Global Women's Health Team Provides Insight on the Year of 2020

What a year it has been! The year of 2020 was like no other that any of us have ever experienced, either professionally - in particular in the practice of clinical medicine - or in any capacity. The word “unprecedented” sounds trite by now and yet there is little other way to express the changes in professional and personal existence that we have all had to become accustomed to as we experience the global COVID-19 pandemic. 

Nowhere has this proven more profound than in the arena of Global Health, in the realm of our co-leadership in the AMPATH Reproductive Health collaboration in Eldoret, Kenya. For the first time in over a decade of daily in-person reproductive health collaboration, we were required to pull out our long-term North American faculty amidst a general return of all North American faculty in the entire program - the first time that this was required in the more than 30 year history of AMPATH.

And yet the other catchword of the past year has been “resilience” and, again, our commitment to our Global Health programs as a cornerstone of our department’s mission remains unwavering. 

The articles that follow indicate how our commitment to the Kenyan population and the tripartite AMPATH mission of clinical care, research and education have pivoted, persisted and thrived despite the pandemic. 

Our local and Kenyan fellowship programs continue to educate future generations of women’s health specialists and subspecialists, adapting to using virtual technology for teaching and examination. 

Our local Toronto trainees have excelled with advocacy initiatives to support the most vulnerable in our own communities with innovative advocacy programming, bridging across students, residents and faculty for support and implementation. 

Educational rounds and novel teaching opportunities have been developed to continue to share educational opportunities between North America and Kenya and our long experience with Zoom meetings and videoconference rounds in Maternal-Fetal Medicine have served us well as they become routine in so many more areas of practice and collaboration. 

Our journal clubs have examined the impact of the pandemic on Women’s Health and vulnerable populations, contraception access and intimate partner violence and we look to describe the impact of the pandemic on our Kenyan patients and programs. 

Our awards have continued to recognize the selfless contributions of our faculty and trainees – this year honouring Dr. Nan Okun and Dr. Rebecca Zur. 

Dr. Marie Buitendyk, our senior Global Health and Equity and Maternal-Fetal Medicine fellow completed her experience as Team Leader in person in March 2020, contributing in particular to all areas of reproductive clinical care and with research and teaching centred around prenatal diagnosis and management of such conditions and the diagnosis and management of pre-eclampsia in the setting to provide best outcomes for at-risk mothers and babies. 

Our advocacy and global health track record and ongoing commitments are a source of great pride for us all. As I write this, vaccination programs are rolling out for clinical care providers across Canada and the United States, and long-term clinical faculty have started to return to Eldoret. We anticipate the return of a Team Leader to function locally in the day-to-day clinical work alongside our Kenyan colleagues and anticipate American trainees returning for rotations in Eldoret in the near future, with in-person Canadian trainees and Kenyan electives to Canada still a little further off. We look forward to the day that we can once again travel easily between our countries. Without a doubt, our newfound confidence in the work that can continue remotely will add to our abilities and strengths in international collaboration. 

I wish all of you reading and supporting our work health and happiness in this new year 2021 and may we all be able to return to a personal and professional life of togetherness. We hope that you enjoy reading the stories of our remarkable colleagues and look forward to providing updates on our programs as we move forward in the coming year. 

Dr. Rachel Spitzer 
Director, Global Health and Advocacy 
Department of Obstetrics and Gynaecology 
University of Toronto

Contents

• Canadian/Kenyan Team Collaborates on Qualitative Projects
• Global Education Continues During the COVID-19 Pandemic
• Adapting to COVID-19 as a Global Health Resident
• A personal reflection on the COVID-19 pandemic in a national referral hospital in Kenya
• The COVID-19 Pandemic: How the Moi University Maternal Fetal Medicine (MFM) Adapted to Remain Relevant

Global Women's Health Updates

Canadian/Kenyan Team Collaborates on Qualitative Projects

For the past six months, a team of Kenyan and Canadian AMPATH staff and students have been working together on qualitative analyses for two reproductive health research projects. 

Caroline Jepkemboi Kerich and Omukagah Christabell Okaronon are Research Coordinators at MNCH AMPATH in Eldoret. Mia Kibel is a University of Toronto medical student, who joined the AMPATH MNCH team as a summer student. Caroline, Christabell and Mia have been working together on qualitative analyses for two reproductive health research projects at AMPATH/University of Toronto, under the guidance of investigators Dr. Caitlin Bernard, Dr. Astrid Christoffersen-Deb, Dr. Violet Naanyu, Dr. Rachel Spitzer, Dr. Julie Thorne and Dr. Faith Yego. 

