Monday, 8 November 2010

Technology Problems and Traditional Birth Attendant Training

It has been weeks now since I have been able to update my blog. I have had a series of frustrations with technology including problems with computer charging cables, generator and internet modems but am now back in the online world. It brought home to me how much I rely on the limited internet access we normally have here in Kamakwie to feel connected with friends, family and the wider world.

This year has flown by and I can’t believe I only have 5 weeks of my World of Difference Year left. Since writing last I have spent a week training midwives, nurses and doctors who work in faith based hospitals in Sierra Leone on emergency obstetric care. During October I was working with the hospital staff at Kamakwie to complete the work we have been doing on the maternity ward to improve documentation and clinical guidelines. During our final review meeting staff said although they were initially concerned about increased workload, the new system is helping them. They say it is especially useful having more comprehensive information about each woman and baby when shifts change and new staff take over and it makes it easier to detect problems earlier. Medical staff reported that improved recording of the condition of the mother and baby, including treatment and medications given make planning and evaluating care easier. One area that we are still working on improving is recording of care given to women during labour using a partograph – this is a tool used to record information about maternal and fetal wellbeing during labour, it also helps health staff identify prolonged labour. A colleague and I have spent some time teaching the Maternal and Child Health Aides to help them understand it.

In 2008 in Sierra Leone almost half of women gave birth with Traditional Birth Attendants and in the remote communities we work with the number of women giving birth with TBAs is higher still. In a drive to reduce the high maternal and child mortality rates in Sierra Leone the Government launched free healthcare for pregnant women in April this year and is now urging all women to give birth in a health centre. The Government is advising TBAs to refer labouring women to a health centre to give birth instead of helping them to birth at home. At Health Poverty Action we try to take a grass roots approach to improving health of women and babies. We believe strengthening links between the community and the health care system, increasing knowledge of healthy practices at community level and supporting women to access available services are important if the expected results of the free healthcare initiative are to be realised.

We have been working to design a training course and toolkit for Traditional Birth Attendants to enable them to work as Maternal Health Promoters in their remote villages to share maternal health messages to promote healthy behaviour including, seeking of appropriate care during pregnancy, birth and the postnatal period, exclusive breastfeeding and use of family planning. These women are almost all illiterate so we have developed a toolkit of pictorial flashcards which they will use to promote discussion and share health messages. These women will work closely with the health workers in the rural health centres, they will mobilise women to access skilled care during birth and offer them additional support and encouragement during labour. Part of this project is to ensure women in the remotest areas have equal access to health services; we are planning to pilot birth waiting homes close to 8 of the rural health centres we work with. Women living long distances from the health centre will be able to come and stay in these rooms to be close to the centre when labour starts. The Maternal Health Promoters will also give support and health information to the women who stay in the home.

The training was incredibly fun but we had a few challenges. Language was the biggest. During this training the trainees spoke Loko, Temne and some also spoke Krio. There was lots of translation needed to be sure everyone understood. The fun part was the singing; I think we now have a song for every part of the training. The culture of song and dance is incredibly strong here. I was in awe of these women who can rustle up a song on any topic at the drop of hat. I also enjoyed immensely talking to these women and hearing about their work. Many of them although unable to read and write have kept meticulous records of the births they have attended by asking community members such as a teacher who can write to help them. I feel lucky to have the opportunity to work with these women, who hold so much information on the culture and history surrounding childbirth in Sierra Leone.

Sunday, 5 September 2010

Two different lives

I’m back in Sierra Leone having been in the UK during August. In some ways it feels as if I currently have two lives. Moving between the two countries I find it hard to really believe that it is possible to spend only 7 hours on a plane and experience such dramatic contrasts.

I still can’t really comprehend that it is possible for aspects of life in Kamakwie and the UK to be part of the same world. I have left behind electricity at the flick of a switch, water that comes out of the tap, food flown in from all over the world and iphones and other incredible technology at every turn. In Kamakwie, we live without electricity or running water. I see on a daily basis the visible and grinding poverty of many of the families close to my house; where, quite literally, because of the lack of an exercise book costing 10p, children are not going to school. Women needlessly die giving birth and children don't survive until school age.

