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Travel Bursary Reflective Piece
The following is a reflective report detailing my recent overseas elective
midwifery placement. All cases detailed within this report have been
anonymised in accordance with the Nursing and Midwifery Council’s
Code of Conduct (2008). Please note that this report contains graphic
descriptions of medical procedures, which some readers may find
upsetting.
Since a young age I had wanted to undertake voluntary work in Africa. After school I
was fortunate enough to be accepted onto a midwifery degree at the first time of
applying, as a result I was not able to undertake the voluntary work I had wished.
When I found out that as part of my final year I could undertake an elective
placement, there was only one place in my mind I wanted to go, Africa.
During the researching process the financial burden of undertaking an elective
placement in Africa became apparent. It was not something that myself or my
parents would be able to fund independently. I heard about the travel bursary fund
via previous successful applicants. Fortunately I also gained the funding and
consequently was able to book my trip of a lifetime through Work-The-World (WTW),
a company who specialise in medical electives abroad. In discussions with WTW
regarding my aims and objectives of the placement, it was decided that the most
appropriate African country to visit would be Ghana.
In undertaking my elective with WTW much of the stress of organising the placement
was alleviated as they arranged this for me in my preferred area. In addition, they
provided transport to and from the airport, accommodation and meals. I was left to
book my flights, insurance and vaccinations.
On arrival in Accra airport, we were met by a representative from WTW. He had a
car waiting for me and my travel partner, Bethan, and we were taken to a local hotel.
The journey from the airport to the hotel opened our eyes to the sights, sounds and
smells that would become normal for us over the next three weeks. The road
surfaces were full of potholes, the driving was manic and the music loud, it was
much like taking a ride on bumper cars at the fair.
Bethan and I shared a large double room, it was our last chance for a spot of luxury
and the air conditioning was greatly appreciated. We were awoken early the next day
to commence our journey to Takaradi, the city we would be living and working in.
During the journey to Takaradi a preacher read us some passages from the Bible
and spoke to the coach passengers about the importance religion has on an
individual’s life. He explained that if religion was not at the forefront of your life, then
your life was incomplete and indeed worthless. He continued that if you did not pray
regularly throughout the day then both personal and professional ambitions would be
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impossible to achieve. Initially I was shocked by the level of importance the preacher
was placing on religion, but throughout my time in Takaradi I was able to understand
the important role that religion plays for individuals and society. On an individual
level religion enabled people to believe that the situation they were in would improve,
whether it is in their current life or their afterlife. In addition, it gave people a reason
to come together, to pray; sing and support one another. On a larger scale it was
apparent that religion played a great part in social control. For example, people were
too afraid to disobey the Ten Commandments, this is demonstrated in the low levels
of crime within Takaradi. From my time on placement it was interesting to see how
religion played an important part of the childbearing continuum.
One particular moving aspect was during the postnatal clinic. The clinic is held every
Wednesday and women must return on week 2, 4 and 6 postnatally with their baby
to check their condition. Before the clinic starts all mothers sit together with their
babies and sing and pray for half an hour to give thanks to God for the safe delivery
of their child. In England, community postnatal clinics are just starting out, but
women have individual appointments, so rarely mix. The postnatal clinic in Ghana
allowed mother’s to come together, share experiences and bond, this process was
initiated via prayers. Although in England often there is not the same emphasis
placed on religion, the idea of a postnatal clinic being held in a setting were mothers
can attend at any time, to allow them to meet one another and share experiences
with others who have experienced similar things, is something that is extremely
interesting to me, and something I hope to develop in my future practice.
On our first Monday in Takaradi we were given an orientation to the hospital we
would be working in. Before embarking on my journey to Ghana I undertook some
research on what to expect from the hospital, I expected a decrepit unit and many
patients, but no research or expectations could have prepared me for what I would
see at the hospital. On our orientation we observed patients and relatives sleeping
rough within the hospital grounds. Relatives were only allowed onto the wards during
visiting hours, which were after 4pm. However, they had to do all cares for patients,
provide all their meals and collect all their prescriptions from pharmacy. The nurses
did very little ‘hands on’ nursing for patients. From observations the only real duties
they performed involved dispensing medication and performing observations twice a
day.
