a detailed report from the ardingly old jeshwang...
TRANSCRIPT
1
Introduction page 3
Chapter 1 Child Health Programme Page 5
Chapter 2 Control of Infectious Diseases in Children Page 7
Chapter 3 Antenatal Care Programme Page 13
Chapter 4 Normal Delivery Page 17
Chapter 5 Exchanges Page 19
Chapter 6 Engineering Services Page 22
References Page 23
Treasurer’s Report Page 24
CONTENTS
A Detailed report from the Ardingly OldJeshwang Association
2
IntroductionConstruction of Phase Two, Old Jeshwang Health Centre
This year we reached a milestone in the development of health care in Old Jeshwang. On the 6th ofFebruary, Phase Two of the Health Centre was opened by the Secretary of State for Health, Dr. YankubaKassama. The Vice President of The Gambia was represented by the Minister of Justice. The Mayorof Kanifing and many other local dignitaries attended.
Twenty-nine members of the Association in the UK and three medical students from the University ofBirmingham Medical School attended the ceremony. Some members took the opportunity to assist atthe antenatal and child health clinics, some undertook “snagging” – fault finding – on the building andothers visited schools or helped with office work.
Since the official opening we have worked with Techniques Ltd. to finish the building. We hope thatall outstanding work will have been completed by the end of this year.
Student Exchanges
Two medical students from the University of Birmingham carried out their projects for the intercalateddegree in public health medicine at the health centre. Anna Hall evaluated the vaccination and diseasecontrol programme in an outstanding piece of work. She has identified the strengths and weaknesses ofthe programme and reported on the women’s perceptions of the need for vaccination. Her report willstrengthen the programme.
Sabrina de Bellio Howell looked at the role of volunteers in the health services. This proved quitedifficult as the number of volunteers was a lot less than we had been led to believe. She extended hersurvey by including volunteers from previous years.
Ardingly College Sixth Formers
Ardingly College Sixth Form Students assisted at two primary schools in Old Jeshwang to developscience and health education teaching. The project was very successful and we hope to repeat it nextyear.
Attendance at the Old Jeshwang Health Centre
Abdoulie Sowe, General Administrator in Old Jeshwang, has provided basic statistics on the healthcentre use. These are set out below:
1st December 1998 – 5th February 2002
Babies under five seen 17,989 Pregnant mothers seen 3,664
6th February 2002 – 30th April 2002
Babies under five seen 1,697 Pregnant mothers seen 216
The grand totals are 19,686 infants and 3,880 antenatal patients respectively at Old Jeshwang Inaddition 1,034 patients were seen for eye conditions at Bakau and Old Jeshwang Health Centres during2001.
3
Laboratory Services
The health centre has space for a small laboratory. It has been named in memory of David Bunker,who died last year. He made a major contribution to the Association. His family has continued to raisefunds for the laboratory.
Finances
Under the existing Memorandum of Understanding, the Department of Health meets the routine cost ofhealthcare and the Association meets the cost of administration and development. The Association hasmaintained its fundraising during the year; details are set out in the financial report. We shall need toincrease our fundraising activities in the coming year to meet these responsibilities. We shall also needto focus on fund raising to commission the health centre.
Thanks
In conclusion we should like to take this opportunity to thank all those people who have worked so hardto support the Ardingly Old Jeshwang Association in the UK and in The Gambia. We have come along way, but there is still a lot to be done.
Dr. John Dale, Chairman Ardingly Old Jeshwang AssociationMr Bye Samba Njie, Chairman Old Jeshwang17th April 2003
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Chapter 1 Child Health Programme
Infant Welfare Clinics
Weekly infant welfare clinics have been held in Old Jeshwang Health Centre since December 1998.The clinics are staffed by a trekking team from Bakau Health Centre, consisting of a seniornurse/midwife, two community health nurses, a nursing assistant and a public health officer. Staffshortages frequently reduce the team and the time they are at the clinic. Children aged up to five yearsattend the clinics. They are weighed and screened for nutritional disorders. They also receive routineimmunizations.
All children attending Old Jeshwang Health Centre are registered by the administrative staff. It is notyet possible to distinguish repeat attendances as the necessary information technology is not yetavailable. Attendances have risen steadily from 5,000 in 1999 and are expected to exceed 7,000 by theend of 2002. (See Chart 1.1).
Throughout the period there have been fluctuations in weekly attendances which may reflect problemswomen face bringing infants to the clinic. Key staff may be absent because they are attending in-servicetraining. The women may need to attend their gardens for subsistence and arrive late. Infant welfareclinics are approaching 200, too large for effective care. Additional clinics are necessary. (See Chart1.2).