How can it be possible that only 7 hours travel away many people have so much disposable income that shopping has become a leisure activity (I can’t deny I did quite a bit myself having been away for 7 months – it was stressful, who knew August was already Autumn/Winter season? I live in Africa I need cotton not wool!. That most people in the UK worry about losing weight, rather than how to fill their stomach more than once a day and children refuse to eat things they don’t like instead of ravenously eating anything put in front of them. How can it be possible to cross two countries (including a stretch underneath the sea) on a train so comfortable the journey feels like a holiday in itself in less time than it takes to drive 55 miles between Kamakwie and Makeni. How?

I don’t want to paint a bleak picture of Sierra Leone. It is an incredible country and there are many things in Sierra Leone which we could learn from. The strong sense of family and community means that despite the basic living conditions and almost daily sightings of rats in my house which I am terrified of (my reaction to which, is still a source of great amusement to my colleagues) I genuinely enjoy life my life in Kamakwie. I have experienced such genuine hospitality here in the remotest of areas and poorest of villages, at times I have felt quite overwhelmed by it. It just seems incomprehensible at times though that these two worlds exist side by side.

I am not yet back in Kamakwie, I am in Freetown which feels a bit like a bridge between these two worlds in some ways. Going for a Chinese meal last night, sitting in a café having lunch today, followed by a trip to the supermarket I could almost be in London. Walking back home past children filling water buckets from the stand pipe, a power cut last night and having a wash with a bucket of cold water reminds me I am not.

I have to admit to feeling sad as my holiday came to an end, I realised how much I have missed all my family and friends when I saw them at home. Arriving back in Sierra Leone on Sunday felt good though. It is hard to describe the sights, smells and slightly chaotic feel of Freetown but it feels like I have come home, which is funny really, as that is the same feeling I had arriving back in the UK 4 weeks ago.

If anyone is interested in donating to Health Poverty Action go to their webpage or my justgiving page

Friday, 23 July 2010

An afternoon in the Baray

It has been a while since I have had a chance to update this blog. I have been writing regularly for the Royal College of Midwives website click and also for the Vodafone World of Difference webpage. I have written more on what I have been doing during June and early July on the RCM page here and the WOD page here.

This week I have had my first experience of the traditional justice system. The justice system in Sierra Leone comprises of three separate systems. The traditional system presided over by the Paramount Chief (PC), each district (similar to county) is divided up into Chiefdoms and is ruled by a PC who has a number of other Chiefs (including Town and Section Chiefs under him), then there is the local court system which mainly deals with land issues or personal disputes and finally the Magistrate court system which deals with criminal cases.

Our main project is the ‘Kombra en Pikin Welbodi Community Project’ focusing on improving maternal and child health and reducing maternal and under 5’s mortality. We have a number of smaller projects which run alongside this including a Sexual and Gender Based Violence (SGBV) project. Sexual and gender based violence has been common in Sierra Leone and often seen as something that is between a husband and wife, or to be settled within the family or in a traditional way through the Chief. Three Gender Acts were passed as law in 2007 and sexual or gender based violence is now an offence and punishable by law.

We now have an extremely dynamic field officer who is the focal person for our SGBV project. Our project aims to support survivors of SGBV, including paying for medical treatment, offering a safe home with women we have trained as ‘community hosts’ and supporting the woman to access justice through the legal system if she wishes to do so.

It is important to change attitudes of community members, community leaders and the police towards SGBV. HPA has been doing this in a number of ways, through holding a rally to raise awareness of women’s rights and the gender acts in Kamakwie. T shirts were printed with slogans such as ‘Nor fose ooman na bade’ (do not force a woman into bed) ‘Ooman na posin jus lik man’ (A woman is just like a man and should be treated equally), airing radio discussion programmes and conducting trainings with community leaders and police. We work closely with the Family Support Unit section of the police which deals with these matters.

