Africa

2014/03/05

Dr Sophia Webster

“The assumption is always that flying a light aircraft, especially a single engine, is a risk.” Sophia is a UK-basedRead more →

2014/03/05

Dr Lesong Conteh

“If you are looking at the economic impact of surgery on women and their households, then the costs associated withRead more →

2014/03/05

Dr Isabeau Walker

“Safe surgery should be a basic right that is available to all women who require it during childbirth.” Isabeau isRead more →

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Dr Sophia Webster

“The assumption is always that flying a light aircraft, especially a single engine, is a risk.”

Sophia is a UK-based obstetrician who recently flew a small airplane from the U.K. to South Africa, landing in 26 African countries along the way to promote safe pregnancy.

Which is more dangerous, having a baby in a low-resource setting or single-handedly flying a plane over an ocean?

Definitely the baby. Unsafe pregnancy is impacting directly on the safety of the life of mothers and children on a daily basis.

The assumption is always that flying a light aircraft, especially a single engine, is a risk. The fact that it’s comparatively much safer demonstrates the level of risk that women around the world are putting themselves through – not just once, but multiple times through their reproductive life.

I don’t think people realize the extent to which women’s lives are at risk just for the fact that they want a family.

What was the idea behind the journey?

It’s difficult to measure women’s health, there are a lot of different angles. Whereas a fairly simple way of thinking about how healthy a pregnant population is: how many women survive that journey?

Women who are going through pregnancy and childbirth in high-resource countries don’t really understand what their counterparts in sub Saharan Africa have to face. There’s under-recognition even within the professional community.

It’s always difficult to marry what you read and what you see. Generally statistics read true on the ground. But a statistic versus seeing the reality is something different. I compared what I saw and it fired me up. It’s not fair on so many levels.

What is the likelihood of childbirth by C-section?

Most women in their lives will get pregnant. We’re all at risk of the same clinical problems, but only in some countries will they advance unmanaged; only in some countries will you die from them.

For a first pregnancy in the U.K. there’s a 20% risk of having a C-section. The exact percentage varies around the world, but one thing remains the same: it needs to be conducted in a theatre with an anaesthetist and a surgeon. In some of the countries I visited women will be laboring in the village without even a skilled midwife.

What does this mean for the healthcare community?

The local professionals work really hard. They’re swamped, under-resourced, overworked, and at times are limited by what they can do as individuals.

The reasons women are dying in pregnancy are usually associated with haemhorrage. They need blood but there’s no transfusion; they have high blood pressure but there’s no doctor to give medication – or no medication at all. Monitoring is a problem – there’s a functioning blood pressure machine but then you find it doesn’t work.

That becomes exhausting after a fairly short period of time. There’s this idea of wanting a healthy mother and baby, and it’s just not always achievable.

Did you bump into a lot of internationals NGOs along the way?

What really struck me was that some places would have lots of outside donations, and NGOs working in the same places. Other countries were really lacking in that funding and collaboration.

In Darfur I landed on a gravel strip, UN helicopters all around – it was quite a difficult area to get to. But when I arrived, all of the student midwives were lined up with a banner, singing. They’re relatively ignored by the global midwifery community and they wanted to show a great welcome to someone coming to talk to them about maternal health.

What did you notice, switching so often between the sky and the land?

As you travel further south the weather changes – there’s cloud and rain and suddenly over Chad, Sudan, you start to see very good views.

You appreciate the beauty, how small we are in comparison to the earth, the moon the stars. But you also realize quite how remote some of the communities on the ground are. Sometimes I couldn’t believe I was looking down into the Sahara desert and there are villages there. You’re looking for roads, and there are no roads. Of course there will be women, and women having babies – and at some point they will need medical help.

You start to marry that up with the maternal death rate.

The first clinic she gets to might not have a theatre or surgical staff; by the time she gets to a place where she can have a C-section, she’s often moribund and the baby’s often dead. If women can’t access a safe place to give birth, what is their chance of a successful delivery?

What’s the change you’re hoping to see?

There was a poster on the wall of a hospital in Zambia that said “no woman should die because she gives life.” You want to see a change in attitude – a fight. I hope the communities I visited will be inspired to make a stand – that it’s not good enough that our women are dying. What can we do at local and national level.

We need to think more about the problems that are happening. Even when it’s not hugely local to us we need to think about it on a wider scale – because effectively it’s a war against woman that so many are not surviving.

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Dr Lesong Conteh

“If you are looking at the economic impact of surgery on women and their households, then the costs associated with surgery are not straightforward.”

Lesong is a senior lecturer in health economics at Imperial College London. Her research focuses on low- and middle-income country (LMIC) health economics and health system research, primarily in sub-Saharan Africa. She’s a Commissioner on the Lancet Commission on Global Surgery.

Your background is in health economics and infectious diseases. Did anything surprise you when you first started looking at global surgery?

Lack of economic evidence. I assumed there would be more data on the costs, cost effectiveness and financing of surgery, but what we have is so disparate.