O l d J e s h w a n g H e a l t h C e n t r e I n f a n t W e l f a r e C l i n i cC h a r t 1 . 1 - A n n u a l a t t e n d a n c e s 1 s t J a n 9 9 t o 1 s t O c t 2 0 0 2
0
1 0 0 0
2 0 0 0
3 0 0 0
4 0 0 0
5 0 0 0
6 0 0 0
7 0 0 0
1 9 9 9 2 0 0 0 2 0 0 1 2 0 0 2
Y e a r
Atte
ndan
cies
O ld J e s h w a n g H e a lth C e n tre In fa n t W e lfa re C lin icC h a rt 1 .2 - A tte n d a n c e s 1 s t J a n to 1 s t O c t, 2 0 0 2
0
5 0
1 0 0
1 5 0
2 0 0
2 5 0
1 5 9 1 3 1 7 2 1 2 5 2 9 3 3 3 7 4 1 4 5 4 9
W e e k n o
Atte
ndan
ces
5
O l d J e s h w a n g H e a l t h C e n t r e I n f a n t W e l f a r e C l i n i cC h a r t 1 . 3 - E t h n i c g r o u p i n p o p u l a t i o n s a m p l e a n d e x i t p o l l
0
1 0
2 0
3 0
4 0
5 0
M a n d in g o S e r r e r e J o la W o l lo f F u la M a n ja g o S a r a h u l i O t h e r s
T r ib e
Perc
enta
ge
s a m p lee x i t p o l l
A medical student from the University of Birmingham Medical School, Anna Hall, has recordeddemographic data on a sample of the village population. She also carried out an exit poll of those womenwho had brought their children to the clinic. Her study showed that the Mandingo tribe form 40% of thepopulation but are under-represented in the exit poll. Members of the Jola, or Arrameh, tribe are alsounder-represented. Many are refugees and many are older women. Often the children do not have properhealth records.
Members of the Serrere tribe are over-represented. These are predominately fishermen, originating fromSenegal and most are now resident in The Gambia. Some return to Senegal for a period of two to threemonths each year for cultural reasons - marriage, wrestling and visiting relatives. (see Chart 1.3).
Demographic data on those attending can assist the planning of health education interventions.
No analysis is yet possible on the nutritional state of the children attending the clinic. However it isapparent that many children attending local schools are undernourished. A new "Feed Yourself"programme has been started in the schools.
Target
We plan to:
• Establish a computerized child register
• Collect data on infant nutritional state
• Monitor the new Feed Yourself programme for school children
• Improve the health education programme
6
Chapter 2 Control of Infectious Diseases in Children
Expanded Programme on Immunization
Infants in The Gambia are immunized against the following diseases: tuberculosis, polio, diphtheria,pertussis (whooping cough), haemophilus influenzae, measles, yellow fever and hepatitis B. Theimmunization schedule is set out in Table 2.1 below
Data Sources
A public health officer immunizes children attending an infant welfare clinic and enters a record of theimmunization on the child's personal health card. Routine statistics on immunizations at clinics in TheGambia are collected as part of the National Health Information System. The administration staff atthe health centre collect more detailed data on attendances. This data cannot be analyzed in detail untilthere is a computer system in operation.
In 2002 a third year medical student from Birmingham University, Anna Hall, evaluated the immuni-zation and disease control programme at the Centre using an adapted form of the World HealthOrganization protocol. She reviewed the procedures for immunization and interviewed mothers andothers bringing the children.
All three sources of data have been used in compiling this report.
Immunization against tuberculosis using BCG, (Bacillus Camille Guerin)
Tuberculosis is prevalent in The Gambia and the risks of infection for an infant are relatively muchhigher than in developed countries such as the UK. Only about 5% of those who contract tuberculosisas a primary infection go on to develop clinically apparent disease. When it does occur it may takethe form of meningitis or miliary tuberculosis. In the remaining 95% of those infected the primary
T a b le 2 .1 . Im m u n is a tio n s c h e d u le fo r in fa n ts in T h e G a m b ia
A n ti -tu b e rc u lo sis im m u n isa tio n W h o o p in g c o u g h , (P e r tu sis), T e ta n u s,D ip h th e r ia a n d H ib Im m m u n isa tio n
B C G in je c t io n a t b irt hD P T & H ib 1 s t in je c t io n a t 2 m o n th s
H e p a ti tis B im m u n isa tio n D P T & H ib 2 n d in je c t io n 3 m o n th sD P T & H ib 3 rd in je c t io n 4 m o n th s
H e p B 1 s t in je c t io n a t b irt h D P T B o o s te r 1 y e a r a fte r 3 rd in je c t io nH e p B 2 n d in je c t io n a t 2 m o n th sH e p B 3 rd in je c t io n a t 4 m o n th s M e a sle s im m u n isa tio n
P o l io m y e l i ti s im m u n isa tio n M e a s le s in je c t io n a t 9 m o n th s
O ra l p o lio va c c in e 0 a t b irt h Y e l lo w F e v e r im m u n isa tio nO ra l p o lio va c c in e 1 a t 1 m o n thO ra l p o lio va c c in e 2 a t 2 m o n th s Y e llo w F e ve r in je c t io n a t 9 m o n th sO ra l p o lio va c c in e 3 a t 3 m o n th sO ra l p o lio va c c in e 4 a t 9 m o n th sO ra l p o lio b o o s te r a t 1 8 m o n th s
N o te In te rva ls b e tw e e n d o s e s a re m a in ta in e d a fte r la te im m u n is a t io n s
7
lesion heals without intervention. However the disease can be reactivated in such diseases asHIV/AIDS. Reactivated tuberculosis carries a high mortality. Good tuberculosis programmes canreduce the transmission of tuberculosis and the incidence of drug resistant disease.
In The Gambia an infant is immunized with BCG vaccine at birth or soon after, whereas in the UKimmunization is delayed to fourteen years. In the year 2000 BCG immunizations at Old JeshwangHealth Centre peaked at just over 300 but have fallen slightly since.
