Welsh journey to the Horn of Africa

In 2008 Life for African Mothers – a Welsh-based charity which provides aid to mothers in childbirth – was approached by the Somaliland diaspora community in Cardiff, requesting that it provide medicines vital during childbirth which are in short supply there (see panel). A needs assessment visit was planned but had to be cancelled because of a serious security incident in Hargeisa when 29 people were killed by a single suicide bomber.

We sought advice from Dr Charles Ameh at the Liverpool School of Tropical Medicine who regularly travels to Hargeisa in order to provide clinical skills training. He said there is a huge need for the drugs. The staff know how to use them and the hospitals have the appropriate protocols in place for administering them. However, they just don’t have them.

We decided to help and the first shipment of Magnesium Sulphate arrived at the end of December 2008. Within a week, the charity had received a report on how a woman who had suffered from severe eclampsia, was in a coma but had been saved using our medications. Since then we have received a number of invitations to visit Somaliland, but concerns around security prevented this happening.

Half-a-million deaths in childbirth Every year more than 500,000 women across the world die in pregnancy and childbirth. One of the biggest killers in the developing world is post-partum haemorrhage – excessive bleeding following delivery – which claims approximately 34 per cent of lives. It can be prevented using a drug called Misoprostol which costs 15p per tablet. A woman would need three. The other significant cause of death is eclampsia (high bloodpressure during pregnancy) which claims 14 per cent of the total deaths. It is treated with a drug called Magnesium Sulphate, which costs 55p per dose. A woman would need three to five doses. Both of these drugs are always available on delivery units in the West. In the developing world they are either nowhere to be seen, or even worse, are available but at a cost. If women cannot pay for them, they die. Total fatalities from these two conditions amount to almost half of the 550,000 deaths a year. Yet it is extremely cheap and easy to either treat or prevent them.

However, late last year the Hayaat Women’s Trust, a Cardiff based group committed to improving the lives of African women, was successful in securing a grant from the Wales for Africa Community Links Fund to cover the costs of a visit. Given that the country has had no further security incidents and has been through peaceful elections, the decision was taken to visit.

The visiting team comprised Fowzia Mohamed, Chair of Hayaat Women’s Trust, Maria Granville, Deputy Ward Manager at Llandough Mental Health Unit, and myself. Our objectives were to:

• Visit and undertake a needs assessment in order to explore the possibility of a link between Hargeisa Group Hospital’s Mental Health Unit and Cardiff and Vale Hospital Trust, facilitated by the Hayaat Women’s Trust.
• Visit hospitals where the medications provided by Life for African Mothers are impacting on maternal mortality including hospitals outside the capital and within rural areas.
• Meet with the Ministry of Health, the United Nations Population Fund, and other stakeholders involved with improving health provision.
• Strengthen communication with the charity’s partners, the Somaliland Nursing and Midwifery Association led by Fouzia Ismail.
• Hold an event in order to raise awareness of both health issues, that of mental health needs and maternal health with local media, business leaders and therefore possible funders.

What follows is a diary of our experiences during last December’s visit. The outward journey was not without problems, with the airline changing the departure time from Addis Ababa leading to an eight hour wait before flying onto Somaliland. Additionally, the airport at Hargeisa is being rebuilt, so flights are currently arriving in Berbera which is around three hours by road from the capital. The team made a brief visit to Berbera Hospital to meet the Director, before finally arriving in Hargeisa at 10pm on Tuesday 4 December instead of at 10am as originally planned.

Wednesday 5 December

A meeting with the Somaliland Nursing and Midwifery Association was the first appointment. The group then visited Hargeisa Group Hospital where we met the Director and were shown around the hospital and in particular the maternity unit where we donated two suitcases of baby clothes.

Angela Gorman (left) visiting Hargeisa Group Hospital’s maternity unit

The labour ward was clean and seemed to be well resourced. The mental heath unit was the final stop and it was clear that major work was needed to improve the environment for the patients. The team met with the senior staff and were told that they had received no training in the care of patients with mental illness, particularly the management of violent patients and how to protect themselves.

