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MCAI project: Training midwives in emergency obstetric surgery in Liberia

Please note that this is not an RCOG Fellowship and all enquiries should be made to MCAI directly.

Seeking senior obstetricians to train experienced midwives in advanced obstetrics including abdominal surgery in Liberia 

The international medical charity, Maternal and Childhealth Advocacy International (MCAI), is seeking volunteer senior obstetricians to work in an innovative programme in Liberia. Following a successful pilot in training the first two experienced Liberian midwives in advanced obstetrics, including abdominal surgery, from September 2015 in partnership with, and partially funded by, the World Health Organization (WHO), MCAI is rolling out the programme to train another 7 midwives/ nurse midwives and 1 physician assistant over the next 3 years.

The number of doctors able to undertake obstetrics in Liberia is extremely small, largely as a result of emigration to well resourced Western countries.  This is the major factor contributing to the very high maternal and neonatal mortality rates in this country. Therefore, this innovative task shifting approach is necessary and fully supported by the Liberian Ministry of Health.

The project is based in three training hospitals in Liberia and ideally would require a minimum of working in Liberia for regular 2 - 3 month periods with alternate equal times spent in the UK. MCAI will cover the costs of travel and accommodation.

The senior volunteers must have MRCOG or higher and be experienced in advanced medical and surgical obstetrics. Experience of working in a low-income setting is desirable but not essential.

Please see the MCAI website and the MCAI book website for more information on the program. 

If you are interested, please contact the Honorary Medical Director and Liberian project lead of MCAI, Professor David Southall at director@mcai.org.uk or telephone +44 7710 674 003.

Project overview

Our partnership plans to train eight nurse midwives, to undertake obstetric emergency surgery by a system of overlapping placements of experienced UK obstetricians (3.5 months duration). Our goal is to provide an effective comprehensive Emergency Obstetric Care service (EmOC) to rural areas of Bong County in Liberia. The project is based in two hospitals in Bong County which are equipped for obstetric care; CB Dunbar and Phebe.

Volunteers must have passed MRCOG or equivalent, and may be senior trainees, consultants or Trust doctors, who may have recently retired from practice.

First year of the project

The first year of this project commenced in October, 2013 when 2 midwife trainees were recruited, registered and commenced their training in Bong County’s government maternity hospital, CB Dunbar.

The training has been facilitated by a Gambian consultant obstetrician supported by MCAI senior international volunteer consultant obstetricians (one from both the UK and the Netherlands). After an incredibly promising start to the program, international volunteers had to be withdrawn from Liberia in May 2014 when the Ebola out-break escalated.

Since then, our two midwives who were undergoing training in advanced obstetrics, including abdominal and other life-saving surgery, have continued to work under the supervision of their local trainer, and CB Dunbar, the hospital where they work. They have succeeded in continuing to provide comprehensive emergency obstetric and neonatal care throughout the Ebola crisis. This has been extremely valuable for Liberian women as the vast majority of maternity services in Liberia closed completely throughout most of this period, and those hospitals that remained open offered minimal obstetric activity.

This success has in no small part been due to the continued work and skills of our trainees, who for the last 6 months have been operating independently. We are hopeful that their success will lay the groundwork for continuing this program in Liberia post the Ebola epidemic, and we have 2 further midwives identified to enter the program and hope to commence their training in the next few months

Project partners

The project has been undertaken in partnership with the Liberian Ministry of Health, the World Health Organization (WHO)Maternal Childcare Advocacy International (MCAI) and the Advanced Life Support Group (ALSG)

This project was funded by THET and UKAID and from 1 September 2012. MCAI is now responsible for funding the project.

Liberia in context

Largely as a result of recent armed conflict, there is an extreme shortage of trained healthcare workers in rural areas. Although three hospitals in Bong County have facilities for obstetric surgery, pregnant women and girls in rural areas have to travel great distance on very poor roads to reach a facility where they can be treated.