Hepatitis B
Hepatitis B is an acute viral infection of the liver. It is a severe disease and can cause long term carriage,eventually leading to cirrhosis and cancer of the liver. It can be transmitted through contaminated blood.It can also be transmitted sexually.
In developed countries selective vaccination is recommended only for high risk groups. In The Gambiaall children are immunized at birth or soon after. The programme requires a second injection at twomonths and a third injection at four months.
The number of infants receiving the first dose has increased steadily. However, fewer childrencompleted the second dose and fewer still the third dose. The importance of attending for all threeinjections will need to be stressed. (See Chart 2.3)
O l d J e s h w a n g H e a l t h C e n t r e I n f a n t W e l f a r e C l i n i cC h a r t 2 . 2 - B C G i m m u n i s a t i o n s 1 s t J a n 9 9 t o 1 s t O c t 2 0 0 2
0
5 0
1 0 0
1 5 0
2 0 0
2 5 0
3 0 0
3 5 0
1 9 9 9 2 0 0 0 2 0 0 1 2 0 0 2
Y e a r
Imm
unis
atio
ns
O ld J e s h w a n g H e a l th C e n t re In fa n t W e l fa re C l in icC h a r t 2 .3 - H e p a t i t is B im m u n is a t io n s 1 s t J a n 9 9 to 1 s t O c t 2 0 0 2
0
5 0
1 0 0
1 5 0
2 0 0
2 5 0
3 0 0
3 5 0
1 9 9 9 2 0 0 0 2 0 0 1 2 0 0 2
Y e a r
Imm
unis
atio
ns
d o s e 1d o s e 2d o s e 3
8
Poliomyelitis
Poliomyelitis is an acute viral infection of the nervous system. Its public health importance lies in theability of polio viruses to cause permanent paralysis and sometimes death. It is readily transmittedcausing endemic and epidemic disease. WHO aims to eradicate polio globally.
Immunization against polio requires six doses of the vaccine. The initial dose is given at birth or soonafter and is followed by three doses at one month intervals, a fifth dose at nine months and a boosterdose at eighteen months.
Polio immunizations at the child health clinic reached a peak in the year 2000. There has been a fallingoff in immunizations for the remaining doses. Again there is a need to encourage attendance for alldoses.
Many other children received polio vaccination in Old Jeshwang in 2000 as part of National Immuniza-tion Days. (See Chart 2.4)
Diphtheria, Pertussis (Whooping Cough) and Tetanus
Diphtheria is an infection of the upper respiratory tract and sometimes the skin. It is a rare infection butis potentially fatal if untreated. It is preventable by immunization. Whooping cough is an acutebacterial respiratory infection. It can produce a severe disease, particularly in young infants. It ispreventable by immunization. Tetanus is an acute illness caused by the toxin produced by the tetanusbacillus. It also can be prevented by immunization. It is usual for the immunization against all threediseases to be combined in one injection.
The number of children immunized was at its highest in 2001 but was considerably reduced in the firstpart of 2002. (See Chart 2.5)
O l d J e s h w a n g H e a l t h C e n t r e I n f a n t W e l f a r e C l i n i cC h a r t 2 . 4 - P o l i o i m m u n i s a t i o n s 1 s t J a n 9 9 t o 1 s t O c t 2 0 0 2
0
5 0
1 0 0
1 5 0
2 0 0
2 5 0
3 0 0
3 5 0
1 9 9 9 2 0 0 0 2 0 0 1 2 0 0 2
Y e a r
Imm
unis
atio
ns d o s e 1d o s e 2d o s e 3d o s e 4d o s e 5
O l d J e s h w a n g H e a l t h C e n t r e I n f a n t W e l f a r e C l i n i cC h a r t 2 . 5 - D P T i m m u n i s a t i o n s 1 s t J a n 9 9 t o 1 s t O c t 2 0 0 2
0
5 0
1 0 0
1 5 0
2 0 0
2 5 0
3 0 0
3 5 0
1 9 9 9 2 0 0 0 2 0 0 1 2 0 0 2
Y e a r
Imm
unis
atio
ns
d o s e 1d o s e 2d o s e 3b o o s t e r
9
Haemophilus Influenzae B
Haemophilus Influenzae B (Hib) is a bacterial infection primarily of young children under four yearsof age. Older children and adults rarely carry the type b strain. It is one of the major causes ofmeningitis in children under four but rarely causes disease in adults. It can also cause pneumonia,epiglottitis and other generalized infections. It has a high rate of complications but can be prevented byimmunization.
Immunizations against Hib are given with the first three doses of whooping cough, diphtheria andtetanus immunizations. The number of children immunized was at its highest in 2001 but wasconsiderably reduced in the first part of 2002. (See Chart 2.6)
Measles
Measles is a viral infection. It is highly infectious and can be prevented by immunization. In TheGambia a single dose of measles vaccine is given at nine months.
Despite the apparent high levels of immunizations achieved there have been recent severe outbreaks ofmeasles in Western Division. Equipment for cold storage of vaccines needs to be replaced, the coldchain reviewed and the availability of vaccines increased.
