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Somaliland Outreach Project - Level I

Project Title: ISUOG Outreach training in ultrasound in obstetrics and gynecology, Part 1

Location:
Hargeisa, Somaliland – a city at 1300 m (4,000ft) in western Somaliland near the border to Ethiopia; population of approximately 1.3 million.

Dates:
Sunday, March 27 - Thursday, April 7, 2011

Partners: Edna Adan University Hospital, Médecins sans Frontières (MSF), SonoSite

ISUOG Volunteers:
Dr Lisbet Hanson, Virginia Beach, Virginia (Team leader)
Dr Alfred Abuhamad, Norfolk, Virginia
Dr Jude Crino, Baltimore, Maryland
Dr Philippe Jeanty, Fairview, Tennessee
Dr Katya Nekrasova, St Petersburg, Russia

 

From left to right:  Dr Alfred Abuhamad, Dr Lisbet Hanson, Dr Jude Crino, Dr Katya Nekrasova and Dr Philippe Jeanty. 

Trainees:

  • 12 Nurse-Midwifery students and graduates of Edna Adan's University Hospital NMW program
  • 15 Physicians, NMWs and radiographers from MSF sites in Somalia, Somaliland and Kenya

Context and background

Somaliland is an unrecognised self-declared sovereign state that is internationally recognised as an autonomous region of Somalia located in the Horn of Africa. The government of Somaliland regards the territory as the successor state to the British Somaliland protectorate, which was independent for a few days in 1960 as the State of Somaliland, and on 26 June 1960 gained independence by uniting with the Trust Territory of Somalia (the former Italian Somaliland) to form the Somali Republic.

Somaliland is bordered by Ethiopia in the south and west, Djibouti in the northwest, the Gulf of Aden in the north, and the autonomous Puntland region of Somalia to the east.

General Muhammad Siad Barre came to power in 1969 through a military coup and the country allied itself with the Soviet Union. Dissatisfaction with Barre’s regime grew in the Somaliland region, eventually leading to the Somali Civil War in 1991.The war left the economic and military infrastructure severely damaged. After the collapse of the Somali central government in 1991, the local Somaliland government, led by the Somali National Movement (SNM), declared independence from the rest of Somalia on May 18 of the same year. The continuing conflict southern Somalia has for the most part not directly affected Somaliland, which, like neighbouring Puntland, has remained relatively stable.

Since then, the territory has been governed by an administration that seeks self-determination as the Republic of Somaliland. The local government maintains informal ties with some foreign governments, whom have sent delegations to Hargeisa. However, Somaliland's self-proclaimed independence remains unrecognised by any country or international organisation.

Maternal mortality remains unacceptably high across much of the developing world, including Somaliland. Achieving the United Nations Millennium Development Goals 4 and 5, to reduce child mortality and to improve maternal health by reducing maternal mortality, by three quarters, between 1990 and 2015, is a challenging task but ultrasound technology is revolutionizing the delivery of care and ultimately also outcomes.

While many resource poor countries are committed to improving maternal outcomes, they need support to tackle this multifaceted problem. ISUOG Outreach provides training in ultrasound in obstetrics and gynecology in underserved regions of the world to improve clinical service provision and to maximise the chance of reducing maternal mortality levels.

In Somaliland, maternal mortality rates remain significantly high despite some decrease in recent years. In 1997, 1,600 out of every 100,000 women giving birth were estimated to die in Somaliland. According the Ministry of Health, latest figures indicate that this rate is now 995 deaths per 100,000 live births. Major causes of maternal death in Somaliland are by post-partum haemorrhage, pre-eclampsia, hypertension, abortions, pulmonary embolism, ectopic pregnancy and ruptured uterus, as well as complications derived from a high rate of female genital mutilation.  Another factor of high maternal deaths is the low level of contraceptive prevalence rate of 4.5% and high total fertility rates of 5.9 births per woman.

[Data from Edna Adan http://www.irinnews.org/Report.aspx?ReportId=82387, PSI http://www.psi.org/resources/research-metrics/publications/africa-eastern/prevention-treatment-post-partum-hemorrhage-s, THET http://www.thet.org/about-thet/our-programmes/somaliland/]

Project partners

The Edna Adan Hospital, run by former first lady and Foreign Minister Edna Adan Ismail, is an NGO hospital (45 beds) and nurse training school, which opened its in-patient facility in March 2002 to address the high maternal and child mortality and morbidity rates in the local community. Edna Adan’s mission is to give the gift of knowledge to her fellow Somalilanders, and to this end she teaches midwives and nurses at her hospital so that they in turn can save lives and teach others to do the same. Edna Adan also aims to give a larger focus on diagnostic and preventive medicine in her hospital.

