David Southall and Rhona MacDonald of Maternal & Childhealth Advocacy International (MCAI) describe a distance learning project to train obstetric clinicians in Liberia from the Highlands of Scotland.
An analysis by the World Health Organization (WHO) of the number of persons per doctor in countries around the world shows that Liberia has the worst figures: only one doctor for every 71,429 people in a population of 4.6 million. In contrast, the UK has one doctor for every 356 persons.
The multi-factorial reasons for the dearth of Liberian doctors include armed conflict; the 2014-2016 Ebola outbreak; and the exodus of doctors trained in Liberia who emigrate to richer countries, the private sector, and other organisations external to the public health system, such as the United Nations (UN) and non-governmental organizations present in the country.
Obstetrics where there are so many night calls is a particularly challenging specialty for a stretched healthcare workforce in Liberia. Due to the extreme lack of doctors there are inadequate safe standards of hospital maternity care. Work on the frontline can be grinding with many clinicians eventually leaving hospital work to find alternative jobs that better suit themselves and their families.
Four years ago, a partnership of the Ministry of Health of Liberia, WHO, UN Population Fund, the Liberian Board for Nursing and Midwifery and the international charity that we run (MCAI), agreed that the only way to achieve sufficient numbers of adequately trained health workers able to safely undertake advanced hospital obstetrics was to train senior midwives. This task-shifting meant training senior midwives as obstetric clinicians so that they can carry out abdominal surgery such as Caesarean section.
An immediate problem faced by the training program in Liberia was the shortage of obstetricians able to provide practical as well as classroom-based teaching. However, with support from a senior Liberian obstetrician, the first two trainees have now completed a three year course and are fully licensed by the Liberian Medical and Dental Council to practice as obstetric clinicians.
At the start of the project MCAI had intermittent support from two international volunteers to help with training. However, recruitment of international experts after the West African Ebola outbreak has become difficult and the shortage of experienced trainers is now critical. MCAI is currently training seven new midwives and two physician assistants in advanced obstetrics, including surgery, in three public hospitals. In addition to the ongoing full time support from a senior Liberian obstetrician, the project relies on Liberian generalist doctors who undertake all aspects of hospital work despite limited specialist training in advanced obstetrics.
With support from partners, MCAI has established a weekly, classroom-based, protected training day for the nine trainees that involves supervised reading and some limited face-to-face training undertaken by local clinicians. A most helpful initiative has been the development of an interactive, distance-learning, tutorial system that has enabled classroom-based training to be delivered by clinicians based in the UK. Remarkably, although Liberia is poor and has few doctors, the country does have widespread internet coverage with download and upload speeds that rival the internet performance achieved in the Highlands of Scotland where MCAI is based (Box 1).
Box 1: Technical details of the interactive, distance-learning tutorial system
– In Liberia a budget laptop capable of multimedia is used in each of the hospitals where a three-way headphone splitter is used to output the audio across separate headphones to a maximum of 3 trainees. A single USB microphone is shared by the trainees when they are speaking.
-The trainees’ laptops use mobile 4G capable routers (costing 25 USD per month) to access the internet. The average upload speed from connections in Liberia is 1.07 Mbps and download speed is 6.21 Mbps.
-In Highland Scotland, at the headquarters of MCAI, a multimedia laptop is used by the trainer who sets up meetings using online conferencing software.
-The upload speed from the internet at MCAI’s headquarters in Highland Scotland is only 0.4 Mbps/ second and the download speed 5Mbps/ second.
The project’s senior Liberian obstetrician is based at CB Dunbar Hospital in Bong County and is able to conduct tutorials in person but trainees based at the project’s other hospitals (CH Rennie Hospital in Kakata and Redemption Hospital in Monrovia) are attending two-hour weekly tutorials held using the distance learning system. Three trainees are present at each tutorial and there is a weekly plan for the subjects to be covered. At the beginning of each weekly training day, there is a one hour written examination covering the subjects taught the previous week. Once marked by the trainer in Scotland, the examinations are discussed during the next week’s online conference. Using screen sharing, the trainees can see their marked examination papers on their computer screen and the trainer in Scotland goes through the results with them.
The main advantage of online conferencing software is the ability for the trainees and trainer to share computer screens to read out written text and, using the trainer’s screen as a whiteboard, to work together in constructing written educational material for use and display in their labour and delivery wards. Despite the relatively poor quality internet in the Highlands of Scotland, videos on patients with relevant obstetric and neonatal disorders, as well as illustration of essential hospital-based procedures, such as Caesarean section, can be shared and viewed together by trainees and trainer. The videos are stopped and discussed whenever there are questions about what is happening or being recommended. Details of the eLibrary, which is updated every three months, used in this training can be accessed on the MCAI website: www.mcai.org.uk.
The online tutorials have resulted in valuable educational achievement, demonstrated by improving academic marks, and an increase in clinical competence, and confidence. But we have observed other benefits. One of the main problems with educating midwives in Liberia has been the relative lack of education in basic reading and writing undertaken during childhood due to the armed conflict and poverty the country has experienced. Reading aloud from the MCAI textbook (International Maternal and Child Health Care; a practical manual for hospitals worldwide), and other relevant documents, has meant that, in addition to their education in obstetrics the written and spoken English of the trainees has also improved.
We have found that online, interactive, distance-learning tutorials have improved the ability to provide essential education in advanced obstetrics for trainees in Liberia. In combination with apprenticeship based and direct face-to-face training, this educational technique is making a particularly valuable contribution to the achievement of safely skilled and knowledgeable obstetric clinicians. Given the paucity of both Liberian doctors and international volunteers willing to work in Liberia, efforts such as this are likely to be increasingly important in supplementing the training Liberia’s desperately needed future healthcare workers.
We are aware that others are using similar systems to help support doctors on the frontline in conflict zones, such as Syria, and we hope that sharing our experience might encourage others to take advantage of distance-based learning systems to help support health workers in great need, wherever they are in the world.
Professor David Southall, an expert in hospital paediatrics and medical obstetrics, is the founder and Honorary Medical Director of MCAI, an international medical charity based in the Scottish Highlands. Dr Rhona MacDonald is the Honorary Executive Director of MCAI.
Both declare no conflicts of interest
Featured Image Credit: United Nations Photo, Flickr