During the orientation the standards of care we would see over the next 3 weeks
were observed. Accident and Emergency consisted of two rooms, we observed 1
doctor, an emergency technician and numerous nurses, whom were all sitting
around a desk laughing and joking. We observed A&E’s ‘waiting room’, which
consisted of a wall outside, which was surrounded by patients, suffering from varied
ailments. One particular image which will stay with me was that of one woman
‘unconscious’ (likely dead) in a ‘wheelchair’ (A garden chair with wheels attached to
it) waiting to be seen, with her relative frantically trying to wake her. Although A&E
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was well staffed and had only one patient, there was no urgency, or in-fact interest
from the staff to see any more patients, regardless of the severity of their condition.
This lack of urgency was demonstrated throughout the placement, during numerous
emergency situations staff seemed very blasé. It is something I still do not have a
valid rationale for. From speaking to hospital staff and local people there were some
suggestions that ‘it is too hot to rush’, which in a hospital which largely has no air
conditioning and temperatures of up to 36* in the rainy season is reasonable. But in
an emergency situation when a life is at risk, and can potentially be saved it is
inexcusable.
Initially I thought the lack of urgency may be due to a lack of knowledge surrounding
emergency situations. However throughout the placement I repeatedly questioned
the midwives on their theory and knowledge base and it was very much similar to
that currently in the UK, as was the supposed treatment. In reality though, treatment
and medical interventions were extremely slow, if at all, even where resources were
available. From observations, although the nurse and midwives have the current
knowledge base frequently the interventions performed were extremely outdated and
unsupported by evidence.
One particular case that that will never be forgotten was the case of ‘Paulina’ a 19
year old first time mother. She had progressed well throughout her labour and
became fully dilated at around 14.00. Policies in both the UK and Ghana state low
risk first time mothers should be given 1 hour for ‘descent’ of the fetal head after
confirmation of full dilatation and then a further hour for pushing. In addition the fetal
heart should be listened to every 5 minutes throughout this period. Although policies
in the UK and Ghana are similar and when asked the midwives were aware of them,
in practice they were completely ignored. During the case of Paulina, after
confirmation of full dilatation she was transferred to the delivery room, where she
was laid flat on her back with her legs in stirrups. Paulina was urged to push by both
midwives attending delivery, however no guidance was offered on the best
techniques and positions to push and facilitate delivery. At 14.10 Paulina was again
encouraged to push, both midwives repeatedly slapped her legs and told her to
‘push properly’, but again never guided her. Myself and Bethan were demonstrating
to Paulina the most effective ways to push in the position she was in, but we were
shot down by the sister in charge. She then told Paulina that ‘her baby was dying
and it was her fault because she was not pushing’, in addition she was asked ‘if that
is what she wanted to happen?’ It was very shocking to hear, especially considering
the fetal heart had not been listened to for over half an hour, so the condition of the
baby was unknown.
At 14.15, 15 minutes after confirmation of full dilation, scissors were prepared, in
order to undertake an episiotomy. In the UK episiotomies are frequently performed
under local anaesthetic when the fetal head is at the perineum but delivery is
delayed because perineal tissues are firm. In giving an episiotomy for this reason it
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allows more room for the head and facilitates delivery. In the case of Paulina the
head was still high in the pelvis and not near the perineum, this caused many
complications, particularly a great blood loss. Paulina was given no pain relief
throughout her labour or attempted episiotomies. In addition the midwife used blunt
scissors and attempted to perform the episiotomy numerous times. The combination
of the sound of the blunt scissors attempting the episiotomy and Paulina’s
subsequent screams were the most horrific things I have experienced throughout my
short midwifery carer.