It is a big step for women to seek justice through the legal system. She may well be doing this against the wishes of her family and community who would rather resolve the matter within the family or through the Chiefs. Since our SGBV officer started work in May we have had many women coming to our office reporting that they have been victims of SGBV and asking for assistance. Some of these women have required hospitalisation. Not all of them have taken the perpetrator to court but some women have been clear that they wanted justice even if it is not an easy decision for them personally. Two perpetrators have now been successfully prosecuted and given custodial sentences which is an important step as it will hopefully be an example that the law can and will be upheld and that women have a right to a life free of violence.

One of our field officers was summoned to the PC this week through the traditional justice system as a result of a local councillor being unhappy at how he publicly defended this part of the organisations work in response to a statement made by the councillor. Of course we went along to support him.

The hearing was held in the Paramount Chief’s ‘Barray’ which is a round building with low walls, a tiled floor, open sides and a conical thatched roof. The Paramount and other Chiefs gather to hear both sides of the case. Other people can also sit and listen. We do not have this kind of forum for settling disputes at home. The person summoned has to pay money (in this case 15,000 Leones about £2.60 which is a fair amount of money in a country where a large percentage of people are earning less than £1 per day) before appearing at the Barray.

The two individuals with the dispute sit in front of the PC and other Chiefs, they each have to pay money for the case to be heard (30,000 Le) they then each have to say how much they want the other person to compensate them if they win the case (100 -150,000 Le in this case). They are each allowed to call witnesses, every witness is given 2,000 Le by the person who called them as a witness and before they give their statement they are asked to hold the money and state that if they tell the truth they will 'eat' the money to get ‘welbodi’. Everything is done orally, there are no notes taken and written evidence is not permitted. The person who summoned the other tells his story first, the other person and the Chiefs can then ask him questions; this is followed by the person who was summoned doing the same thing.

The witnesses wait outside and are called individually to give their account of events and can be asked questions by either of the people involved in the dispute or any of the Chiefs. Once this has all taken place the Chiefs go and ‘hang heads’ to decide on a verdict. In this case the Chiefs ruled in favour of the councillor although they emphasised they have full support for the work that HPA is doing around SGBV in the community and they were deciding on a personal dispute which has no bearing on how they felt about the issue of SGBV.

The family of the person who summoned our field officer decided that he should not pay the compensation money as they felt the situation should not have gone this far. This whole situation highlights what sensitive and emotive work supporting victims of SGBV. As one of the Chiefs rightly said if they community is to ‘go before’ (Krio for develop/improve) it is crucial that violence against women stops and those responsible are punished

Monday, 14 June 2010

Changing Seasons

It suprises me how clear the changing seasons are here. The rainy season is coming, although more slowly than it seemed at the beginning of May. Mostly the days are still hot and sunny and although we get the occasional rainy day, mostly the rain is still coming at night which makes sleeping much more pleasant. Every evening the sky is incessantly lit with bursts of lightning, it is a bit like falling asleep with a strobe light outside the window, and very beautiful to watch as we sit outside our house in the evenings.

What really indicates the changing season however is the baskets carried on women's heads as they walk past our office on the way to the market. At home it is difficult to get a sense of the changing seasons from our food as although I go to the local farmers market sometimes my sense of what is in season is diluted by regularly being in the supermarkets where everything is available all year round.

It is exciting here enjoying a new delight and I feel sad as delicious things come to an end. We are almost at the end of the mango season; to me it seemed as if there were mangos galore, although I have been told that this year was not the most plentiful. They have been incredibly delicious and we have been eating them every day. There are now virtually none on the trees and I will miss this treat.

Our office is very conveniently on the main street in Kamakwie which means that people from surrounding villages pass on the way to the market, we are lucky to be able to meet the sellers and buy things such as avocados which never reach the maket. John our security guard (who is my Saloneon father - due to the fact he is my fathers namesake!) has a keen eye for trading women. We have been lucky enough to get pineapples, bananas and often bread fresh from the oven and still almost too hot to hold. The baker lives very near us and kamakiwe has the best bread I have had yet in Salone except for the home baked bread we ate in Sanya.

We have just seen the first of the oranges which will be the next thing to arrive after the mangos; they are green on the outside and orange inside and are delicious. The saloneon way to eat them is to peel the skin down to the pith, cut a small slice off the top and then suck all the juice and flesh out until there is an empty shell, there is a definite knack to this - I don't really have it yet.