In the process of working on these projects, learning and mentorship have flowed all directions, with each team member bringing different knowledge and expertise to the table. At Zoom meetings at least twice a month since June, Mia has been teaching Caroline and Christabell about qualitative research methods, and Christabell and Caroline have been teaching Mia about study design, implementation and putting the study data into context. The team of three brought their work to the larger group of investigators for help and feedback. With ample guidance, they’ve developed strategies for qualitative coding and are figuring out the stories that are in the data. 

Caroline, Christabell and Mia have had the privilege of teaching and being taught in turn as they work on their projects. They’ve had a number of wonderful experiences together as a team, including fun photos on Zoom (think cakes and babies); learning how to code across continents; and laughing at Mia before she’s had coffee, as well as many of the same challenges everyone has had trying to do normal work in this sad, strange year. In figuring out new ways to work together, the team has pushed themselves to learn things they would not have otherwise, take leadership, and hopefully helped to produce meaningful research to support reproductive health. Stay tuned. 

Caroline Jepkemboi Kerich 
Research Coordinator, MNCH AMPATH 
Eldoret, Kenya 

Omukagah Christabell Okaronon 
Research Coordinator, MNCH AMPATH 
Eldoret, Kenya 

Mia Kibel 
Medical student, MNCH AMPATH 
University of Toronto

Global Education Continues During the COVID-19 Pandemic

It’s hard to believe that nearly a year has passed since those of us on the ground in Kenya landed back in North America. In a matter of days, talk of the coronavirus mushroomed from a distant, nebulous idea to a stark and sometimes scary reality. With little warning, no time for preparations or proper farewells, we said goodbye to our Kenyan family and said hello to mandatory quarantine, masked faces and our socially distant new life back home. 

For many of us, our hearts and minds are still in Kenya. We continue to reach out to our colleagues and friends and, as the dust begins to settle, try to create a new “normal” from halfway around the world. 

Just as it was a priority for the Team Leaders while in Eldoret, teaching and education have remained central to our role from abroad. In the Department of Reproductive Health, fellowship activities in Maternal-Fetal Medicine (MFM) and Gynecologic Oncology have continued. Despite the restrictions placed on elective surgery and the rapidly declining patient load on the antenatal and postnatal wards, we have persevered in our educational activities. 

In MFM, we have continued our weekly case discussions (without skipping a beat!) and welcomed two new fellows to the program in May. We have implemented an online platform to allow sharing of all fetal ultrasound images from the antenatal ward at MTRH with the team at Sinai. This has contributed substantially to the depth of our discussions and collaboration with the MFM division in Toronto. 

The Kenyan fellows have joined me in twice weekly departmental rounds hosted virtually by the University of Toronto and have also been invited to participate in our weekly Monday morning Fetal Chart review rounds. Our lively discussions bring a smile to my face and make me feel like I’m back on the wards of Riley Mother Baby. We are still a team! 

In collaboration with IU, the University of Toronto and MTRH, we have initiated formal virtual teaching sessions for the Kenyan registrars now that they have been called back to Eldoret. Informally, I have been in contact with many of them; sharing kind words, discussing difficult cases and creating online repositories of learning materials. Similarly, I have created an online Reproductive Global Health curriculum for those North American medical students and residents who were called home early, or will not have the opportunity to visit Eldoret as scheduled in the upcoming academic year. I certainly hope that it provides some baseline knowledge in lieu of clinical exposure. 

I think it goes without saying that we are all looking forward to the day we are back in Eldoret. But in the meantime, let’s continue to make the most of this unprecedented challenge. Many of the skills we are creating, learning, adapting and implementing will continue to strengthen our relationships within AMPATH long after COVID-19 has become a distant memory. 

Dr. Marie Buitendyk 
RH Team Leader 2019-2020
University of Toronto

Adapting to COVID-19 as a Global Health Resident

I was a very happy senior resident in January 2020 when our schedule for the special rotations was shared. This is usually a milestone that marks the beginning of the end of the Master’s program in Reproductive Health in Moi University. It meant that if all went well in 2020, my colleagues and I were going to sit our final examination in March 2021, according to the Head of Department. We were all excited. Being a final year resident in Reproductive Health, a wife, a mother and an employee of Nakuru County Government, I was looking forward to going back to what I considered normal: back to Nakuru county - now as a consultant; reuniting with my family and giving back to the society as I offer my specialist services in the County Hospital. 

Our excitement was however short lived as Kenya recorded her first COVID-19 case on 12th March 2020. This sent shockwaves far and wide; with panic and a lot of uncertainty on what was going to happen next. This was made worse by the news on how developed counties like Spain were being ravaged by the pandemic and the then horrific death toll that was being reported in Italy. We were all thrown into this milieu of uncertainty given the limited healthcare infrastructure in our country. 