 
Edna Adan University Hospital in Hargeisa, Somaliland.

Before the ISUOG Outreach Somaliland project, the Hospital had two old ultrasound machines but there had not been any significant training in their use. This project is supported by SonoSite who have donated 4 NanoMaxx ultrasound systems. Established in 1998, SonoSite has produced machines for the US military for use on the field, which are highly rugged and can endure unstable electricity currents and therefore ideal for remote settings. The NanoMaxx systems donated by SonoSite are highly portable, and could also have a future use in developing Edna’s mission of training “village midwives”, who can fill the gap between doctors and nurses who tend to stay geographically closer to major hospitals.  

ISUOG also partnered with Médecins Sans Frontières for this project. MSF’s mission in Somaliland is to fill critical gaps in the local health system, with a particular emphasis on emergency care and response. MSF works in and around both the Somaliland and Somalia regions, also covering refugee camps in Kenya with a very large Somali population escaping the civil war. One of MSF’s aims is to decrease pregnancy-related morbidity and mortality within their target population, and to see an increase in the number of deliveries taking place within health centres. MSF also provided invaluable logistic support to this project.

Training course

The course consisted of pre tests, lectures, hands-on scanning, interactive case presentations, post tests and a course evaluation, all given over five days. The first day consisted of all lectures, the next four of lectures in the morning and hands-on scanning in the afternoon followed by case presentations. Five additional days of supervised scanning by Katya and Jude followed in the Outpatient Clinic at Edna Adan’s University Hospital with Edna’s physicians and nursing midwives.

 
Dr Philippe Jeanty lecturing during the course

Trainees learned basic OB scanning as well as documentation of findings in an official report. Presentation, viability, placental position, number of fetuses, amniotic fluid and gestational age were the parameters on which the training focused. The ISUOG Trainers presented information, answering questions and adjusting lecture materials to fit the needs of the group. An excellent lecture on management of post partum haemorrhage that was originally not included in the course material was also carried out.

 
Trainee scanning in action

Patients for scanning were recruited from Edna Adan Hospital’s patients as well as a large part from MSF’s clinics around Hargeisa.

 

At the conclusion of the teaching, trainees were given a series of evaluation questions and the opportunity to provide feedback on their impressions of the course. The trainers were very happy to see that all participants were very happy with the material taught during the course, and were also encouraged by the constructive feedback given to further improve future visits.  The trainers were delighted when the trainees decided to start their own “ISUOG Scanning Club”, which will meet on a monthly basis to review scans, discuss cases and upload images for consultation purposes.

Certificates of participation and CDs containing the entire course were distributed. Lisbet thanked and gave Edna a gift of crystal candle sticks and tapers and Edna spoke eloquently about the gift and power of knowledge. She expressed her thanks to all who had participated and to the partners that had made it happen. The MSF representative expressed her organisation’s sincerest thanks to everyone and also distributed gifts.

 
Volunteer trainers and trainees after a hard day's training

The trainers were also able to enjoy a day of rest in the company of Edna Adan, who took the ISUOG trainers to visit her farm, followed by a dinner at a local restaurant.

 
Trainers with Edna visiting Edna's farm on their day of rest

Following the conclusion of the course, Drs Hanson, Abuhamad and Jeanty departed, and Drs Nekrasova and Crino remained at the Edna Adan University Hospital for an additional five days in order to supervise and assist trainees in integrating ultrasound scanning into their daily clinical practice. Both trainers were impressed at how much progress their trainees had made since the first day of class.

ISUOG would like to thank Edna Adan for being a wonderful host, MSF for partnering with us and helping ISUOG make this project a success, SonoSite for their extremely generous donation of four SonoSite MicroMaxx systems and last but not least our dedicated trainers for their commitment, enthusiasm, energy and personal contributions to this project. ISUOG looks forward to continuing this fruitful collaboration with its partners. Thank you!

Pre and post test results

Average % improvement: 46%

Average % improvement: 26%