Measles immunizations were at their highest in the year 2000, but have dropped almost to zero in 2002,owing to shortage of vaccine. (See Chart 2.7)
O l d J e s h w a n g H e a l t h C e n t r e I n f a n t W e l f a r e C l i n i cC h a r t 2 . 6 - H i b i m m u n i s a t i o n s J a n 1 s t 9 9 t o O c t 1 s t 2 0 0 2
0
5 0
1 0 0
1 5 0
2 0 0
2 5 0
3 0 0
3 5 0
1 9 9 9 2 0 0 0 2 0 0 1 2 0 0 2
Y e a r
Imm
unis
atio
ns
d o s e 1d o s e 2d o s e 3
O ld J e s h w a n g H e a l t h C e n t r e In f a n t W e l f a r e C l in icC h a r t 2 .7 - M e a s le s im m u n is a t io n s 1 s t J a n 9 9 t o 1 s t O c t 2 0 0 2
0
5 0
1 0 0
1 5 0
2 0 0
2 5 0
3 0 0
3 5 0
1 9 9 9 2 0 0 0 2 0 0 1 2 0 0 2
Y e a r
Imm
unis
atio
ns
10
Yellow Fever
Yellow Fever is a virus infection which in urban areas is transmitted by the bite of an Aedes AegyptiMosquito. In urban areas the mosquito acquires the infection from an existing human patient. Theillness can be severe.
Immunization against Yellow Fever is carried out at nine months. Fewer children have received yellowfever immunization than immunization against other diseases.The immunizations dropped almost to zero in 2002. (See Chart 2.8)
Coverage Levels
"Coverage" is the name given to a statistic used to estimate the proportion of a population immunizedwith a particular antigen. We have not yet determined the catchment population of the Centre andcannot therefore estimate cover from routine statistics. However Anna Hall recorded demographic dataon a systematic sample of the village population. By using the children's health record of immunizationsheld by the mother she was able to estimate cover for each type of immunization in Old Jeshwang. (SeeChart 2.9)
She found that in the Old Jeshwang sample the proportion of children fully immunized by one year was66% and by two years was 74%. These results compare very favourably with the national figures andwith those for Western Division .
0
5 0
1 0 0
1 5 0
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3 5 0
1 9 9 9 2 0 0 0 2 0 0 1 2 0 0 2
Y e a r
Imm
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O l d J e s h w a n g V i l l a g e W e s t e r n D i v i s i o n a n d T h e G a m b i aC h a r t 2 . 9 - I m m u n i s a t i o n c o v e r 2 0 0 2
0
2 0
4 0
6 0
8 0
1 0 0
B C G P o l io D P T H ib H e p B M e a s le s Y FA n t ig e n
Perc
enta
ge c
over
O JW DG a m b ia
Old Jeshwang Health Centre Infant Welfare ClinicChart 2.8 - Yellow Fever immunisations 1st Jan 99 to Oct 2002
11
Health Education
In her interviews Anna Hall found that the chief source of health information for the women was radioand television. Roughly half of the women had been advised by the public health worker but 45% ofthe carers interviewed reported that they had never been given any advice. Some mothers do not attendthe clinics with their infant but delegate the task to inappropriate carers such as younger children. Thewomen are not able to benefit from health education measures and young carers may not be able toreport problems.
The new building has a health education area and this will be used to enable a health educationprogramme for the community to be developed.
Evaluation of the Programme
Logistical and organization problems hinder the programme and will need to be addressed. Communityawareness of the Health Centre in Old Jeshwang is good but un-reached populations still exist.Knowledge about immunizations is poor. It could be increased through educational programmes andsensitizing the people of the village as to the purpose of the health centre and of immunizations.Despite the high coverage there is still a large proportion of children who are not fully immunized.
Targets
We plan to:
• Establish a health education programme on immunization
• Extend the child register to include a record of immunizations
• Organize a “Catching Up” programme for children who are not fully immunized
• Improve the organization and logistics of the programme
• Install vaccine cold storage in the health centre
• Increase the availability of vaccines
12
Chapter 3Antenatal Care Programme
The Antenatal Care Programme aims to ensure that all women in the community go safely throughpregnancy and childbirth, and that their infants are born alive and healthy.
Causes of Maternal Death
The causes of maternal deaths can be classified into three groups: direct, indirect and coincidental.Direct causes refer to diseases or complications that occur only during pregnancy; indirect causes arediseases that may be present before pregnancy but are aggravated by the presence of pregnancy;coincidental causes are fortuitous events unrelated to pregnancy itself. The main causes are set out inTable 3.1 below.
Table 3.1 - Causes of Maternal Death
Direct causes occurring during pregnancy Indirect causes present before pregnancy
abortion heart disease ectopic pregnancy essential hypertension(high blood pressure) hypertensive disease of pregnancy diabetes mellitus antepartum haemorrhage diseases of the red blood cells postpartum haemorrhage obstructed labour Coincidental causes puerperal sepsis road traffic accidents
WHO has estimated the incidence of complications in pregnancy for developing countries. We cannottransfer these incidence figures directly to The Gambia but the relative proportions of causes are likelyto be the same. The proportion of obstetric complications, the proportion of the resulting maternaldeaths and the proportion of the deaths that can be averted, for each main cause, are set out below. (SeeChart 3.2).
The highest proportions of complications and deaths are attributable to haemorrhage followed by sepsis,eclampsia and hypertensive diseases of pregnancy, and obstructed labour. Unsafe abortion is also amajor course of death and can be averted.
