International Health Studies Grant 2014-15 in Action: Obstetric and Gynecologic Care Barriers in Ghana

In October 2014, Sarah Napoe – at the time, a 3rd year OB/GYN Resident working at Mass General Hospital and Brigham and Women’s Hospital , received a grant from the Foundation’s International Health Studies Grant Program. Below is a synopsis of her international experience from December 1, 2014 to December 29, 2014

 Sarah Napoe - Ghana

I arrived in Accra, Ghana on December 2, 2014 after a long 18 hour trip from Boston. The next morning, I started work as a volunteer in the department of Obstetrics and Gynecology at the Korle-Bu Teaching Hospital. I was assigned to a team focused on Urogynecology with a promise that I would be able to rotate through all aspects of the service.

I spent some time in obstetrics rounding with the junior resident on our team who managed antepartum and postpartum patients.  Many of the patients were undergoing treatment for pre-eclampsia, and others were there for preterm premature rupture of membranes.  The management approach was again similar to what we do in Boston: magnesium and antihypertensive for preeclampsia, and latency antibiotics and steroids for preterm premature rupture of membranes.

One of the major differences was taking a labor floor call. All of the women labored without anesthesia and without any family presence on the labor ward.  Labor was managed by the residents and faculty.  However when the patient becomes fully dilated, the pushing and delivery is managed by a midwife.  If patients need a cesarean section or if they have a higher order laceration such as a third or fourth degree laceration, their management is returned to the physician team.

Another area where we differ is the management of ectopic pregnancies. While in Boston, we encounter few ruptured ectopic pregnancies and mostly manage them with laparoscopy when they occur; in Accra, every call seemed to have at least one if not several patients presenting with ruptured ectopic pregnancies.  All of those patients are then given laparotomies. 

In the outpatient setting, I saw some patients for prenatal care as well as postpartum.  I was surprised when it was assumed that I would also do the well-baby check at the postpartum visit.  I had not done a pediatric exam since my third year of medical school, but I did manage to complete a few with the help of the intern.

Once a week, I had ambulatory gynecology clinic where we saw new, preoperative and postoperative patients.   Given the Urogynecology focus of my team, we saw many patients with uterine prolapse, fitted some with pessaries, and took some to the operating room.

 My experience in Ghana was crowned by a trip to the Tamale Fistula Center in Northern Ghana.  The Urogynecology team takes frequent outreach trips to other regions of Ghana for fistula repair.   The repairs and hospital stay are free of charge for the patients.  While ten patients were expected to be operated on during our trip, only 3 had arrived the night prior to our operation.  I later learned that transportation cost prevent some patients for coming in.  The first day we were able to do three surgeries, but the second day, a shortage of water limited our ability to operate as instruments could not be sterilized. The third day, after purchasing water and being ready for surgery, an obstetric emergency delayed our surgeries as we only had one operating room.   

Upon reflection, my lessons learned are that infrastructure is just as important as surgeon training and availability.  In addition, free surgical care alone is not enough as many of the patients are so poor that the travel fare may be a deterrent to having a fistula repaired. As I think about the next phase of my career, this valuable experience will shape the ways in which I approach these challenges.

- Sarah Napoe, MD

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