The current situation for pregnant women and girls and their newborn babies in Liberia is as follows (2008 adjusted figures):

  • Maternal mortality rate: 990/100,000 live births
  • Neonatal mortality rate: 34/1000 live births

A ‘needs assessment’ was carried out in February 2012 (recommendations of the report are indicated below). The visit revealed:

Pregnant woman, sleeping

  • Bong County’s population is 357,431, area 8,772 sq. km with travelling distances for basic EmOC long and distances for comprehensive EmOC extremely long for women and girls with complications of pregnancy and delivery and ill neonates.
  • 8216 deliveries (In 2011), with 7135 undertaken in health facilities by skilled birth attendants.
  • Tribal Chiefs decided in November 2011 that all women should deliver in a health facility. Those who do not will have their families and any traditionally trained midwife involved sanctioned. This policy should mean that health facility deliveries will go up.
  • Most of 37 clinics offering basic EmOC (many at long distances from hospitals where there is comprehensive EmOC) have single-handed midwives
  • 3 hospitals offer comprehensive EmOC and 37 clinics offering basic EmOC but two of the hospitals are very close to each other in distance. Many maternal and neonatal fatalities are due to delays in reaching hospitals and a lack of health workers trained in emergency obstetric surgery were reported.
  • There are no critical care services in the county.

How to get involved in Liberia

Please note: this opportunity is currently postponed due to the Ebola virus situation in Liberia. Applications will open again once the situation has improved.

The main role of the UK obstetricians is to train nurse midwife surgeons to provide safe emergency obstetric surgery.

On completion of the training programme, the eight nurse midwife surgeons working in partnership with nurse midwife surgeons working in partnership with nurse anaesthetists will provide along with the very small number of available Liberian doctors comprehensive EmOC in rural Bong County, thus reducing maternal mortality and morbidity.

The selection process

The eight midwives will be selected on the basis of performance on Emergency Maternal and Neonatal Healthcare courses (see below), and following an interview by Liberian and UK obstetricians, as well as by representatives of MCAI, MOA and WHO. Final examination of the candidates will be undertaken by visiting senior UK obstetric faculty and in-country Liberian obstetricians. The midwife surgeons who successfully qualify will be registered by the Liberian Ministry of Health. Two Liberian surgeons will continue to mentor the qualified midwife surgeons following the completion of this project.

The UK obstetricians will be assisted in training the midwife surgeons by:

  • A specific obstetric surgery manual for midwife surgeons developed by MCAI
  • Log books
  • Curriculum
  • Relevant obstetric textbooks

Mother kissing baby, Liberia

In this Liberian programme, a number of doctors, nurses, midwives, midwife surgeons, nurse anaesthetists and nursing auxiliaries will undergo EESS/EMNH (Emergency and Essential Surgical Skills/Emergency Maternal and Neonatal Healthcare) 3- day courses, incorporating the WHO Integrated Management for Emergency & Essential Surgical Care toolkit. In addition, those suitable to train others will complete a Generic Instructor Course (GIC), and become competent to teach EESS/EMNH courses.

The Strengthening Emergency Care programme (SEC)

This programme of nurse midwife surgical training is one part of our project to strengthen emergency health care in West Africa. The SEC is a sustainable whole-system programme for the emergency care of pregnant women, newborn infants and children in countries where there is extreme poverty.

The SEC programme is a partnership between the Ministry of Health of the country, MCAI, ALSG, WHO and other UN partners and:

  • Provides a sustainable training programme for healthcare professionals and community workers in emergency care for pregnant women and girls, neonates and children. The training course is called EESSE-EMNCH: Essential and Emergency Surgical Skills–Emergency Maternal, Neonatal and Child Healthcare.
  • Ensures the availability of essential drugs, as well as medical and surgical supplies and equipment
  • Renovates existing hospital premises, and makes the “emergency chain of care” functional by developing communication and transportation for the critically ill or injured.