W H O G lo b a l E s tim a teC h a rt 3 .2 - P ro p o rtio n o f o b s te tric c o m p lic a tio n s , m a te rn a l
m o rta l i ty a n d p re v e n ta b le d e a th s b y c a u s e
0
1 0
2 0
3 0
4 0
5 0
H a e m o rrha g e S e p s is E c la m p s iaH D P
O b s truc te dL a b o ur
U ns a fea b o rtio n
O the r d i re c tc a us e s
Ind ire c tc a us e s
C o m p lic a tio n
Perc
enta
ge
C o m p lic a tio nsD e a thsP re ve n tab le d e a ths
13
The reasons why women die in pregnancy are multifactorial. Behind the medical causes are failures ofthe health care system; lack of transport, poor design and maintenance of facilities. There are also social,cultural and political factors which affect the status of women and their behaviour.
Good antenatal care is the first step in achieving the aim in reducing morbidity and mortality.
Antenatal Care
Attendances for antenatal care have increased from over 1000 in 1999 to an estimated 1300 in 2002. (SeeChart 3.3). We have not yet separated first attendances of pregnant mothers attending the clinic fromrepeat attendances. Pathology tests still have to be carried out at Bakau Health Centre. This hasinvolved the women travelling to Bakau Health Centre, 2.5 km from Old Jeshwang Health Centre as thecrow flies, farther by road. They have to travel at least twice to have the test and to get the results,sometimes more. Women have complained about the time and cost involved. We plan to provide simplelaboratory facilities in the new building.
Weekly attendances for antenatal care fluctuated from 13 to 54 in 2002. (See Chart 3.4).
Women have many other duties. They need to water their gardens, plant rice, sell produce for "fishmoney", (daily housekeeping), and care for their children. Many husbands are unemployed. The trendover the whole period the health centre has been opened shows fluctuations in attendance which do notappear to be seasonal as one would expect if these duties were the major cause. At present the trekkingteam from Bakau must first attend to the patients there. The time they arrive at Old Jeshwang can varyfrom week to week. The duration of the clinic also varies. Several studies have shown that where thetime of the clinic varies women are less likely to attend regularly. We believe that this may have affectedattendances at Old Jeshwang, particularly since the attendance of children has not varied so much. Thisproblem needs attention.
O l d J e s h w a n g H e a l t h C e n t r e A n t e n a t a l C l i n i cC h a r t 3 . 3 - A n n u a l a t t e n d a n c e s 1 s t J a n 9 9 t o 1 s t O c t 2 0 0 0
0
2 0 0
4 0 0
6 0 0
8 0 0
1 0 0 0
1 2 0 0
1 4 0 0
1 6 0 0
1 9 9 9 2 0 0 0 2 0 0 1 2 0 0 2
Y e a r
Ann
ual a
ttend
ance
s
O l d J e s h w a n g H e a l t h C e n t r e A n t e n a t a l C l i n i cC h a r t 3 . 4 - T r e n d i n a t t e n d a n c e s 1 s t J a n 9 9 t o O c t 2 0 0 2
0
1 0
2 0
3 0
4 0
5 0
1 2 1 4 1 6 1 8 1 1 0 1 1 2 1 1 4 1 1 6 1 1 8 1 2 0 1
W e e k n o ( m e d ia n )
Atte
ndan
ces
(5 w
eek
runn
ing
mea
n)
2002
14
Hypertensive Disease due to Pregnancy
This group of diseases includes pre-eclampsia and eclampsia.
Pre-eclampsia is characterized by high blood pressure, protein in the urine and swelling of the tissuesthrough oedema during the second half of pregnancy. Symptoms may remain mild but can becomesevere. Headaches, vomiting, impairment of vision, and pain in the upper abdomen may occur. Theaffected woman may stop producing urine. In the last stage convulsions may develop. This stage iscalled eclampsia. If left untreated, the woman rapidly becomes unconscious and dies. In tropical Africathe disease can develop rapidly, progressing from the earliest physical signs through to eclampsiawithin a few days, sometimes in as short a time as 24 hours.
We have provided digital sphygmomanometers for the clinic to improve the measurement of bloodpressure . Recordings of blood pressure readings are made in the mother's card but no central clinicrecord is made. We aim to establish a computer register for antenatal care which will enable accessiblerecords to be kept. Routine testing of the urine for proteinuria will help identify cases of pre-eclampsia.
The symptoms of eclampsia, which start with a headache, are not likely to be recognised by the patient.For those patients who do present at the health centre, treatment will need to be started at the healthcentre and urgent transfer to hospital will be necessary. This will require an ambulance.
Anaemia in pregnancy
Anaemia is a common cause of maternal mortality in The Gambia. The causes of anaemia are complexand include a diet deficient in iron and folate, a short gap between pregnancies, high parity, HIVinfection, sickle cell anaemia, malaria and hookworm. Severe anaemia can cause maternal death.Moderate anaemia can contribute towards death from other causes. Anaemic mothers do not tolerateblood loss as well as healthy women; they are poor anaesthetic and operative risks, and prone tocomplications from infection.
Ruth Keele, a medical student from Imperial College School of Medicine in the UK reviewed anaemiain pregnancy at Old Jeshwang Health Centre antenatal clinic on a small sample (56) of those registeredat the clinic. Women should have at least two haemoglobin measurements in pregnancy, an initialmeasurement at the first visit, and a second at 36 weeks to identify those who are still anaemic. Shefound that 5% of women had not had a baseline haemoglobin recorded by their second visit. Moreworrying is her finding that 83% of the women did not have a haemoglobin measurement at 36 weeks.
