi Hospital has given me a huge appreciation for the extraordinarily high standard of care available to us in the UK. I learnt theoretically and practically and have gained valuable experience in history and examinations, delivery and feel I have gained significant knowledge in the area. My experiences at Kisiizi hospital have only increased my desires to specialise in obstetrics and gynaecology and will stay with me professional and personally for the rest of my life. I am so grateful for the opportunity to witness the work of, and be involved in, the team there - thank you so much for assisting me in making of this experience. References: Ref 1 - Variation in rates of caesarean section among English NHS trusts after accounting for maternal and clinical risk: cross sectional study - BMJ 2010; 341 doi: 10.1136/bmj.c5065 (Published 6 October 2010). Fiona Bragg, David A Cromwell, Leroy C Edozien, Ipek Gurol-Urganci, Tahir A Mahmood, Allan Templeton, Jan H van der Meulen. Figure 1 -baby boy 'Michael' - my first independent delivery in Uganda Figure 2 - an antenatal clinic in the community .
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