When COVID-19 struck in Kenya, all clocks had to be reset. With the Moi University closed, just like was all schools and colleges in the country; and a myriad of COVID-19 mitigation measures that were introduced, all spheres of life had to be readjusted. We had to adapt to the situation as it unfolded. All postgraduate residents in Moi University were redeployed to their employers, Nakuru county in my case in order to provide the crucial human resource support in the health facilities during the pandemic, until such a time when the school of medicine was reopened. 

Academics

The shift to social media for real time information and Internet-based learning was instantaneous. The use of applications like Zoom and Google Meet drastically increased. There were global webinars, regional as well as local on various issues that were emerging around COVID-19. The links were shared via social media platforms like WhatsApp. I logged into as many webinars as time would allow me for learning, updates on COVID-19, as well as sharing experiences with colleagues, learning best practices from various facilities and learning from other peoples’ experiences. 

This continued until July 2020, when the University rolled our web-based learning; a point at which we restarted the courses, albeit online. We still continued working in the respective hospitals in various counties until such a time when the school was to reopen for resumption of clinical rotations. This was challenging because sometimes a scheduled online session coincided with theatre cases in the facility and I would be forced to miss some theory sessions when busy operating in theatre. However, the online sessions provided hope to eventual reopening of schools with resumption of the academic calendar. 

Even with the eventual reopening of the school for postgraduate students in September 2020 with resumption of clinical rotations, the theory sessions have continued online. 

During the clinical sessions, the distance from the patient cannot be maintained as examination in obstetrics is intimate, like pelvic examination. The measures that I have learnt to take religiously is hand hygiene, use of face masks and use of face shields in the labor and delivery unit.

We are taking clinical rotations in pairs and, at most, in threes hence the number of people in an area at any given time is less than would have otherwise been. I am conscious of my environment and surface cleanliness, more than I was before COVID-19 struck. With the thought of having to decontaminate and disinfect; without discoloring my clothes, I stocked on white scrubs for work. Just like most of my colleagues, I don scrubs to work and from work, and decontaminate them daily with chlorine bleach. As of shoes for the workplace, in this COVID-19 era, white Crocs and white leather shoes do it for me, as they easily decontaminate in chlorine bleach. Or, maybe, am I developing obsessive compulsive disorder? 

Social and Spiritual Life 

Having a young one is always a joyous experience. The hugs when coming home from a hard day’s work usually make all the fatigue melt away. Now, is there a term known as “delayed hugging”? With COVID-19, I had to painfully teach the young one that from work, Mommy must take a shower before hugging. Initially, it was heartbreaking to watch the young one run towards me only to remind him that hugs will only happen after Mommy is changed. His young mind had to learn quickly that no kisses, no hugs and no handshakes. 

Having seen my colleagues suffer from COVID-19, some asymptomatic, mild disease or severe disease needing ICU care and some passed on, at various ages always gave me the chills. The thought that it can easily be me. I hug my son every day in the morning before leaving for work, knowing that they may be the last hugs I give him. That is the new, sad reality that I have had to accept. 

My class loved fun and food! We held gatherings and eat outs at least every fortnight. With COVID-19, we engage in more of video calls and phone calls, as we have not had a class gathering since resumption of studies. 

Church-going was a common activity I attended, as well as church fellowships. Since COVID-19 struck, thanks to online masses, I have attended all masses online to minimize interaction. 

As the scourge rages on with no end in sight, it is just a matter of living one day at a time, hoping for the best and preparing for the worst. Sticking to this new dogma has been my only option, as much as attending one social event may be enough to expose me, hence lead to exposure of numerous other people (at my workplace and in my family), whose interaction is not avoidable. 

With the schools fully reopening this January 2021; the high patient volumes, amalgamated with the opening up of the economy and loosening on the adherence of COVID-19 mitigation measures; it is just a matter of time that we will get to realize the full scale of this pandemic and how it eventually ends. From my point of view, infection rates are likely to worsen. It’s just a matter of time, hoping that we shall all emerge from this pandemic alive! 

Dr. Wawuda E. Righa 
Postgraduate Resident, Reproductive Health Finalist 
Moi University 
Eldoret, Kenya

A personal reflection on the COVID-19 pandemic in a national referral hospital in Kenya

The outbreak of the COVID-19 pandemic in late December 2019 in Wuhan, Hubei Province, China (Zu et al, 2020), and its unprecedented spread to different parts of the world, including Kenya, has caused an unprecedented change in lifestyle. In Kenya, the first case of COVID-19 was diagnosed on March 13th, 2020 and, so far, the country has seen 100,675 infections and 1,753 deaths (1.74% Case Fatality Rate).

At an institutional level, both Moi University (MU) and Moi Teaching and Referral Hospital (MTRH) have faced significant challenges in their effort to led the fight against COVID-19, and to continue offering care, teaching and training. Despite the country having a relatively low mortality rate, COVID-19 has significantly affected the two institutions, not the least of which involved significant staff anxiety/stress, staff infections, and even deaths. Among the COVID-19 deaths is a senior surgeon and specialist plastic surgeon.

