First Returning Thoughts

The Road down to the Hospital at Motta

I remember that when I left Motta after my first spell here, in January this year, I doubted there would be any lasting improvements in the way the Maternity unit was run – it seemed despite repeated attempts at instilling some basic principles of maternity care, nobody seemed to really get it. Since then the continuing series of volunteers coming here all seem to have reached similar conclusions as they came to the end of their time here, expressing the same frustrations and disappointments I did. In fact what I have found on my return, to my surprise, is that things have definitely improved: the rooms are cleaner, there is no actual mud on the floors any more, the stench from the toilets has disappeared, women are no longer lying on beds with filthy sheets  or even no sheets or blankets, Midwives are more often writing on the whiteboard and keeping it up to date, they are doing regular observations and updating the bedside charts, and, thanks to the husband of one of the midwives who came here from Australia there is running water to several taps in Maternity and the Operating Theatre.

I wouldn’t want to create the impression that things are all wonderful here now – far from it – in fact someone coming here for the first time would probably regard what goes on as appalling, and could hardly be worse – but if they had been here a year ago, they would realise that it has been worse and that now it is better, albeit not by much, but definitely better. The truth is that the cultural differences between us are so huge that bridging them will take a very long time. This I think is the lesson I learned last time.

Take medical records for example : much of our record keeping in the west is for “medico-legal” reasons, and we are almost obsessional about it – a midwife in Australia will usually note the exact time that she rings me to come and asses a labouring mother that she has concerns about, and record the exact moment that I get there as well – how has that got anything to do with managing the current problem? In fact it is recorded by the midwife to protect herself in the event that there is an adverse outcome and an investigation. Much of modern medicine is what we call “defensive” medicine – that is, we do things to protect ourselves from medicolegal consequences of adverse outcomes. It doesn’t  matter that an adverse outcome may have been unavoidable - if a lawyer can find a test or an observation or an investigation that could have been done but wasn’t, even if in the judgement of the clinician it wasn’t an appropriate test, or it  was so unlikely to affect the management that it seemed inappropriate to waste money on it, the clinician may then be found negligent. So we order all the possible tests without much reference to their appropriateness, and we do them again if they are slightly borderline, and document all this in the Medical Record.

My Op Notes from Caesarean Birth on Thursday night : note the Ethiopian Date should be 2005 not 2004!

Here in Ethiopia of course, there doesn’t appear to be any such thing as medico-legal concern – if a patient dies, the Doctor is presumed to have been doing his best and is praised for trying. This is a two edged sword of course – it means Doctors can be lazy and careless, they can fail to truly uphold the ethical standards of the medical profession and yet because nobody is any the wiser, continue to receive respect and be honored for the role they play in society. I am afraid I have witnessed this sort of behaviour here. The reality is that Doctors are people too, and subject to the same frailties, and the Legal profession plays an important role in maintaining standards in the west – but many of us feel sometimes it goes too far. In Ethiopia people more readily accept that “shit happens”  than they do in the West – perhaps because of their religious beliefs? In the west when something isn’t perfect  the tendency is to look for someone to blame.

In any case, getting back to medical records, though we obsess about them, my Ethiopian colleagues must wonder why – after all if the woman comes in and has a baby, why do we need to record at what time she arrived, at what time the baby was born exactly, exactly what the babies weight is, or how much blood the mother lost? Surely its enough to record she came and had her baby and went home?

There is more to it than that though – some of the information we collect in the west helps us manage a womans future pregnancies, it gives us information that when collected and audited can be used to improve and fine tune standards and outcomes that benefit all women . But here in Ethiopia we only have the resources for basic care – fine tuning is an unaffordable luxury for now. And in any case the filing system is so hopeless old notes are rarely found or of any use even if they are. Just today I saw a woman who had a stillborn baby when I was here last time – we did find her old notes but amongst the jumble of dusty paper I could find only one with my writing on it, and that was written on the day of her discharge from hospital – the preceeding page or two that would have had all my – yes, obsessional – notes were missing! 

So good note keeping is pointless if there isn’t a decent filing system, and pointless if no use is going to be made of all the information they contain, and not needed for any sort of medico-legal purpose either. So why do we hassle the midwives so much about doing it? The answer is because that’s what’s appropriate in the culture that WE come from. But what about THEIR culture?

For the time being, as far as note keeping is concerned I just would like them to get into the habit of writing something.  Its too big a jump to go from writing almost nothing to writing and recording almost everything!