Mongolia is a sparsely populated landlocked country located in Asia. It is bordered by China in the south and Russia in the north. With a population of 2.6 million, the traditional lifestyle is nomadic. In recent decades, there has been greater urbanization and currently about 50% of the population lives in urban or semi-urban areas.
The climate is harsh with sub-zero temperatures for much of the year and high temperatures in the summer. The Gobi desert is to the south and grassy steppes cover much of the remainder of the country. In the north, there are rugged mountain areas with some impressive lakes that provide spectacular scenery.
Healthcare is provided under the Soviet-styled Semashko system. This enabled delivery of basic healthcare to even the remotest population groups. Unfortunately, there is a large degree of redundancy in the system with many hospitals that are in various states of repair that are frequently ill equipped and poorly staffed; or staffed by doctors and nurses with limited training. Training has improved over the years. With the advent of democracy, medical providers have been able to visit other countries and have had visits by international teams to educate and equip the staff and hospitals respectively.
Maternity care in Mongolia is delivered by primary health care providers in the 21 aimag hospitals (an aimag is an administrative division of Mongolia) and clinics around the country. The referral centres and specialists are based in the cities. In the capital city, Ulaanbaatar, there are four main maternity hospitals, with a combined annual delivery rate of 25,667 in 2008.
Kybele was approached in 2008 with a request from one of the major maternity centres (First Maternity Hospital) to visit and address some of the educational needs of the providers of obstetric care. The hosts identified the provision of safe labour analgesia (either via spinal or epidural analgesia), the management of pre-eclampsia and post partum haemorrhage and the care of women with sepsis and co-existing medical disease as major areas of need. They were also very keen to learn more about laparoscopic surgery. The neonatologists were keen to gain guidance on the management of sepsis, meconium aspiration and respiratory care of the newborn. We were asked by our hosts to assemble a multi-disciplinary team to visit the four large maternity hospitals in Ulaanbaatar.
Our team of 10 arrived for our nine-day visit on the 12th of June 2009. It consisted of two obstetricians and gynaecologists; Dr Stephen Cole and Dr Kym Jansen (both from Melbourne, Australia), two neonatologists; Assistant Professor Cyril Engmann and Dr Ross Vaughan (both from North Carolina), and 6 anaesthetists; Dr Phil Morgan (paediatric anaesthetist), Dr Margaret Sedensky, Assistant Professor Jo Davies (all from Seattle), Dr Maggie Wong, Dr Daniel Jolley and Dr Amanda Baric (all from Melbourne). Our visit coincided with a seminar on airway management for the Mongolian Society of Anaesthetists that was being run by Dr David Pescod, an anaesthetist from Melbourne, who has made a significant contribution to anaesthesia training in Mongolia since 2000. Three of our anaesthetists (Dr Maggie Wong, Dr Daniel Jolley and Dr Phil Morgan) were able to help him run practical skills workshops and lectures at his seminar. Many of the Mongolian doctors from the rural Aimag hospitals were at this seminar and spent time learning at the obstetric hospitals from our team when their seminar had finished. They also attended our obstetric seminar, which was held on Saturday after our hospital placements had finished. In this way, our group was able to facilitate the obstetric anaesthesia education of the rural doctors as well as the city doctors.
Our team visited four hospitals; the Maternal and Child Health Research Center (MCHRC), First Maternity Hospital, Second Maternity Hospital and Third Maternity Hospital. Our hosts were lead by Dr Lkhagvasuren Bat-Erdene from MCHRC who was instrumental in organizing our temporary licenses and gathering information and requests from each of the participating hospitals, as well as with the running of our one-day educational seminar on obstetrics, anaesthesia and neonatology and on our final day. She helped us with the running of the orientation half-day for the group and with a visit to the countryside where we saw an Aimag and a Sum hospital and were able to visit a traditional nomadic family.
Our hospital visits began on Monday and each team was asked to make observations and gain an understanding of the way obstetric care is delivered in Ulaanbaatar for half a day before the commencement of teaching. The hosts were very keen for us to teach and show them what we knew. In spite of the language barrier, we were able to make a start on our teaching objectives.
