Aruna Kamath, MD
Aruna Kamath, MD
Anesthesiology · Seattle, WA

Safer Anesthesia from Education (SAFE) Somaliland

May 8th
Hargeisa, Somaliland

Project Description

I plan to teach the SAFE Obstetrics and Pediatrics, which is a 5-day intensive course, to local anesthetist providers in Somaliland. The goal is to provide high-yield content and life-saving skills in obstetric and pediatric anesthesia (i.e. critical airway management; maternal and neonatal resuscitation; management of cardiac, neurologic, trauma, septic conditions; pain control necessary for surgery) where there is high maternal and child surgical mortality, compounded by a shortage of providers with limited training. Course format involves interactive lectures, small group discussions, hands-on workshops, and a pre-post assessment of knowledge/skill retention and provider satisfaction.

Population Served

Somaliland has one of the highest maternal and child mortality rates in the world (UNICEF 2014, Lundeby 2020). As a region of roughly 5 million people, Somaliland has no physician anesthetists, 32 non-physician anesthesia providers, and 14 providers without formal training. We plan to teach this SAFE course to 34 of these 46 anesthetist providers who serve obstetric and pediatric patients in district and regional hospitals of Hargeisa city, Borama, Gabilay, Wajaale, Berbera, Burao, Cerigabo, and Ias’anood. (The remaining providers must remain on clinical duty).

Expected Impact

SAFE course aims to enhance anesthesia provider knowledge and skills, which may improve the delivery of quality care and reduce perioperative complications and mortality for women and children in Somaliland. Since 2014, SAFE course has been implemented in several low-resource countries (i.e. Bangladesh, Bolivia, Columbia, Congo, Ethiopia, Kenya, Madagascar, Malawi, Mozambique, Sierra Leone, Swaziland, Uganda, and Zambia), with evaluations showing the benefit of this program (Moore 2020, Boyd 2019, White 2019, Livingston 2014). SAFE course will be taught for the first time in Somaliland during this educational trip. We hope to strengthen the local anesthesia workforce, with subsequent progress towards better patient care outcomes for this region.

SAFE is a well-regarded educational program developed by World Federation Society of Anesthesiologists (WFSA) and Association of Anaesthetists of Great Britain and Ireland (AAGBI), in partnership with Edna Adan University (EAU) Hospital in Hargeisa, Somaliland. EAU is the primary training site and referral hospital for obstetric and pediatric care in the region. Mubarak Mohamed is Head of Anesthesia at EAU and local coordinator for this trip. The SAFE program is supported by the Somaliland Society of Anesthesia (nurse anesthetists society). No physician anesthesiology society exists in Somaliland.

A 1-day training of trainer (ToT) session for 6 anesthesia providers, will immediately follow the 5-day SAFE course to build local capacity in teaching future refresher sessions and promote sustainability with continuing education after the course is complete.

Trip Photos & Recap

Recently in May, I had the opportunity, thanks to the Dox Foundation, to engage in an educational trip. As an instructor/facilitator, I taught the SAFE (Safer Anesthesia from Education) Pediatrics and Obstetrics course in Hargeisa, Somaliland at Edna Adan Hospital. This was my first time traveling to Somaliland. Somaliland has one of the highest maternal and child mortality rates in the world. An important need in the specialty of anesthesia for the country of Somaliland is the workforce shortage crisis and educational development of existing anesthetist providers. Only forty non-physician anesthesia providers (NPAPs) exist and serve a population of five million people. Investing in education through SAFE courses, works towards gaining the knowledge and confidence of the current anesthetists to provide safer surgical care for their patients and ultimately reduce maternal and child mortality.

This was the first time SAFE courses have been taught in Somaliland. SAFE Pediatrics and Obstetrics, developed by the World Federation of Society of Anesthesiologists (WFSA), is a 6-day intensive refresher course given to the local anesthetist providers. The aim of the course is to cover high-yield topics and life-saving skills that are critical to improving quality anesthesia care and reducing perioperative complications. The instructor team consisted of eleven of us from the United States, United Kingdom, and Chile. We taught thirty of the local NPAPs who deliver care across the country and traveled to the city of Hargeisa to attend this course. Topics for this refresher course included critical airway management; maternal and neonatal resuscitation; management of neurologic, trauma, septic, and cardiac conditions; pain control; and effective communication skills for the perioperative work environment. Course format allowed for small group learning, interactive hands-on workshops, simulations, and lectures. The last day of the course was dedicated to “Train the Trainee”, in which 5 selected trainees were taught on effective teaching for adult learners, teamwork, and leadership skills, in preparation for longitudinal efforts of future rounds of SAFE course in Somaliland. “Train the Trainee” allows for continuing education after the course is complete, and work towards a sustainable, locally led initiative. A pre-post assessment of knowledge/skill retention and provider satisfaction was also conducted.

Given that SAFE course is a well-established initiative through the WFSA and has been taught previously in several low-resource country settings since 2014, there were no major needs that were surprising to us before traveling there. We were fortunate to have a strong partnership with the head of the hospital and lead NPAP, along with excellent organization by our experienced trip leaders before arrival. Collaboration and preparation began in 2019, and due to the pandemic, benefited from an extended time of preparation and local needs assessment.

The most memorable part of this trip was the academic and personal exchange between learners and facilitators. We, as teachers, learned so much from our trainees! I believe the small group discussion and interactive format, as well as break time together allowed for this. We had great discussions that extended well beyond our course curriculum or our expectations. For example, we learned and thought about informed consent in another country, cultural sensitivity of their patients, and the medical and supply challenges of their health system through the views and personal lens of our trainees. It made our teaching come alive, and really tailor the teaching to the local context to which they wanted. Overall, the learners were an enthusiastic and engaged group. Our local partners were truly inspirational on how much they have done for their country and the practice of anesthesia, their excitement to put into practice what they learned from the course, and hear their vision forward.

Overall, I chose to work with SAFE because of its focus on capacity building, knowledge transfer, continuing education, and sustainability to improve patient outcomes in areas where there is the most need. I greatly appreciate the opportunity to do so through the Dox Foundation and hope this summary of my trip may inspire other clinicians! Thank you for your incredible support in improving anesthesia provider education and patient care in Somaliland.