Food feels much more real here than at home and it reminds me of being a small child on my parents farm where meat was obviously from an animal rather than something you buy in a plastic box from the supermarket. Sometimes we have been given gifts of chickens and cooking and eating these birds is a very different experience from eating chicken at home. There is so much preparation involved in killing and preparing the meat before you even start with the cooking. I often feel completely useless here as no self respecting women in Kamakwie would be unable to prepare a chicken and I have no idea what to do with a just killed chicken. The meat bears absolutely no resemblance to the enormous fleshy, pink chicken breasts that are for sale every at home, I suppose because the chickens here are truly 'free range', but it seems as if they come from a different animal. It makes me realise that even food I don't think of as being processed has been to a certain extent.

I am learning how to cook with some of the local ingredients, on Saturday when we were not working Isha and I went to the market and then spent the afternoon cooking rice, with fish and cassava leaves. At home I really enjoy cooking, there are so many ingredients I don't know here and have absolutely no idea how to prepare or cook them so it is nice to have someone to show me what to do with them.

I started writing this morning and I think the weather must have heard me saying that the rainy season was coming slowly as we had torrential rain for about 7 hours in the evening, it felt like autumn in England, sitting inside in the early evening with the sky dark, rain lashing down, drinking cups of tea, this morning it was cold enough at 6am when I got up to mean I couldn't face a cold bucket wash and I warmed some water on the gas for the first time, it felt like a real treat washing my hair with warm water.

Tuesday, 1 June 2010

Village Life

It has been a while since I have posted an update, having time out in the field, problems with internet access, limited electricity and a week of training last week has meant that it hasn’t been possible. The fieldwork for our survey went well, we gathered a huge amount of data from households, Community Leaders, Traditional Birth Attendants and health workers. I really enjoyed the opportunity to get to know some of the Community Health Volunteers (who work with Health Poverty Action to promote ‘welbodi bisness’ in their remote communities through facilitating weekly health club meetings. Covering topics relating to maternal and child health and raising awareness of issues such as human rights and sexual and gender based violence). It was a good team building opportunity all round, both for us working in Health Poverty Action and also developing links between the CHVs across the 5 Chiefdoms.

Our operational area is made up of some remote and difficult terrain and we have had some adventures along the way, breakdowns, flat tyres and some interesting river crossings involving many people knee deep in the water! During our 9 days of fieldwork, we covered large distances on some of the poorest roads in the country, the discomfort has been worth it though as the landscape is incredible we have passed through lush jungle, with mountains rising out of the early morning mist as the dew sparkles in the sunlight all around, gone through the rocky gold mining areas, through National Parkland and through the customs and immigration post at Sanya, which is almost on the Guinea border, the phone network and money used here are Guinean.

Everywhere people have been working on their farms as it is planting season with pepper, tobacco, cassava and cocoa all being nursed or planted out. Some of the remotest villages the researchers could only reach on foot and had to walk for miles, some villages sadly lack even basic sanitation facilities including clean water. The challenges that communities and health workers face in areas with poor road networks, no mobile phone coverage and long distances to the referral hospital mean that it is essential for organisations such as Health Poverty Action to work to support the government to improve health in these remote areas.

What village life in rural Sierra Leone lacks in luxuries it makes up for in abundance with what one of my colleagues describes as ‘solidarity’. He rightly said ‘isn’t Africa great’ as we arrived in a village at 6.30 and the nurse offered us a place to sleep, relit the fire and organised food to cook for us all without a second thought. I was constantly overwhelmed by the hospitality of people we met. Life here is more communal and seems in many ways friendlier than at home, everywhere we went we were given fruit, chickens or plates of food to share. It is the custom for a household to share from one plate and myself, Souleymane, Ibrahim and Moses who were supervising the fieldwork and carrying out the research with health workers have been one ‘household’ for the time we were away. Sharing all our meals in this way means that eating from individual plates begins to seem unfriendly. I am growing to love Sierra Leonean food, and rice which was never my favourite food is now my staple diet. In Sanya we had ‘pot roast’ which is a bit like satay chicken. We ate it with bread cooked by creating an oven by heaping hot coals onto a large pot. It was delicious and since then Ibrahim arranged for someone to teach me how to make it, so I will be able to recreate a taste of Salone for some of you later this year.

