Country of focus: Malawi

Written by Maria Lisa Odland, PhD Candidate, Norwegian University of Science and Technology (NTNU)

 

About research, medical training and other experiences from Malawi

 

First time in Malawi

People´s knowledge on Malawi varies a lot. Some people don’t know the difference between Mali and Malawi, some people know it’s one of the poorest countries in the world, some people don’t know it exists, and some people know it is a popular place to do research and aid work, and some people even know it as a tourist destination. For me I didn’t have a clue before the first time I travelled down there, but now I can safely say that Blantyre is my second hometown and Malawi will always have a special place in my heart.

I went to Malawi for the first time as a medical student and did rotations in Obstetrics and Gynecology, Pediatrics and Nephrology. There was a lot of impressions, both good and bad. Doing rounds at the ward for malnourished children and participating in a data collection on underfed children was probably one of the most difficult things I have ever done. I more or less saw children die from lack of food. Additionally, seeing patients with chronic kidney disease without money to buy drugs or the possibility to get a transplant or dialysis also made a very big impression on me and is something I will never forget. The bright side were seeing all these talented and dedicated doctors doing everything they could with very little resources. It made me a little bit hopeful that some of these patients could be saved, and maybe get better lives.

 

 

Unsafe abortions, complications and maternal mortality

Personally, my interest was always in Gynecology and naturally my further work went in this direction. It was devastating seeing girls even younger than me that had done horrible things to induce an abortion. An abortion is not legal in Malawi unless to save a pregnant woman’s life. Still, there is estimated around 140 000 induced abortions in the country every year. Considering the abortion law most of these are unsafe which leads to many complications that have to be treated.  Retained products of conception in the uterus, referred to as incomplete abortions, consists of more than 50% of the patients in a gynecological or female ward in Malawi, and takes up a lot time and resources. If incomplete abortions are left untreated it can lead to hemorrhage, sepsis and in worst case scenario death. One thing I noticed as a medical student was that they were treating all these patients with sharp curettage, while in Norway we mostly use medical treatment with misoprostol or electrical vacuum if surgical treatment is necessary. Treatment with curettage requires more resources like general anesthetics, a doctor or clinical officers, and electricity. Also, it is known to lead to more complications such as bleeding, uterine perforation and Asherman Syndrom. Potentially complications after this treatment can make women infertile in the future which can be devastating for a 16-year-old girl who maybe would have wanted a child later in life. In Malawi, they prefer to treat patients surgically for different reasons. If medical treatment is given out it can be used to induce abortions illegally. Additionally, medical treatment is not as efficient as surgical treatment and patients are supposed to return for follow up to ensure the uterus is empty. In Malawi, this is difficult due to lack of transport and money, and the woman can end up with more dangerous septic abortions. Manual vacuum aspiration (MVA) is therefore the preferred surgical method of treatment in Malawi, and recommended by the WHO, FIGO and the Ministry of Health in Malawi. The method is cheap, safe and can be done without electricity by nurses/midwives in addition to doctors.

Research on the treatment of incomplete abortions – My PhD

A fellow medical student, Hanne Rasmussen, had made similar observations with curettage in Ecuador, and came up with the idea to investigate this further. Since I had previous experiences from Malawi we travelled down together in early 2013 to go through all the hospital files on women treated for incomplete abortions the last 4 years in three public hospitals in Malawi. The findings were striking. Even though, the recommendations from WHO and the Ministry of Health was to increase the use of MVA, they were using less and less MVA, and more curettage. This development was in contrast to the guidelines, and curettage is a more costly and dangerous procedure. Malawi already has a high maternal mortality ratio, and a health system that is very low on resources and personnel, and this development would only make things worse, or at least not better. So, we decided to do something about it. Over the last few years I have with my collaborators conducted trainings at three public hospitals in Malawi to increase the use of MVA. We achieved a 21.3% increase in the use of MVA at the intervention hospitals, while there was only a 3% increase at the control hospitals during the same time period. This indicates that simple trainings should be done on a regular basis to sustain the use of MVA rather than curettage. However, it is essential that donors and policy makers make the equipment available and this is something that has to be dealt with.

More trips to Malawi in the future?

So, after living in Malawi three times already I still don’t feel it’s over. When you identify a problem, you can’t just leave it and expect someone else to sort things out. I therefore think my research in Malawi will continue to try and make things better for young women in the country. At the same time, Malawi is captivating and it sucks you in. First of all, it’s a beautiful place, and most importantly the people are amazing. So, you push through the power cuts, lack of water, the broken-down cars, the fear of malaria and different parasites. If you have a rough day you soon forget everything when you are going for run or having a gin and tonic with your friends in the amazing African sunset. To conclude, Malawi is maybe not for everyone, but it’s definitely for me.

 

 

Facts about Malawi

Population	18.09 millions
Gross Domestic Product	5.43 billions
Human Development Index	0.476, Place 170
Life Expectancy at birth	63
Mortality rate (under 5) per 1000	55
Maternal Mortality Ratio per 100 000 births	439
Prevalence of HIV, total (% of population ages 15-49)	9.2

Resource: The World Bank 2016 and Malawi Demographic and Health Survey 2015-2016.

A personal experience from Nepal Earthquake in 2015: Lesson learned from a local hospital

Written by Samita Giri, PhD candidate at NTNU, the Norwegian University of Science and Technology

This is a story about how a collaborative project between Dhulikhel hospital (DH) in Nepal, the Norwegian University of Science and Technology (NTNU) and St. Olav’s Hospital, University Hospital Trondheim, Norway, showed fruitful and life-saving result during the Nepal earthquake in 2015.