As the fetal head was still high in the pelvis when the episiotomy was performed it
did not facilitate delivery of the head. Instead one midwife placed both hands inside
the vagina, she stated she was “stretching the vagina and attempting to pull the baby
out”. Whilst another midwife (who was in excess of 20 stone) sat on Paulina (a very
slim girl) and placed pressure on the top of her uterus, she stated she was “trying to
push the baby out’. Both aspects of practice are massively contraindicated and can
have major negative complications for both mother and baby. When asked the
midwives were aware of the contraindications but chose to perform the practices
regardless.
During the labour I got out a ‘bag and mask’ to resuscitate the baby should it need it
once delivered. When the baby was born, there were again multiple demonstrations
of bad practice, which I shall not go into detail about. But the baby was born in a
poor condition and needed resuscitation. The midwife seemed to understand the
baby needed resuscitation but was not very keen to perform it, I was trying to dry the
baby and stimulate it and repeatedly suggesting to the midwife that she should start
resuscitation. Eventually she obliged, I passed her the bag and mask, she put it
down, went to a cupboard and came back with a cut off top of a coke bottle. She
detatched the mask from the resus bag and attached the nozzle of the cut of bottle
onto the bag and began to perform ‘resus’. Unsurprisingly the bottle top was not
properly attached to the bag, as a result the pumped air was simply escaping and
the baby was deteriorating. I asked the midwife if I could take over the resus
attempts, she thankfully obliged. I reattached the mask and placed the baby in the
correct position, after 15 minutes of resus, the baby had a good heart rate and good
respirations.
This ‘resuscitation’ attempt is one example of how midwives appeared to have the
theory, knowledge and to a certain extent resources but choose not to utilise them.
Although an appalling experience, I was able to improve my non communication
skills. I tried to advise Paulina and comfort her throughout, even though we did not
speak the same language. I was able to act as an advocate for Paulina and
challenge the practice of senior staff; something I believe will give me confidence in
my practice within the UK. In addition I was able to improve my skills in neonatal
resuscitation – something I have had limited experience of in the UK.
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Throughout my time in Ghana the staff at WTW were fantastic. Within the house we
had a project manager, who organised placements and accompanied us on our
hospital orientation. We had a tourist guide, who gave us a local orientation, helped
us organise weekend trips, activities and local visits, such as visiting an orphanage,
in addition to facilitating weekly Fante lessons. We had a house keeper who cleaned
the house each day and a cook who made us breakfast and an evening meal. In
addition we had two security guards, who ensured we were living in a safe
environment. Throughout my time in Ghana, I felt so well looked after by all the staff,
we were able to contact them 24/7 with any issue we had. Both the WTW staff and
the other students Bethan and I met during our elective were amazing and made our
trip to Ghana extremely special!! As an organisation I cannot praise WTW highly
enough and would definitely recommend them to any healthcare students wishing to
travel abroad for an elective placement.
Although at times this elective placement was extremely challenging, it was the best
experience of my life. I feel I have developed both individually and professionally. I
am a more confident individual and I hope this will be reflected within my future
practice. I believe this elective placement has strengthened non-verbal
communication skills in addition to my basic caring skills. I have recently gained a
midwifery post in a multi-cultural city so I aim to utilise these newly strengthened
skills within my practice, as I again may be caring for women were English is not
their first language. In addition I feel I have more confidence in my own midwifery
practice, this placement enabled me to relate theory to practice and I was able to
identify deviations from normal parameters, although they were not always acted
upon. One aspect of Ghanaian health care I hope to one day replicate in the UK is
the idea of communal postnatal clinics. The idea of a postnatal clinic being held in a
provision that has the facilities to provide a communal area and a private room. In
doing this women still have their individual private appointments with their midwife
but also have an opportunity to join together and share their birth, postnatal and
feeding experiences. This is something I believe would benefit many women and
something I hope to develop within my trust.
I would like to take this opportunity to thank you for the funding provided as this trip
would not have been possible without you, it is greatly appreciated and something I
believe will shape the rest of my personal and professional life.
Laura Jane Doran