Of those women who had haemoglobin measurements, 13% had no anaemia, 80% were moderatelyanaemic by WHO standards, and 2% were severely anaemic. (See Chart 3.5)
O l d J e s h w a n g H e a l t h C e n t r e A n t e n a t a l C l i n i cC h a r t 3 . 5 - A n a e m i a a m o n g w o m e n r e g i s t e r e d f o r A N C
0
2 0
4 0
6 0
8 0
1 0 0
N o b a s e l in e N o t a t 3 6 w e e k N o a n a e m ia M o d e r a t ea n a e m ia
S e v e r e a n a e m ia
H b n o t r e c o r d e d A n a e m ia s t a t u s
Perc
enta
ge
15
Puerperal Sepsis
Women are particularly susceptible to infection of the genital tract following delivery or abortion. Thesite in the uterus at which the placenta was attached is left as a raw area. Tears in the lining of thegenital tract may occur as a result of birth. The entrance to the uterus is open unlike at other times inthe women's life.
Germs may enter the genital tract in various ways; from the birth attendants hands, from unsterileinstruments, or from contamination of the site by the woman herself. Traditional remedies used byuntrained birth attendants are also a cause of infection.
The health centre building has been designed to reduce the risk of infection. The labour ward is of amplesize. There is a scrub up room to allow the birth attendant to prepare for delivery. Clean and dirty utilityrooms have been provided. An ample supply of gloves and swabs will be required.
Malaria in Pregnancy
Anna Last, a medical student in the University of Birmingham Medical School, reviewed the manage-ment of malaria in pregnancy.
Malaria in pregnancy is a major health problem in The Gambia. The prevalence of malaria parasites inthe blood during pregnancy in urban areas in The Gambia has been estimated at 12% by Dr Greenwoodof the Medical Research Council.
Malaria prophylaxis in pregnancy can benefit both mother and foetus. It reduces the incidence of lowbirth weight babies and consequently the infant morbidity and mortality. It also reduces the incidenceof anaemia in the mother. The effect is greatest in women pregnant for the first time, "primigravida".We shall need to consider the introduction of malaria prophylaxis at least for primigravidae.
Permethrin impregnated bed nets have been shown to reduce morbidity and mortality in Gambianchildren. They should have a similar effect on pregnant mothers.
Targets
We plan to:
• Improve the management of antenatal clinics to encourage attendance
• Set up a computer register of pregnant women
• Provide laboratory facilities for urine testing
• Provide laboratory facilities for measuring haemoglobin
• Improve staff training to ensure haemoglobin is monitored adequately throughout pregnancy
• Ensure adequate supplies of consumable items for the health centre.
• Ensure a continuous and adequate supply of medicines
• Consider the introduction of malaria prophylaxis for primigravidae
• Set up an impregnated bed net programme in the village
• Improve antenatal health education
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Chapter 4 Normal Delivery
Normal Delivery
The new building at Old Jeshwang Health Centre provides facilities for normal deliveries. It has amaternity suite consisting of a delivery room, scrub-up, and clean and dirty utility rooms. It has a two-bedded antenatal ward and a four-bedded postnatal ward as well as bathrooms. A nursing station hasbeen provided that allows a nurse/midwife to oversee the whole suite.
The Women's Wing of the Old Jeshwang Committee wishes emphasis to be placed on privacy, aftersafety considerations have been met. The inpatient facilities are physically separated from the rest ofthe building to provide such privacy.
The suite has been designed to provide ample space for normal deliveries and to minimize the risk ofinfection. It provides better facilities than are available at either Bakau Health Centre or SerekundaHealth Centre and should therefore be brought into service as soon as possible.
Refugees
There are many refugees from Guinea Bissau and the Cassamance living in Old Jeshwang. Thiscommunity lives in the market buildings still under construction. Most of these women give birth athome, because of a lack of resources, where they are attended by traditional birth attendants. Thesewomen will be encouraged to use the Health Centre for the delivery.
Mother and Baby
There are two patients to be considered during a delivery, the mother and the baby. The major causesof maternal morbidity and mortality were summarized in the previous chapter. The major causes ofmorbidity and mortality in newborn infants are set out below. (See Chart 4.1)
Birth asphyxia, birth injuries, sepsis and other causes of disability and death can be reduced by goodcare in delivery.
W HO G lobal Estim ateChart 4.1 - Proportion o f new born deaths by cause
0
5
10
15
20
25
B irthasphyxia
B irthinjuries
Neonata lte tanus
S epsis &meningitis
P neumonia D iarrhoea P rematurity C ongenita ldefects
Othercauses
Cause of death
Perc
enta
ge
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Training
The WHO Safe Motherhood package sets out in detail procedures to make delivery safer for bothmother and baby. Effective health care for mother and baby means making the best use of material andhuman resources. To implement the Safe Motherhood package we shall establish in-service trainingprogrammes for midwives in the Centre.
The Association arranged the first in-service training for midwives in The Gambia in association withthe Gambia Nurses and Midwives Council and Greenwich University, UK. We have also arranged forstudent midwives from Greenwich University and from Brighton University Institute of Nursing andMidwifery to spend an elective period in the Health Centre and at other facilities in The Gambia. Weexpect to arrange equivalent experience for Gambian student midwives. We are very grateful for thehelp we have received from the Registrar, Mr Tom King, in arranging these exchanges.
We are in the process of linking the Old Jeshwang Health Centre to the Institute in Brighton to facilitatethis joint training.
