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Postgraduate Public Health Personal Statement

Like many medical students, I was unsure of which specialty I would venture into after medical school. I had very broad clinical interests. Majoring in public health was not one of my choices until I moved to Kilifi District hospital after an extensive one year internship period at the regional hospital (Coast Provincial General Hospital).

My practical experience at the district hospital taught me first hand the necessity of public health. In the monthly maternal mortality meetings conducted in the hospital, we realized the bulk of the maternal deaths were mainly attributed to delays in seeking medical care in relation to the onset of the presenting complains .A small percentage was due to delays at the facilities in provision of emergency care.

Kilifi district is unique, aside being one of the poorest district in the Kenya with high illiteracy level, it's endowed with the deep rooted social cultural belief of massage (external cephalic version) , a crude way to align the baby which in most cases resulted in silent rupture of the uterus ,use of herbal therapy to augment labour and tendency to deliver at home with assistance from traditional birth attendants whom are not prepared to handle obstetric emergency.it;s maternal mortality as per the recent Kenya demographic survey was 440/1000,000 compared to the country maternal mortality of 414/100,000 .sadly many causes are preventable.

Danida, a Danish organization working in the district was very much troubled by the high maternal mortality. The organization decided to put up radio calls in the remote facilities and the district hospital to assist in improving the referral system and minimize delays. in addition, they renovated the old maternity block which later became the maternal shelter after putting up a modern maternity wing in the district hospital. The maternal shelter was to house high risk women and those pregnant women coming from far to reach areas who were willing to stay near the hospital awaiting delivery at no fee. Despite the above intervention, the maternal deaths in the hospital were still frightening.

During one of my calls, I saw a 26 year old Para 3+0 at term, with one living child. She had two previous caesarian sections done secondary to a borderline pelvis. Her current presenting complaint was vaginal bleeding, abdominal pain and history of massage by the traditional birth attendant in an effort to relieve the pain and aligning the baby.

On examination, I found the patient to be in shock. Examination of the abdomen revealed palpable fetal parts. I made a clinical diagnosis of a ruptured uterus. She was rushed into the operation room where I found that she had ruptured both her uterus and bladder. The baby was alive, but gasping. I performed a subtotal hysterectomy and repair of the bladder. The mother did well post operatively and she was discharged home with her daughter.

The case was extreme but not unique. This experience gave me a desire to work beyond the hospital and address the underlying issues of the maternal deaths at a community level. My colleagues and I developed a proposal to evaluate reasons for the low utilization of a maternal shelter, which was put up to house 'high risk mothers' from out-lying areas. Its utilization prior to the study was at 25%.

The survey was conducted in all the facilities in Kilifi district. the study population comprised of health workers who were directly involved in attending to pregnant women, Antenatal mothers visiting health facilities in the district and in-depth interview to mothers who had previously used the maternal waiting home .the survey was to help us understand the knowledge, practice and attitude of health workers on maternal waiting home. while for the pregnant women, was to get their views as to whether they perceived pregnancy and delivery as a risk. And also their knowledge of the maternal shelter.

Our study came up with a set of recommendations which included extensive community mobilization, improving male involvement, setting up a clear referral networks and feedback system and introduction of skills training to retired /unemployed midwives .these were taken very positively by the hospital and stakeholders. We have now seen not only an increase in the utilization of the structure but also a reduction in the maternal mortality. I realized that the issue was not affecting Kilifi district alone but the whole province at large.

Like many developing countries, Kenya is mainly focusing on curative health and partly neglecting the much more important arm of promotive and preventive health. I join a non governmental organization to be able to work more with the community in strengthening the linkages and referral system between the community and the health facilities, training both health staffs and domiciliary midwives at the community on safe motherhood.

On community facility linkage, I support forums where community elders meet with health facility staffs and discuss how best they can assist each other on advocating for safe deliveries by qualified skilled attendants, empowering an d training community health workers on key messages related to maternal and child health, HIV and AIDS ,environmental and sanitation and linking them to health facilities to improve referral network.

For the health facilities, we have supported the facilities to cope up with the raising demand of services from the community to be able to provide quality care through training on various interventional areas ranging from emergency obstetric care, focused antennal care post partum care and child health, family planning, HIV and AIDS and attitude change. We have also been able to support procurements of equipments for facilities.

I'm proud to have been part of the team that helped to improve the linkages between the facility and community in coast province through empowerment of the community and setting up a clear referral network. I'm confident the next demographic survey will give us promising results as far as the maternal mortality is concerned.

I'm certain that the knowledge and skills learnt in your prestigious public health school will prepare me to work best with the community and subsequently create a sustainable link between the community and the health facilities. I thus believe that with this training I shall be able to focus more on this important arm and help avert preventable health issues.

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This personal statement was written by mbarak20! for application in 2009.

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