Maternal and perinatal mortality has decreased steadily over the past 10 years in Mongolia and obstetric services are well organized. There is a clear division of responsibilities between primary, secondary and tertiary hospitals and the quality of surgeons is very high. There is quite a division of services between the primary care physicians and the obstetric hospital doctors, with most antenatal care being provided by the primary care doctors and the delivery being managed by the maternity hospitals. The patients carry their own histories, but are often not seen by the delivering obstetric team until they present (up to one week) before delivery. This has implications for the provision of good quality antenatal care and continuity of care at the hospitals. At the Second and Third Maternity Hospitals, there is a quality and safety officer who is an obstetrician and has some responsibility for organizing ongoing education of doctors.
There are some issues with the availability of drugs and equipment at many of the hospitals and not all of the hospitals necessarily have the same supply problems. There is also a disparity in the way patients are cared for and the level of care available between the hospitals, with little exchange of knowledge between the doctors from different hospitals. Many practitioners will be employed at the same hospital for much of their working life.
The First Maternity Hospital doctors were very keen to establish a laparoscopic surgery service. One of their obstetrician and gynaecologists had spent time abroad learning the technique and was ready to embark on laparoscopic surgery. Dr Kym Jansen helped her perform surgery and our anaesthetists provided general anaesthesia whist Kym and Dr Unuruu performed the first laparoscopic operation at First Maternity Hospital. It was reported on the evening news and Dr Unuruu has now been granted operating rights for laparoscopic surgery. This is a major step forward, as many obstetricians still do open procedures for ectopic pregnancies and ovarian masses. We identified a need to teach the Mongolian anaesthetists how to perform a general anaesthetic for laparoscopy, as up until now, only spinal anaesthesia has been used and the type of surgery offered has been restricted to diagnostic procedures.
First Maternity is a centre that performs over 9,500 deliveries per year. Currently, only spinal analgesia is offered for labour analgesia in women who have reached 4 cm dilatation. The team identified improvement in the use of foetal and maternal monitoring as an area for further education. The anaesthetists were also keen to set up an epidural service. Margaret and Maggie demonstrated the technique of epidural analgesia and supervised the anaesthetists performing general anaesthesia for laparoscopy. One satisfied patient was featured on Mongolian television, with Dr. Sabuu speaking to reporters while Dr. Sedensky tended to the patient. In the afternoons, the team delivered lectures on a variety of subjects, including monitoring the foetal heart rate and haemorrhage.
At the Maternal and Child Health Research Center, we had Jo Davies demonstrate how she provides epidural analgesia for labour. Dr Engmann and Dr Morgan spent time with the neonatologists and paediatric anaesthetists managing sick babies in their intensive care unit.
Amanda spent the week at Third Maternity Hospital, teaching safe general anaesthesia, including equipment checking and assembly of a difficult intubation “kit”, practicing intubation, laryngeal mask insertion, the use of a bougie and a Fastrach LMA on a manikin. The doctors were already very proficient in spinal anaesthesia (as in all of the hospitals we visited), but they were keen to use spinal and epidural anaesthesia for labour. We spent time doing both in labour ward and discussed indications and contraindications as well as monitoring of both mother and baby after regional for labour analgesia. We also spent time on clinical rounds of sick ante and postnatal patients giving us the opportunity to discuss the management of PPH and PE in the clinical context.
Every afternoon, time was allocated by the Quality and Safety Officer to allow us to give informal lectures and question and answer sessions. We covered pre-eclampsia, maternal cardiac disease (by Maggie), neonatal resuscitation (by Ross) and Steve gave instructions on how to perform a vacuum assisted delivery and spoke about the team approach to the management of post partum haemorrhage.
Daniel spent most of the week at the Second Maternity Hospital and later in the week, Cyril and Steve were able to join him. Dr Bayanaa, the head obstetrician, is the secretary of the Mongolian Society of Obstetricians and Gynaecologists and she was very keen to explore the potential for future teaching for the Mongolian obstetricians and the obstetric trainees. She introduced Steve to the president of their society and there appears to be support for future structured educational visits for the obstetricians.
Although many parts of this trip were very much a ‘site visit’ there were multiple opportunities for teaching. The immediate feedback from the hosts has been positive and all centres are very keen for a repeat visit. The team worked very well together and is keen to repeat the experience in a more structured program. We are keen to focus on two of the centres and concentrate our efforts on the obstetricians initially, with particular focus on PPH, PE, laparosocpy and teamwork in crisis situations. It is not clear what the future direction will be for the neonatologists, but the anaesthetists are currently undergoing a major revision of their training program thanks to the efforts of the Mongolian Society of Anaesthetists and Dr David Pescod’s team from the Australian Society of Anaesthetists. We look forward to future visits to Mongolia. |
