Where's the baby girl?

“Dr Robert, why have you not brought a baby girl with you? You really do need a third child.” Mamma Kabba was a kind midwife but her ability to convey a sense of disappointment was well honed. Up until this point I thought we were doing reasonably well; successfully obtaining the necessary visas, negative Covid tests and immunisations to travel safely with our two (not three) children from London to Freetown, then make the 350-kilometre onward journey to the hospital in Segbwema. Arriving with essential supplies including jars of Marmite, enough anti-malarials to start a small pharmacy and a portable ultrasound scanner in the midst of a global pandemic, I thought progress so far had been acceptable to good. However, our failure to expand our family size was in direct contradiction to the strict instructions Mamma Kabba had given us when we last saw her 18 months ago and was met with a wry but disapproving smile as we sat outside.  It was likely to be the first of many expectations we would be unable to fulfil whilst in Sierra Leone.  

Just over half away through specialty training in Obstetrics & Gynaecology in the UK we have returned to the small rural hospital I first visited as a student 10 years ago and subsequently worked at in 2013-2014 leading up to the Ebola epidemic. Repeatedly visiting the same health facility in a distant corner of West Africa may reflect a personal lack of imagination or aspiration (or a desire to find somewhere cheaper than London to live) but I hope also acknowledges that sustainable progress, however marginal, takes time and investment.  

There are benefits of being returnees; from the trivial of knowing which house to stop at for fresh eggs or the friendliest place to find a cold drink in town (Victor Kahlon’s Far East Enterprise- on the corner opposite the community bank before you get to the market), to the more significant gains of building upon existing relationships with hospital staff.  My re-induction to the hospital consisted of the medical superintendent (and sole doctor on site) giving a masterclass in paw-paw preparation on our doorstep. Interestingly, it was only after he had given vast quantities of the fruit to Benjamin and Theo did he warn us of the potential of its fibrous content to accelerate digestion a little too much. Perhaps he wanted to check if my management of childhood diarrhoea was up to scratch…..  

Although there are some familiarities (the green garden string washing line was surprisingly still up in the bathroom 6 years on from when we first strung it up and the patient folders we introduced still present on the ward) a period of adaptation is still required. The boys have settled in well although Theo (2) did remain insistent for several days that our new home was on a farm rather than a hospital; understandable given the number of goats and other fauna on the compound. Benjamin (5) has enjoyed dancing in the thunderstorms outside but is less keen on the size of some of the spiders. (He is also keeping busy writing a blog with the help of his Mum (benjiandtedsafricanadventure.wordpress.com)– we agreed we would mention each other’s although he is already putting me to shame with the number and breadth of his entries).  

Daily life is one of contrast. Some juxtapositions are temporary and inconsequential; washing in a bucket with water from a well using Crabtree & Evelyn soap from the airport hotel at Heathrow. Others like the smart phone next to the malnourished infant with severe malaria are more complex and harder to comprehend.  

There have been some small successes over our first few weeks; the young woman with an ectopic pregnancy who we were able to safely diagnose with the new ultrasound scanner. As a result of a blood donation from her relatives and a successful operation she made a good recovery despite losing nearly half of her blood volume and was discharged home today. Finding the positives in other encounters can require a deeper search. The 15-year-old that required a Caesarean section following a prolonged and obstructed labour sadly won’t leave hospital with a baby and the implications of surgery so early in her reproductive years are not insignificant. However, the fact that she will leave hospital at all is unfortunately not always a given; that she will leave without the potentially devastating complication of an obstetric fistula that could have arisen without intervention is also regrettably not universal. I accept this is minimal consolation given her life course to this point.  

Already the three midwives have enjoyed grasping the basics of ultrasound scanning to help augment the antenatal care they provide. I’m a little worried that at their rate of learning they will exhaust the extent of my limited knowledge and skill embarrassingly quickly.  Other areas of provision may be more difficult to enhance. Although not unachievable, it feels like an uphill struggle trying to advocate for increased contraception provision when the majority of women seeing me in clinic do so because of sub-fertility concerns rather than a desire to delay or prevent pregnancy.  

Clinically the work stretches me to areas beyond the comfort zone of an Obstetric & Gynaecology trainee.  The paediatric trauma case from a road accident or the difficult male catheterisation at 6am on a Sunday morning-sticking to your specialty isn’t a luxury afforded when you are half the medical workforce at the hospital. Incidentally, I failed at the catheter but fared slightly better with the child who is now slowly on the mend. Maybe an indication that my choice of speciality was correct.  

Six years ago, I remember racing against a generator which was only used for a couple of hours every other night to upload updates to a blog (healthmattersinsegbwema.blogspot.com). Thankfully we (and the hospital) now have the extravagance of electricity on tap thanks to a solar panel installation. Small but significant progress!  

We hope we can keep friends, family and anyone who is interested updated although make no guarantees on frequency or quality! While the challenges here are considerable, we are also aware that the UK is not expecting an easy winter. We are thinking of everyone at home and hoping you stay safe.