Sunday, March 1, 2015

We know how to prevent nearly all deaths in childbirth, but women still die daily, says Séverine Caluwaerts in this excerpt from the e-book “Because Tomorrow Needs Her: The Fight for Women’s Health.”


Chantal giving birth
A MSF nurse examines Chantal, 20, at Kabezi State Hospital in Burundi. Her two previous Caesarean sections put her at risk for uterine rupture if she tries to give birth vaginally.
Credit: Martina Bacigalupo/VU

 (WOMENSENEWS)–I was a gynecologist in Bo, Sierra Leone, when Mariama arrived on a motorcycle in front of our clinic. She was heavily pregnant and pale, sandwiched between her mother and father. She was 16, bleeding and in a lot of pain.

Two nurses helped Mariama, whose name has been changed to protect patient privacy, off the motorcycle and put her on a stretcher. One of them put in an IV line while I palpated her abdomen and asked her family what had happened.

Four days earlier, Mariama had gone into labor and like half of women in the developing world, she tried to deliver without the help of a skilled health worker. Instead, she stayed at home and was assisted by a traditional birth attendant. Things did not go well. After three days, the family decided to bring her to the hospital. It was the rainy season, and traveling was especially difficult. Before getting hold of the motorbike, the family had gone part of the way by boat. It took them a full day to reach the hospital.

I had been in Bo just a month and it was my first assignment with Doctors Without Borders/Médecins Sans Frontières. I had never seen a patient in this state in my 10 years of working as an OB/GYN in Belgium. I didn’t understand why the family had waited so long to bring Mariama to the hospital.

Now that I’ve been on 10 assignments with the organization, known widely as MSF, in sub-Saharan Africa and Central Asia, I know that situations like Mariama’s are often the norm rather than the exception. Every day, about 800 women around the world die from easily preventable causes related to pregnancy and childbirth. The majority bleed to death; succumb to a severe infection; die as a result of a sudden spike in blood pressure, called pre-eclampsia; or from an unsafe abortion.

The emergency obstetric care needed to prevent these deaths has been known for a long time. It is not complicated, but it does require skilled birth attendance and the right medical materials and medicines.

Arriving Earlier

I can’t tell you the number of times I’ve thought: “If only I could have seen this woman just a few hours or a day earlier, this disaster would not have happened.” Pregnant women in trouble often arrived at our hospital very late for help. Some were too late, dying en route.

Many had tried to deliver at home with a traditional birth attendant, but most of these attendants are not trained to identify a complication that requires emergency care. Even if they were, some complications cannot be predicted, and families often live a day or more from the nearest health facility, without easy access to transportation.

When Mariama arrived, the nurses and I rushed her into the operating theater. I explained to her parents in a mixture of English and the local language what was going to happen, that this was serious, that the baby was probably dead and that I would try everything possible to not remove Mariama’s uterus. I added that I needed permission to do this if we had to in order to save her life. Her mother started to cry.

The baby was palpable inside the abdomen and was indeed dead. This is almost always the case when uterine rupture occurs outside of the hospital. A quick check of the fetal heart monitor on the operating table confirmed our diagnosis. We set out to repair the rupture of her uterus, which extended all the way into her bladder. Without this surgery, she would probably have died in a few hours.

After this difficult surgery and a transfusion of three units of blood, Mariama was finally stable. We were able to save her uterus, which is extremely important for a young woman, especially in this context. But she was not clear yet. She had also sustained a fistula, an opening in the pelvic tissue between her uterus and bladder, caused by the baby’s head pressing against the pelvic bone for so long.

Dying in childbirth is astonishingly likely in Sierra Leone — with 1,100 deaths for every 100,000 live births in 2014. It ranks with Chad and Central African Republic among the deadliest places to give birth. Compare this with 28 deaths per 100,000 live births in the United States and 6 in Belgium (2013 figures).

It is unconscionable that in many parts of the world today, trained obstetric care is inaccessible, when providing access to it is not complicated.

Governments Need to Step Up

MSF runs 131 projects with dedicated emergency obstetric services in places where the national health system is non-existent or has been severely affected by conflict or neglect. But when 800 women are dying every day in the developing world—not only during crises or conflicts, but in stable places as well—it is clear that national governments urgently need to make this care much more accessible.

Many aid organizations lack the capacity to provide hospital services and big donors—donor countries and organizations—are often reluctant to invest in them. For this to change, governments must recognize the need to provide emergency obstetric care for their citizens. Whenever a country’s health system is non-existent, destroyed or weakened by conflict or neglect, the international community must step in and provide those services. There must be a way to attract doctors, nurses and midwives and to make services available 24 hours a day, seven days a week.

Transportation is also essential. The lives of women with complicated deliveries depend on access to reliable transportation to a hospital. This must be organized before an obstetric emergency hits.

We must also remember that a woman’s control over her body is integral to reducing maternal mortality. Studies by the World Health Organization have shown that providing contraceptive services has the potential to reduce maternal mortality by more than 30 percent.

Mariama recovered at our clinic for six weeks. Then we sent her to the nearby West Africa Fistula Foundation for fistula repair surgery. The sooner she could be diagnosed and treated, the more likely the damage could be repaired.

What strikes me about Mariama’s story is that I will never know what happens next for her or for many of the other women I have treated. We met at a moment of crisis, solved a life-threatening problem and gave her advice for the future, then let her go. But anything can happen once a woman leaves the hospital, and we are never sure she will be able to come back the next time she needs medical help.

If women in developing countries had access to obstetric care, I wouldn’t have to worry about Mariama and the hundreds of other women I’ve treated over the years.

Dr. Séverine Caluwaerts is a referent gynecologist with the international medical humanitarian organization Doctors Without Borders/Médecins Sans Frontières. This piece draws from a new collection of accounts from MSF medical workers, “Because Tomorrow Needs Her: The Fight for Women’s Health.” Electronic and hard copies of the book can be requested by emailing Melissa Pracht at [email protected].