One member of staff had returned to work following a serious assault when her skull was broken, leaving her with a significant scar and facial disfigurement. The group spent a long time at the unit, talking to patients and viewing the now unused ward for which the UK diaspora Somali community are funding a refurbishment. The kitchen which serves the mental health unit was truly shocking in its current state, with food being prepared on the floor and staff doing their best in the worst possible situation.

Thursday 6 December

We started the day by taking the donation of 5400 doses of Misoprostol to the Somaliland Nursing and Midwifery Association so that distribution could commence.

Delivering 5400 doses of Misoprostol to the Somaliland Nursing and Midwifery Association

Mrs Fouzia Ismail accepted the donation and explained that she was having problems with the reporting back on previous donations from recipient hospitals. This is something which Life for African Mothers has struggled with, and only underlines the need for reliable personal contacts within the recipient countries.

We then went to a meeting with representatives of Tropical Health Education Trust where the logistics of providing medications to Somaliland from overseas as donations was explained in detail. The current funding is time limited and at the moment longer-term provision has not been secured. We then visited an organisation called IPS, which is working to reduce maternal mortality and has provided Misoprostol to a limited number of maternity units in Somaliland. They were very interested in our charity’s contribution to the stubbornly high numbers of women dying in pregnancy and childbirth. On the way back to the accommodation, the team visited an orphanage which houses almost 100 children including 18 babies, one of whom was brought to the orphanage when only three days old.

Meetings were arranged for the weekend, so the team had a ‘day off’, part of which was spent with Fatima Ali when she provided lunch and relaxation ahead of a very full and eventful week.

Saturday 8 December

We met with the Minister of Health and his Deputy who were extremely grateful for the contributions of medications and for the proposal to link the mental health units.

Meeting the Somali Minister of Health, Dr Hussein Muhumad Mohamoud

Dr Hussein Muhumad Mohamoud expressed grave concern about the child mortality rates which are amongst the highest in the world with 50 per cent of deaths being neonatal, emphasising the fact that training and resources were desperately needed. The Health Minister agreed to provide a letter of support to the charity which he hopes will help with obtaining resources.

From the Ministry, the team visited the local TV station and spoke to their Director who agreed to help with coverage of the fund and an awareness raising event which was planned for Wednesday 12^th December. A visit to the market then followed for some early Christmas shopping for unusual gifts, thus helping the local economy.

Sunday 9 December

We met with the United Nations Population Fund, a wing of the UN which is mainly concerned with maternal/reproductive and child health. It is trying to attract appropriately experienced obstetric staff to provide skills training and support to local staff. The afternoon was spent planning the programme for the event and contacting significant individuals, before being taken to the National TV station to take part in a programme which will be transmitted worldwide to diaspora Somali communities via cable TV. The programme lasted 40 minutes and we were able to give a very honest and detailed account of their impressions so far.

Monday 10 December

An invitation to visit Salahiley Hospital had been received prior to our arrival.

The visit to Salahiley Hospital

Given the need for an armed guard for visits outside the capital we were offered the use of the Minister of Health’s vehicle, driver and armed guard. The village and hospital are around 90 minutes from Hargeisa, but for most of the journey, the roads were little more than a dried up river bed. As we were thrown around the vehicle, I couldn’t help thinking that as bad as it was for us, how awful it would be for a woman in labour!

At the village, we met with the local Health Officer, a nurse who has acquired skills out of necessity. We toured the health centre and left some Misoprostol, which will hopefully prevent women having to be transferred along the roads which we had just travelled. One of the reasons we had been asked to visit Salahiley, was that two years ago, a woman died in childbirth and realising that she was going to die, asked that something be done to prevent this happening again. Funds were raised from the diaspora community and a new hospital has been built 1km from the village, at the exact spot where she died. The building has not yet been equipped. During the visit we met with the village elders before returning to Hargeisa.

