WA News Feature Articles Offering Skills, Gaining Insight
Offering Skills, Gaining Insight
Written by Dr Chris Gunnell
Monday, 28 November 2016

201612-CS-theatre-Barhardir Nov16Operating theatre at Barhirdar where the CS rate is 10% of deliveries.Despite my aversion to dirt, discomfort and disorder, I answered a small advertisement in the RANZCOG magazine and found myself embarking on a life-changing adventure as a volunteer obstetrician in a town called Barhardir in Ethiopia.

Dr Andrew Browning is an Australian-trained gynaecologist who started his inspiring working life in Africa as a fistula surgeon with the famous Hamlins in Addis Ababa. He went on to open his own fistula hospital in Barhardir where he worked for several years. Realising that prevention is better than a cure, he then started up several maternity hospitals in Ethiopia and Tanzania. He currently lives and works in Tanzania.

Barhirdar is a town in central Ethiopia by beautiful Lake Tana. It is a tourist town so areas are quite Westernised and there are several large hotels (which came in useful when I needed a fix of Wi-Fi or wine!). However, there is also extreme poverty both in and around the town.

The hospital provides free maternity service to the poor. It is staffed by a group of 12 hand-picked and highly skilled local midwives. Two volunteer doctors support these midwives, assisting with difficult medical/obstetric issues, complicated vaginal births and caesareans. I started off there with a Dutch tropical medicine specialist, however, she needed to leave the country to renew her visa – leaving me (very anxiously) alone for two long weeks.

Patients ready and waiting

My first of many confronting experiences was walking into the hospital on the first day to find one big Nightingale ward completely full. Antenatal, postnatal and labouring women are all thrown in together with very little privacy.

When a woman starts to push, she is quickly shuffled into a separate birthing room for the delivery, then afterwards immediately walked back to her ward bed. There is no analgesia requested or offered. Vacuums, forceps and manual removals are all done without any pain relief. The women are generally discharged six hours after delivery to make space for more.

Caesareans are performed under spinal block (done by an anaesthetic technician). The theatre facilities are basic but all essentials are available (apart from consistent electricity). One night during a dramatic thunderstorm, just after I made the initial incision, the power went out and plunged us into total darkness. While waiting for a staff member to brave the rain and manually turn on the generator, I continued the surgery under the light of the midwife’s smartphone torch.

Even in Ethiopia there is debate about the appropriate Caesarean section rate! This procedure has dramatically decreased both maternal morbidity and mortality, but there is then the risk of uterine rupture in subsequent labours; particularly in those women living far from a hospital. It is even more important, therefore, to perform only those caesareans that are absolutely necessary.

10% CS rate hard to beat

At the hospital in Barhirdar, the CS rate is generally steady at a very respectable 10%. I couldn’t quite bring myself to confess our rate in Western Australia!

The hospital delivers between 150 and 210 babies a month. There have been no maternal deaths for three years and, given the background rate for Ethiopia, this is an incredible achievement. The perinatal mortality rate is low compared to many other hospitals and health care centres in the country.

The midwives are very proud of these statistics and this gives them the incentive to continue their hard work. I was amazed to learn that the midwives work 28 out of every 30 days for 11 months of the year.

2012612-Dr-Chris-Gunnell-Barhardir-Staff Nov16Dr Chris Gunnell, centre, and the Barhardir Staff.During my time I found myself faced with some confronting but fascinating medical and obstetric problems. I regularly treated typhoid, amoebic dysentery and syphilis. During my month-long placement, we had several women diagnosed with HIV and a few deliveries of HIV positive women (although the overall rate is quite low compared to other African countries).

I managed a woman who walked herself in from the country with a BP of 220/120 and miraculously prevented her from fitting. Eclampsia is a relatively common phenomenon. However, probably my most rewarding experience was doing caesareans for women with obstructed labour – knowing that not too long ago, these women would have been the ones facing days of labour, a foetal death and subsequent fistula. This is when I truly felt I was making a difference!

Past patients work for others

The highlight of my trip was meeting and spending time with Andrew Browning who paid a visit to Barhirdar and showed me around his old fistula hospital. It was emotionally overwhelming to meet and interact with the staff at this hospital – most of whom were Andrew’s cured past fistula patients.

Their adoration was heartwarming. It is impossible to not be inspired by this humble man who has given so many women their lives back and who has also gone on to establish hospitals to prevent further death and disease. He has made an astounding contribution to global women’s health and I hope one day receives the recognition he deserves.

I was warned about ‘reverse’ culture shock on returning home and prepared myself for the ‘First World problems’ of my private patients. I’ve been surprised by the extent of my emotions dealing with every-day issues. The huge disparity between our lives, our cultures, our health care and our priorities is overwhelming at times.

Although I am slowly settling back into my comfortable Western life, my short visit to Ethiopia has certainly put this life into perspective. I had the most amazing experience and didn’t want it to end. I am already planning my next trip!

ED: If you want to be further inspired or to understand more about fistula surgery, Andrew Browning spoke at the RCOG World Congress in 2013: https://vimeo.com/71503311 and https://www.youtube.com/watch?v=w6DULSxZlpg4