For more information on the SEC programme, please visit the MCAI website.

What does the role for the UK obstetricians involve?

  • Working together with local staff to improve the delivery and management of essential obstetric care by hands – on apprentice style training of 8 midwives to carry out complex deliveries and obstetric procedures, with support from Liberian surgeons.
  • The procedures will include Caesarean section, manual removal of placenta, condom catheter and rarely, emergency hysterectomy, for massive post-partum haemorrhage, laparotomy for ruptured ectopic pregnancy, and evacuations for incomplete miscarriages.
  • Helping to foster an environment of learning and professional development for midwife surgeons, including supporting their appropriate registration and payment, as part of a package introduced by the Liberian Ministry of Health.
  • Promoting high quality obstetric care, focussing on safe, effective practice (for example by setting up regular Mortality and Morbidity meetings.
  • Being a key member of a team working within a challenging environment with many other partners in a country of great need but where support for this programme is very strong. You will be made so welcome!

Skills, qualifications and experience required

  • The UK trainers will have full GMC registration and at least 4 years of specialist experience in obstetrics. The posts will be suitable for current or recently-retired consultants or Trust grade doctors, and for trainees at ST4 level and above. Membership or Fellowship of RCOG (or equivalent) is a requirement.
  • Experience of training others is essential. You will need a flexible and creative approach to solving problems, and the ability to work in a resource-poor environment. You will also need patience and resilience, and the ability to build strong relationships with colleagues.
  • In Liberia the official language spoken is English. We recognise that volunteering to work overseas in Liberia is a significant commitment, but believe that it brings personal benefits as well as benefits to the people of Liberia. Benefits to the NHS are outlined in the Department for Health document entitled ‘The framework for NHS Involvement in International Development’.

Support

This scheme will give UK obstetricians the opportunity to take 3.5 months out of their consultant work or training programme to make a sustainable change to the population of mothers and their children in Liberia through the development of comprehensive Emergency Obstetric Care.

The UK obstetricians will be supported by an in-country Liberian surgeon. In addition, representatives from our partnership group (MCAI, ALSG, RCOG and WHO) will provide support and encouragement, and assessment of the progress of the nurse midwife surgeons through quarterly visits. MCAI will provide comprehensive preparatory training before your placement, and our financial package includes a local living allowance in hospital based accommodation in Phebe, the cost of vaccinations, antimalarial tablets, transport within Liberia, access to the internet and very low cost telephone calls to the UK.

Summary of the whole programme

  • Train 8 obstetric clinicians (midwives) to provide emergency obstetric surgery and anaesthesia in rural areas using developed curricula. Each 3.5 month placement will involve the UK obstetrician working in Phebe Hospital and the Bong County region.
  • Improve capacity of doctors, nurses, midwives, nurse anaesthetists to treat obstetric emergencies and undertake neonatal resuscitation through EESS/EMNH (Emergency and Essential Surgical Skills/Emergency Maternal and Neonatal Healthcare) three-day courses incorporating the WHO Integrated Management for Emergency & Essential Surgical Care toolkit by UK visiting teams of ALSG accredited volunteers.
  • “Training of trainers” through selected Liberian healthcare workers completing a Generic Instructor Course (GIC) and becoming competent to teach EESS/EMNH courses by UK visiting teams.
  • Robust monitoring and evaluation of training and training outcomes throughout the two year program overseen by WHO Geneva.

All photographs © Jaime Kowal

For further information contact:

Dr B Hayden FRCOG (MCAI)

Tel: +44 7515 414385

Email: Brigid.hayden@doctors.org.uk

Dr David Nunns FRCOG (MCAI)

Tel: +44 7887 801279

Email: dnunns@ntlworld.com

Project sponsors

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WHO Africa logo

UKAID (DFID) logo

Liberian coat of arms

MCAI logo

RCOG logo

Elsewhere on the site

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