Laura Spells
I have recently returned from my medical student elective placement at Saint Francis Hospital (SFH), Zambia, for which I was delighted to receive some funding from the RCOG/Ethicon Prize. This brief report provides a flavour of some of the results of my project and is also my opportunity to thank the Royal College of Obstetrician and Gynaecologists for their generous support. As you will see, I found the realities of working in a developing country somewhat more difficult than expected, but the experience has strengthened my resolve to pursue the professional skills that women in the developing world are in such desperate need of.
My typical day would consist of ward round in the morning followed by either outpatient clinic or theatre. Obstetric ward rounds would consist typically of pregnant women with a fever or suspected infection, women with a ‘bad obstetric history', or women who had co- existing medical conditions. CTG monitoring was not available and ultrasound was not routine. Caesarean section was performed regularly due to uterine rupture, prolonged second stage or cephalopelvic disproportion. Gynaecological patients often had very large abdominal masses (usually fibroids or ovarian cysts) infertility problems (perhaps a lesser known complication of HIV) and cervical cancer (a more familiar complication of HIV). I can also proudly say that my first ever delivery was conducted in Zambia!
Malaria in pregnancy audit
As planned, I developed my audit tool and used it to assess current practice in relation to insecticide treated nets (ITNs) and intermittent prophylactic treatment (IPT) and to identify some of the barriers to successful delivery of the RBM programme. I collected data from ninety women, during two different clinics by looking at their antenatal cards (a fairly reliable record of previous doses of prophylaxis) and interviewing them through a translator. The following are some of my key results:
Of the ninety women included, 39% were full term (36 weeks or more). Proper implementation of the RBM programme would result in 100% of the full term women having received three doses. My results showed:
- 40% had received three doses;
- 29% had received two doses;
- 31% had received one dose; and
- 0% had received no doses.
I asked the same ninety women if they owned a mosquito net; if they did was it usable, and if not would they buy one today. I found:
- 47% owned a net, of which 87% were usable and 17% were unusable; and
- 53% did not own a net at all (23% of whom purchased a net that day, the other 77% could not afford the equivalent of 40p);
I recognise that there are a number of limitations to these results, most particularly the exclusion of the significant number of women that never attend an antenatal clinic (and so never obtain either a net or any prophylactic treatment). This factor introduces significant selection bias to the data collected. The supplies of nets and prophylactics were sporadic and so the results would likely be different if conducted over a longer period.
Nevertheless, from these results I would note that: (i) there were no full term women who had not received a prophylactic dose; (ii) 40% of the anticipated 100% had received full treatment; and (iii) despite government subsidy, affordability remains a key factor in the provision of nets.
Personal Conclusion
I believe that delivery of programmes such as the RBM is essential and it is important to understand how they are being implemented in order that they can be more effectively delivered. However, my lasting feelings relate to my recognition that the ability of our medical skills to improve the quality of rural Zambian's lives is limited given the cultural context within which they are being applied. I think these two photos help to illustrate the point:
I now realise that as a doctor I will not be able to completely transform people's lives but, in the developing world, a little bit of knowledge and skill can have a dramatic impact on people's physical health. This elective has shown me that the provision of medical care is a small part of a bigger picture where there are vast cultural and social challenges to achieving wellbeing for everyone.
This elective has furthered my desire to qualify and specialise in obstetrics and gynaecology, and I hope the skills I will develop will be useful to women in Britain and the developing world. I thank you once again for your support.
Laura Spells
Medical Student
University of Leicester