Concerning reproductive health women and children have, for the most part, bore the brunt of the COVID-19 infection. Restrictions in movement and curfews have limited access to health services for this particularly vulnerable group. There has even been documented evidence of an increase in gender and sexual-based violence.

Throughout the COVID-19 pandemic period, there was an initial decline in patients seeking delivery services, mostly due to fear of contracting COVID-19 while in hospital. This was worsened by the strict screening measure put in place and without a clear alternative for accessing emergency care most women opted to deliver at home. It is theorized that during this time there has been an increase in maternal morbidity and mortality attributed to home deliveries in a setting with already high numbers of home deliveries (nationally at 60%) and high maternal mortality.

The above interruption in service only expresses effects on maternal and child health. Other reproductive health services e.g., contraception, cancer screening, and child immunizations services. have been significantly affected and their effects have not been adequately quantified and will likely last for a long time.

On a positive note, COVID-19 has enabled institutions to put in place various isolation facilities to contain current and future pandemics, and it has also enabled facilities to increase their ICU and critical care facilities. With an emphasis placed on handwashing, mask wearing, social distancing, and children being at home, at first glance seems like we have also had a reduction in cases of childhood diarrhea and pneumonia.

Dr. Kosgei Wycliffe
Consultant Obstetrician and Gynaecologist
Director, Reproductive Health
Moi Teaching and Referral Hospital
Eldoret, Kenya

The COVID-19 Pandemic: How the Moi University Maternal Fetal Medicine (MFM) Adapted to Remain Relevant

The impact of the COVID-19 pandemic on the Moi MFM program is not only an emerging issue in the region and the world, but one that will ultimately affect the implementation of the program and patient care. To allow a semblance of normalcy, various infection prevention measures were instituted – wearing of face masks, handwashing and social distance measures were made mandatory at the hospital. 

Initially when COVID-19 cases were reported in our country, changes to our daily life and practice schedules were affected. Clinic bookings were rescheduled and the number of patients per clinic reduced. Relatives were denied access to hospital. Birth companions were allowed, but had to follow strict infection prevention measures like handwashing and wearing of face masks at all times while in the hospital. In the MFM ultrasound room, clients were required to wear surgical face masks, something that never used to happen. Queueing outside the MFM ultrasound room was also banned to improve social distancing. 

Delays in seeking care, extended bookings and fear of contracting the virus in the hospital, led to late presentation for those seeking care in the hospital. When the COVID-19 outbreak was declared a pandemic, travel restrictions led to partner faculty not travelling internationally to support our teaching and learning. An exam that was scheduled for March 2020 was rescheduled to July 2021 and was virtually supervised due to COVID-19. It was an innovative way of exam supervision during these difficult time. 

Most learning activities are now virtual. Courtesy of COVID-19, we have been able to attend international conferences virtually like the ISUOG 2020 international conference in Scotland, an activity that could otherwise may have been difficult to attend physically were not for COVID-19. We do weekly case discussion and join fetal and maternal rounds virtually. All other learning activities are equally virtual. 

The emotional impact, anxiety and fears related to the virus could lead to increased mental and psychological conditions in patients, care supporters and staff alike. A series of virtual meetings on mental health were organized to increase awareness and offer linkage to care for those affected in one way or another. 

Despite the negative impact being caused by the COVID-19 virus, the program remains determined to meet stipulated objectives while observing all the safety measures to keep staff, patients and the general population safe. 

Dr. Bett Kipchumba and Dr. Pallavi Mishra 
MFM Fellows 
Moi University
Eldoret, Kenya

As with other facets of the AMPATH program, the MFM fellowship has been dealt significant challenges and some unexpected opportunities.

As Dr. Bett and Dr. Pallavi have discussed above, the unexpected opportunities came with the huge increase in virtual learning opportunities. These included access to four times weekly rounds in both fetal and maternal medicine with the University of Toronto's MFM fellows, as well as cheaper and high-quality access to international conferences on medical and fetal high-risk pregnancies. The Moi fellows are learning alongside their colleagues internationally, not only having access to state-of-the-art new information, but opportunities to connect and become aware of international authorities on specific topics. We have had such fun attending these international conferences “together”; chatting in real time by WhatsApp as the meetings progress.

I am exceptionally proud of and impressed by the dedication of our Moi MFM fellows to the education at all hours of the days and weekends. Hopefully we will be able to complement the first cohort of graduating fellows with a rotation at the University of Toronto for fetal therapy. There will be no stopping this initiative with these dedicated fellows!

Dr. Nan Okun
Professor
Department of Obstetrics and Gynaecology
University of Toronto

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