Sanneh and Sibbald visit the Gambia on global health rotation
Awa Sanneh, MD, assistant professor in the Division of Academic Specialists in Ob-Gyn, and UW Department of Ob-Gyn resident Carrie Sibbald, MD, PGY-4, recently visited the Gambia as part of Sibbald’s global health elective. Sibbald is the residency class of 2025 global health resident.
During the rotation, Sibbald worked with the Edward Francis Small Teaching Hospital’s Department of Ob-Gyn, participating in both inpatient and outpatient care. During her elective, Sibbald focused on teaching bedside ultrasound skills to junior trainees at the teaching hospital.
Dr. Sibbald shared personal reflections from her time in the Gambia:
Rotation at Edward Francis Small Teaching Hospital, Banjul, The Gambia
February 17-March 14, 2025
It’s easy to focus on the differences between practicing in a low resource area and the hospital in America where I grew accustomed to the vast support and systems that we have at our disposal. It’s easy to focus on the challenges, the lack of availability, the lack of personnel, faculty, and staff, and the stark differences in the cases, burdens, and outcomes seen at the hospital. Every day, with every experience, the differences are overwhelming, especially in the seemingly insurmountable challenges that the teams there face every day. On the surface, what’s most noticeable is what isn’t there. All paper charts, disorganized and excessively difficult to find any information in, lack of any IV pumps, a single ultrasound for the entire department, hand written orders for labs, imaging, and medications that had to be taken by the family to be paid for and performed at an outside facility and brought back, minimal prenatal care, limited preventative care, limited hospital bed space, electricity that can go out at a moment’s notice, even during surgery, few nurses, a single CTG machine for all antepartum and intrapartum patients, not even sheets or pillows for any of the beds. The list could go on for a long time.
I came into the rotation with only my own training, expecting to be able to use the quality education that I’ve received over the past 3.5 years to take care of patients, provide perspective, and teach where I could. This expectation wasn’t wrong, exactly, but it quickly became apparent that a large amount of what I learned and how I practiced in the United States had to be thrown out the window as the setting, more than just the resource challenges, dramatically affected the approach to care at the hospital. I was flabbergasted at how quickly and how often the providers jumped to cesarean section, for indications that I’ve never used myself in my own training, and how resistant they were to opting for induction of labor instead. After a couple weeks on the labor ward, it made sense. With 7 beds on the labor ward, widespread uncontrolled hypertensive disorders of pregnancy, oftentimes limited prenatal care, late term and post term pregnancies the norm, and virtually no access to CTG or any available staff to monitor it, induction of labor would be an incredibly risky endeavor for both the mother and the baby. It made sense that their criteria for induction, and especially for TOLAC, is very strict and more often than not they lean towards cesarean delivery instead.
The conservative approach pervaded all the patient care, with decisions to deliver earlier than we typically would in the US, prescribing only some of the tests so that patients could afford it, even only providing medical management of miscarriage under direct supervision in the hospital. Despite this, the outcomes were exceptionally poor. I estimate a third of the pregnancies that came to the hospital were IUFDs, with placental abruption, severe preeclampsia, and eclampsia all common. We had five deaths during my 4-week rotation, more than I have had in four years at UW, and more fetal deaths than I could count. Every death presented to the hospital too late to be able to do anything about it, indicating the drastic need for systemic improvements to earlier access to care.
Despite the challenges, frustrations, and sad outcomes, the people I had the privilege of working with were incredible. The term the “Smiling Coast of Africa” is well named, and everyone was exceptionally kind wherever I went. The teams were amazing to work with and were eager to accept and incorporate me, and I was impressed by the knowledge level of the medical students and senior residents. They truly do remarkable medicine for the situation and resources that they are given, and I learned so much in providing flexible and innovative medicine pivoted to the circumstances of each patient. My short 4 weeks forever changed my perspectives of ob/gyn and approach to caring for patients, particularly regarding consideration of external contexts.