On 25 April 2015, middle of the day at 11:56, I felt a very high intensity shake. I was inside the house with my husband. My husband told me that it is an earthquake and he immediately ran out of the house and asked me to run with him. I was unable to move for a few seconds, I rather tried to hide under the bed instead of running out. I was seven months pregnant expecting our first baby in July.  My husband came back to take me out. I could hear people screaming and running to the safest place that they would think of. My family and I was safe and our house was still standing. Within an hour after this first quake, the ambulances, motorbikes, trucks, cars or any kind of transport system that were available started rushing towards the hospital. Some of the victims were even carried by their family members & neighbors with some heavy bleeding. I was living in a few minutes distance from the Dhulikhel Hospital (DH). DH is one of the tertiary level hospital for the Kavrepalanchok district and for few other neighboring districts.

Most of the regular health facilities were closed because of the weekend. My husband decided to go to the hospital the first day. After a while, I received a phone call and it was my supervisor (Prof. Erik Solligård) who was asking if we were safe. I was very happy to hear him. We were outside the whole day. I was very scared to go back to the house and the same feeling was with my family members and my neighbors. We bought some dry foods from the local shops and spend that night in a public bus that was parked in the bus station. We spend our nights outside under the tents and sometimes inside the bus for almost a month after the first earthquake. I started to go to the hospital from the second day to help in the areas that I could. Personally, I also felt more safe being in the hospital and making myself busy. I usually started my work from 8:00 in the morning until 20:00.

I still remember, the second day after the earthquake when I was in the hospital, the number of earthquake injuries escalated in the hospital, all the beds and almost all the space in the courtyard was occupied. The working conditions were continuously demanding. No one was prepared to deal with such a large number of injured patients. This was Nepal’s first experience in responding to a major disaster almost after eight decades and DH had never been the first-line health care provider after an earthquake. However, the hospital was in the process of improving emergency health care through the “Dhulikhel Hospital Patient Care (DHPCARE)” project, a collaborative project initiated in 2013 between DH, the Norwegian University of Science and Technology (NTNU) and St. Olav’s Hospital, University Hospital Trondheim, Norway [1]. The main interventions in this project were the introduction of a systematic emergency registry, a systematic triage system, and simulator training among health personnel in the emergency department (ED). As part of the project, the ED was reorganized to separate patients into three treatment zones (red, orange/yellow, and green) according to four triage categories (red, orange, yellow and green), with separate staff attending each zone since Feb 2015. I was the coordinator from the DH in implementing the project.

DH located in one of the most earthquake-affected districts of Nepal started providing 24 hours health services from day one to the earthquake victims. The hospital set up immediate medical direction, 24-hour surgical services, infection control teams, and logistical management teams, who had a vital role in managing unexpected workloads and providing efficient and quality health care. One of the major task force was the establishment of triage zone at the main entrance of the hospital consisting of medical team and volunteers. We started a systematic screening of patients arriving at the hospital using a simplified triage system, and prioritized patients for effective surgical services. We used color ribbons (red, orange, yellow and green) to distinguish the patient according to the severity and were treated in respective treatment zones. This was evaluated as a useful tool by the staffs at the hospital. I believe this is a great example of teamwork in a local hospital with dedicated staffs working 24 hours prioritizing their profession and humanity rather than their family. On the other hand, collaborations between the two institutions could deliver the quality of health service to the people on right time. At the same time, I was collecting the patient information from the triage zone and the treatment area. I thought this would be useful to report for the future preparedness in similar disasters. I find very challenging to have patients’ information during this emergency phase because the situation was very emotional, hospital had large number of caseloads, and in the first few days the hospital was not able to establish the systematic patient registry system. My two dedicated and hardworking research nurses helped me to accomplish this tremendous work.

DH provided emergency health services to more than 2,000 patients. The caseload was unexpected and was almost five times higher during the first five days than the pre-incident daily average. The majority of injuries were lower limb fractures and over 100 severely injured patients were treated. The proportion of severely injured and in-hospital deaths were relatively low indicating that the most severely injured did not reach the hospital. Most earthquake-affected regions in Nepal were rural and mountainous and there were continuous landslides, which affect transportation and prevent timely access to health facilities. The burden of emergency cases was high before the international field hospitals could be established. The international medical teams need some days after a disaster to initiate their services in the disaster affected areas. Until they arrive, patients are often treated by the poorly developed local health system, and many severely injured likely die prior to receiving medical treatment. Our study result and the local hospital experience underline the importance of developing own consistent and robust local health services capable of managing natural disasters such as an earthquake.

I am a PhD student at the Medical Faculty at NTNU under the supervision of Erik Solligård and Kari Risnes who are the project leaders in the DHECARE project. We had presented the experiences from DH including follow-up of earthquake victims in the article “Impact of 2015 Earthquakes on a local hospital in Nepal: A Prospective Hospital-based Study” in “PLOS ONE”, 2 February 2018.

Samita Giri, NTNU

Welcome to the blog of the Norwegian Research School of Global Health!

Being a PhD candidate in global health is not only about research. On this blog the members of the research school are invited to share stories, pictures and anecdotes from seminars, field works, travels, lectures and other relevant activities.

All members are encouraged to contribute to the blog, so don’t hesitate to get in touch. Contact Turid Austin Wæhler, blog coordinator in NRSGH, or Elin Yli Dvergsdal, coordinator in NRSGH.