The last two weeks have been full with preparing proposals for funding, writing reports from our work in the field and carrying trainings. We have trained 30 women to be fistula advocates (more info on this here) and 10 women to become community hosts. Sexual and Gender Based Violence is a big problem and we currently have a one year project aimed at reducing SGBV and supporting victims. These community hosts will raise awareness in their communities of the issue of SGBV, its negative impact on victims and the community and the Gender Acts which came into effect in 2007.

Saturday, 8 May 2010

Village Life

We are well under way on our baseline survey and over the last two days have visited 6 villages to support the teams of researcher and another 4 villages to visit health posts and interview health staff. This is our last night in Kamakwie, as tomorrow we start to cover some of the more remote villages and will be staying out for the next 6 days.

I would love to be able to upload some pictures but it is just not possible, I have been unable to in Freetown, let alone here in Kamakwie. Instead I am going to try and describe the images I have in my head.

Today I woke up to the sound of persistent rain and had mixed feelings, as being able to sleep under a cover for the first time in weeks was lovely; but a cold bucket bath and hairwash at 6.30 when it really doesn't feel that warm is not so tempting. I braved it none the less and it was worth it as the steady drizzle and cool weather for the rest of the morning was a welcome relief from the oppresive heat we have had throughout March and April.

We started this morning with a flat tyre so went to the lorry park to get it fixed, it was raining and the steam coming off the plates of food at the small, corrugated tin shack (which is the cookery shop) looked really inviting as the woman served people rice and cassava leaves for breakfast.

After getting our tyre fixed we were on our way, Sierra Leone is incredibly green and since the rains started a couple of weeks ago, everything has started to grow and ever where are vivid, different shades of green, tobacco seedlings, pepper seedlings (under symetrical rows of palm fronds shelters) rice, lemon grass, mango and breadfruit trees with fruit in abundance and the landscape stretching into hills, bush and palm trees. The contrast of all the greenery with the red earth is striking and this morning with the rain clearing and the light which you get as the day moves between rain and sunshine it was especially beautiful.

Along the road to get to the village we were heading for we pass small mud houses some with straw and some with tin roofs with people sheltering from the rain whilst cooking or sitting outside their houses. We pass goats skip away from the car at lightening speed and sheep which always seem to run towards the car or stand in the road, people carrying 3 metre long bundles of firewood on their heads, or walking along with brightly coloured umbrellas.

I'm going to run out of battery on my computer so I'll describe the villages when we are back next week....

Tuesday, 4 May 2010

An update from April

I am back in Kamakwie typing whilst sitting under my mosquito net listening to the sound of the frogs and crickets outside. We arrived on sunday afternoon, yesterday was spent finalising plans for the fieldwork of our fistula project baseline survey.

We have a team of 12 volunteers who will conduct interviews and facilitate focus groups in 30 villages. Three of us will supervise and support the volunteers, alongside conducting interviews with health workers in 27 health posts. The villages and health posts cover all 5 chiefdoms which Health Poverty Action is operational in. We started our 3 days of training with the 12 volunteers today, covering general fistula information, background information on the fistula project and an introduction to research and communication skills. Tomorrow will be practising interviews and focus group facilitation both in our office and in the field to iron out any last problems and pre-test the interview guides.

Click here to read my blog update for Vodafone which has more information on my work during April.

Tomorrow is International Day of the Midwife, which is a day for midwives to think about others in their profession and raise awareness of what midwives do for the world. The theme is 'the world needs midwives now more than ever' which is certainly true in Sierra Leone. Care from a trained midwife here is a luxury many women do not have.

The Royal College of Midwives is raising awareness about obstetric fistula for The International day of the Midwife. I have written about this condition and the work that we are doing at Health Poverty Action to prevent it and treat women who are already affetced and you can read it here.

Dinner tonight was at Mr Bah's roast meat stand in the town, skewers of goat meat cooked over charcoal with fresh baguette and a hard boiled egg is a simple but delicious Kamakwie staple!