Equipping the Delivery Suite
We need to equip the delivery suite with modern equipment and to provide the necessary consumableitems and medicines. Some equipment has already been purchased. This includes a ResuscitationMachine donated by the Soroptimist International of Kidderminster, modern lockers and medicinestorage donated by Hospital Metalcraft Ltd and nurse call systems donated by Wandsworth ElectricalLtd. The Midwives Association of the UK has also raised money for this suite.
Targets
We plan to:
• Equip the delivery suite
• Appoint a Senior Midwife
• Increase health care staff at the Centre to provide 24 hour coverage
• Introduce Safe Motherhood protocols
• Equip the Centre for education and training
• Run in-service training programmes for midwives
• Provide basic training for traditional birth attendants
• Encourage refugee women to use the health centre
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Chapter 5Exchanges
Student Electives and In-Service Training
Ardingly Old Jeshwang Association was established to relieve sickness and promote the preservationof good health in The Gambia through the provision of local health centre facilities and the establish-ment of primary health care programmes. The Association also has the objective of encouraging directco-operation between local communities in The Gambia and local communities in the UK. The earlierpart of this report has been concerned with the first objective, we shall now turn to the second.
Ardingly Village and Old Jeshwang Village.
A close association has grown up between Ardingly Village in Sussex, UK, and Old Jeshwang Villagein Kanifing, The Gambia. Visits between the two communities are now frequent. Much has beenlearnt from these exchanges to the benefit of both.
Student and In-service Exchanges
The exchange of students between countries through elective studies is now an accepted practice. Ithas proved beneficial in many ways.
• Such exchanges allow the students to experience other cultures, of increasing importance now that so many countries have a multi-cultural population.
• Students learn to appreciate cultural, political, and economic situations from which patients in their own country originate.
• Exchanges enable the students to see aspects of medicine and health care that they may not easily see in their own country.
• Cross cultural contact between different health care systems can provide a framework for identifying strengths and weakness of one's own health care system.
• Students experience conflicting values among health care personnel
• Students learn to manage clinical problems using minimal resources.
• The fresh approach the students bring may encourage those who have become set in their ways to consider new approaches to their professional work.
Similar benefits will apply where staff already in service carry out study visits as part of their in-servicetraining.
An important aspect of our programme is the involvement of students and other volunteers in ourprojects. There are opportunities to assist in direct health care in medicine, nursing and midwifery.There are also opportunities to assist in developing administration, information technology and man-agement.
Volunteers and students on electives may participate in studies or other aspects of health care undersupervision. They are accountable to the General Administrator at Old Jeshwang Health Centre for allaspects of their work.
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Medical Students Electives
Medical students at UK Universities are encouraged to spend a period abroad in their electives toexperience different cultures and forms of medical practice. Students from the University of Birming-ham Medical School, and Imperial College Medical School have undertaken electives in Old Jeshwangunder the supervision of staff of the Department of Health. We wish to thank the Director of HealthServices, Dr Sam, for his approval of student projects; the staff of the Department of Health for theguidance they have given; and Professor MacAdam, Director of the Medical Research Council Labora-tories at Fajara for access to library and other facilities given to the students. We also wish to thankDr Ayo Palmer for acting as mentor to the students.
Some students have audited aspects of health care of women and children. One student has reviewedthe management of large outbreaks of meningitis. Their project reports form part of a submission fora degree in public health medicine, and have been rated very highly by the external examiners.
The student project reports have been of great value in planning health services in the Health Centre.As pilot studies they can be used to identify the type of problem found in the Old Jeshwang communityand in the health services. The reports will assist the development of management systems for healthcare. They have been used in the preparation of this report.
Local supervision of the students by Gambian professional staff has encouraged the latter to reviewtheir own practices. The Administrator and other staff in the Centre have developed considerable skillin the management of these projects.
Midwifery Students
Student midwives from the Midwifery School, University of Greenwich and from the Institute ofNursing and Midwifery , University of Brighton, have undertaken electives in The Gambia under theauspices of the Association, the Gambia Nurses and Midwives Council and the Department of State forHealth. These electives have usually lasted two to three weeks and have been very much appreciatedby the students.
We are extending the link between Old Jeshwang Health Centre and the Institute of Nursing andMidwifery at Brighton and in due course we expect to arrange electives for Gambian student midwives.
School Exchanges
In July 2002 a group of seven students from Ardingly College spent two weeks with two primaryschools in Old Jeshwang. Pupils in Gambian primary schools do not have experience of practicalscience because large class sizes do not permit individual or small group tuition.
The College students developed simple experiments in aerodynamics and the physics of sound, ademonstration of a chemical reaction, a demonstration of how a microscope works, a demonstration ofmolecular structure using chromatography and an experiment on changes of state between a solid, aliquid and a gas. The students split classes of 10 and 11 year old pupils into small groups of abouteight to give them hands-on experience. Each pupil spent about 10 minutes on each demonstration.
The project was evaluated by the Schools Inspectorate and was considered very successful. TheDirector of Science Education and the Secretary of State for Education welcomed the project and askedfor it to be repeated. In the future it will be extended to include health education activities.
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Primary School Links
St Peter's Primary School, Ardingly and Old Jeshwang Lower Basic School have undertaken severalprojects jointly, such as exchanging drawings of life in the two villages. These have been successful inraising awareness. We plan to invite the Deputy Head of Old Jeshwang School for a study tour at StPeter's Primary School.