Tuesday 11 December

We visited Gabiley Hospital, approximately 45 minutes from Hargeisa, which was built using funds raised by the UK diaspora community. The clinical areas were clean and organised, but quiet! The junior doctor who showed us around informed us that the medications which Life for African Mothers sends are the only source of Magnesium Sulphate and Misoprostol available to them. We left another 800 tablets of Misoprostol in their care.

We were pleased to hear that the plan for the next stage of the hospital development is to build a mental health unit and we were shown the spot where the building would be erected. On our return to our accommodation, a meeting took place with a Consultant Paediatrician who was referred to us by Fouzia Ismail. The request from the doctor was that we assist with bringing appropriately experienced clinicians to help with training, thereby reducing the neonatal mortality rate which is among the highest in the world.

Wednesday 12 December

We stayed in and around the hotel preparing for the evening event. A chance meeting with the Minister for Presidential Affairs allowed the question on women to be asked. We were told that there is work going on within the government, but the Regional elections had delayed progress. The fund and awareness raising event was well received although some sensitive issues related to mental health and maternal health were raised and discussed.

There was a mixed audience, with the men sitting in groups. They were asked directly: “If 300,000 men were dying every year, would someone have sat up and done something?” It took some time for the men to respond, but most nodded their heads. Good feedback was received and a couple of verbal pledges to help both causes.

Thursday 13 December

We visited the Nagaard Trust which is an umbrella organisation that encompasses groups who deal with women’s issues. We then travelled to the Edna Adan Hospital. It started as a maternity unit but has now grown to incorporate general wards which we were shown around. We met Mohamed Yusuf Warsame who works for the Somaliland Nurses and Midwives Association  and whose wife died of post partum haemorrhage a year before we began supplying Somaliland with medication. Along with Fouzia Ismail, Mohamed is the main contact for our charity and it is he who co-ordinates the feedback.

Friday 14 December

We packed and left the hotel by 5.15am as we had to travel to Berbera to catch the flight home… as we thought! The reality of an airport which cannot cope with the volume of passengers was brought into sharp focus. Misinformation about the time we needed to arrive at the airport, the need to have every inch of baggage searched because the x-ray machine was broken, a dispute with the airport authorities about whether we needed to pay $34 to leave the country, all left us being told that the flight had closed, minus us and our luggage. The airline put us up in a nearby hotel and we flew back to the UK on the night of Saturday 15 December.

Somaliland Somaliland is an unrecognised self-declared de facto sovereign state that is internationally recognised as an autonomous region of Somalia. The government of Somaliland regards itself as the successor state to the British Somaliland protectorate, which was independent on June 26, 1960 as the State of Somaliland. 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. In 1988, the Siad Barre regime committed massacres against the people of Somaliland, which were among the events that led to the Somali Civil War. The war left the economic and military infrastructure severely damaged. After the collapse of the central government in 1991, the local government, led by the Somali National Movement (SNM), declared independence from the rest of Somalia on May 18 of the same year. Since then the territory has been governed by an administration that seeks self-determination as the Republic of Somaliland. However, Somaliland’s self-proclaimed independence remains unrecognised by any country or international organisation. Somaliland Statistics Population: 3.5 million Areas: 68,000 sq miles Capital: Hargeisa Language: Somali, Arabic, English Religion: Sunni Islam Ethnic Groups: Somali, Swahili, Oromo The population is estimated at 3.5 million, with an average growth rate of 3.1 per cent. 55 per cent of the population is nomadic or semi-nomadic, with 45% living in urban areas or rural towns. The average life expectancy for males is 50 years old, and for females 55. The population is dispersed in Hargeisa, the capital city, and other main towns and cities such as Burao, Borama, Berbera, Erigabo, Gabiley, Baligubadle, Saylac, Odeweyne, and Las Anod. (Unrepresented Nations and Peoples Organization http://www.unpo.org/members/7916) Maternal Mortality is amongst the highest in the world with 1200 deaths per 100,000 live births (State of the World’s Midwifery, UNFPA 2011).