Training in Communicable Disease Surveillance
The Association has arranged for senior staff from the National Epidemiology and Statistics Unit in TheGambia to undertaken short term study visits to the UK. These have included the control of communi-cable diseases, and the management of operating theatres.
Such study visits are essential. There is no substitute for seeing at first hand how something as complexas disease surveillance is managed, even for those who have already completed post graduate studies.We should like to thank the National Meningitis Trust for a grant to support these study visits, the HighCommissioner for the UK and his staff for their cooperation and the Director and staff of the Commu-nicable Disease Surveillance Centre in the UK for arranging training.
Financial Aspects
UK students raise funds for their own electives; the Association has to meet the administrative costs andprovide appropriate insurance cover. Extension of the programme will require specific funding tosustain it.
Targets
We plan to:
• Continue the medical student elective programme with the University of Birmingham
• Establish close links between the Health Centre and the University of Brighton Institute of Nursing and Midwifery
• Encourage further midwifery student electives
• Arrange study visits for Gambian staff
• Build on the school links already established
• Establish close links between the Health Centre and the new medical school at Sussex University
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Chapter 6Engineering Services
The new building was dedicated in February 2002; however there were a number of items, mainlyengineering, that had not been completed. These items have now been finished but not yet checked.
A nurse call system has now been installed.
We shall install computer systems for patient management. These must be protected against lightningstrikes, very common in The Gambia. Electronic Systems Protection, W.J. Furse & Co Ltd., haveadvised us on protection and also contributed to the cost of its installation.
Although the public electrical supply is improving it is still unreliable. A standby generator will berequired. The backup system will require voltage relays to detect power failure and to start up thegenerator from a battery supply. The batteries will require a trickle charger to top them up. A tank fordiesel oil with a level gauge, and all necessary wiring to connect the generator to the existing electricalsupply will also be required. The generator will be housed in the Phase I building approximately 40metres from the clinic. The Facilities Manager will be trained in its use.
We are considering the installation of a solar heating system to provide hot water. The cost of heatingthe water by electricity has been calculated. An estimate of the cost of supplying hot water by solarheating is being made. This will include the cost of installing solar panels, associated piping, pumps andother items. An estimate of maintenance costs will have to be included. If solar heating is installed,allowance must be made for heating the water first thing in the mornings. Once these costs have beenestimated a final decision on a system for water heating will be made.
We shall provide a well for water for the health centre gardens
Clinical waste from the health centre will need to be disposed of on site by incineration. An incineratorwill be constructed.
Targets
We plan to:
• Install a backup generator, associated batteries and equipment
• Train the facilities manager in the operation of the system
• Determine the cost effectiveness of installing solar heating to replace or supplement provision of hot water for the centre
• Provide a well for watering the grounds of the Centre
• Construct an incinerator for clinical waste.
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ReferencesChapter 2
Hawker J.. Communicable disease control handbook. Blackwall Science Ltd. 2001.
Hall Anna. Evaluation and Adaption of the World Health Organization Evaluation of Vaccinationand disease of the population of Old Jeshwang. Inter-collated B.Med.Science project reportUniversity of Birmingham Medical School, 2002.
Chapter 3
Last Anna. Malaria in Pregnancy: Evaluating the implementation of preventive strategies in OldJeshwang, The Gambia. Intercalated B. Med Sc. project report University of Birmingham MedicalSchool. May 2000.
Keele Ruth. A study of anaemia in pregnancy at Old Jeshwang Clinic, The Gambia. Medicalelective project, Imperial College School of Medicine. Sep 2000.
Royston Erica, Armstrong Sue. Preventing Maternal Deaths. WHO Geneva, 1989.
WHO. Mother Baby Package: Implementing safe motherhood in countries. WHO Safe Mother-hood Programme, 1996.
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Published by the Ardingly Old Jeshwang Association.UK Registered Charity Number 1024627
Incorporated in The Gambia as a limited company and charity under the Companies ActRegistration No. 169/1993
Registered Office: The Mount, Selsfield Road, Ardingly, West Sussex RH17 6TJ UK
Treasurer’s ReportThe main item of expenditure during this year has been the construction of the Phase II building. This iscapital expenditure and we expected to have a large one-off payment this year. We have been raisingfunds for this over the past years. In 1999 we received a grant of £98,000 from the UK Community Fund.We have also borrowed £15,000 from the Charities Bank. We managed to secure a favourable rate ofinterest and hope to pay back the loan over the next three years. It should be noted that we may have toborrow an additional amount to cover the cost of the final stage payment on the building, due in the firstpart of 2003.
The remaining expenses are much the same as they have been in previous years. The number of membersof the Association is increasing steadily as is the amount received in covenanted donations. At present70% of all the staff salaries in Old Jeshwang are paid through these covenants. We hope that all staffsalaries will soon be covered in a similar manner.
As in previous years no member of the Association in the UK has been paid for their work. Allprofessional services are donated free of charge. In Old Jeshwang all staff donated their services fromthe inception of the project until 1997. Since then some staff have been paid while others continue todonate their services free of charge.
In addition to our usual fundraising in the coming year we shall seek grants from charitable trusts tocommission the Centre and achieve our aim to have it fully functioning as soon as possible.
Mrs Barbara Monk, Treasurer ArdinglyMrs Worrage Nyang, Treasurer Old Jeshwang