The clinical evidence for surgery is of course strong, but we’re also forced to acknowledge there’s a fixed budget. A minister of finance – who is often equally important as a minister of health in decisions about health provision – needs a strong case for why they should invest in surgery and not some other health or non-health activity.

It’s hard to make your case for investment when you don’t have the data to support you.

Global surgery isn’t a new concept. Why do you think it has taken time for momentum to develop?

Surgery doesn’t have its own Millennium Development Goal [MDG] – it’s subsumed in with the other issues. When we say ‘surgery’ it means so many different things to people that it gets diluted and does not have a clear ‘identity’ or ‘brand’ that people can quickly understand.

When you start talking about an essential package of surgical care even surgeons themselves find it hard to reach a consensus. And if those inside the tent can’t agree, it’s hard for those outside to appreciate what surgery does.

Part of the problem is a limited number of surgeons who have time set aside to advocate for global surgery. They’re so busy that it’s hard for them to protect time to reach out and build a global movement.

Why do you think surgery is an essential component of women’s health, of global health?

It touches everyone, at every age. It relates to the focused MDG on maternal health and also shapes the broader MDG that promotes gender equality and empowerment of women.

It is often life changing, you can go in for your operation, you’re incredibly unwell – then you have surgery and within a matter of minutes, hours, days, you can be back to full capacity.

You could almost couch this in a human rights narrative. It’s a human right for women to access essential, safe, good quality surgical interventions.

What’s the economic perspective?

The first question to ask here is who’s economic perspective?

If you are talking about the Ministry of Health, then when you look at providing surgery it can be very expensive. However, it’s a perfect example of what economists refer to as economies of scope. Build the theatres and suddenly you can provide a range of services and operations. Your costs aren’t necessarily going to escalate linearly and you can do a lot, you can help a lot of people.

If you are looking at the economic impact of surgery on women and their household’s, then the costs associated with surgery are not straightforward. Costs of not accessing care can be catastrophic, however the financial cost of having an operation can also be very high, certainly when there is out of pocket expenditure for the operation itself and add to that costs of transport and food etc. Therefore it is important to compare the cost of surgery to the cost of living with certain conditions for a lifetime, then not only is there a clear health benefit, but there is likely to be a clear economic case for surgery.

And of course from a macroeconomic perspective it makes sense to have these women who need surgery healthy again, contributing to the economy and helping bring up the next generation.

How else do you rationalize the need for global surgery?

What I’m aware of now, as we start this work with the Lancet Commission, is that there is – in a way that works against surgery – emphasis on primary and preventative healthcare. Surgery seems almost a luxury until you have those other things covered.

But as we move to universal healthcare we have to realize that you can’t have either or. Surgery isn’t a substitute, it’s integral to reaching some of these goals.

It touches all of us, in our everyday lives. So the question is, how do you relate the importance of surgery, how do you get peoples’ attention? We all know someone who has had an operation, and that’s a central narrative coming out of our first Lancet meeting. The human element.

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Dr Isabeau Walker

“Safe surgery should be a basic right that is available to all women who require it during childbirth.”

Isabeau is a Consultant Paediatric Anaesthetist in London, Vice President of the Association of Anaesthetists of Great Britain and Ireland and a trustee of Lifebox Foundation.

Who needs a Caesarean section?

We are so used to people talking about caesarean section rates that are too high, and women who are ‘too posh to push’. But for a woman in obstructed labour or with a low-lying placenta, a caesarean section is a life saving procedure, for herself, the baby, or for both…

Safe surgery should be a basic right that is available to all women who require it during childbirth.

Is this not the case?

No, this is definitely not the case. Thousands of mother’s lives could be saved if surgery was prioritised within all health systems. Tens of thousands could be saved from debilitating injuries, and millions of stillbirths, neonatal deaths, or newborn birth injuries could be avoided.

The rates for caesarean section in poor communities in sub-Saharan Africa or southern Asia are consistently less than 2%. It isn’t clear what the ‘minimum’ rate for caesarean section should be, although some academics have suggested that at least 5% of all births should be by c-section; so it is likely that many women die in these communities because they don’t have access to safe surgery.

Thousands of mother’s lives could be saved if surgery was prioritised within all health systems, not just those in high-income countries. Many more women could be saved from debilitating injuries, and millions of stillbirths, neonatal deaths, or newborn birth injuries could be avoided.

What does this mean for a woman in labour in a low-resource country?

Lamula’s story is a true account written by Juliet Tumwebaze, an anaesthetic officer working in Uganda.

Lamula was a mother from a rural village in obstructed labour, carried on the back of her husband’s bicycle ‘amidst her screaming’ for 4 hours to the local health centre. When she got there, they found that the hospital was not equipped to help her.

WHO has estimated that 800 women die every day due to complications of pregnancy or childbirth, and 7300 babies are stillborn, with almost half of stillbirths occurring when the mother is in labour. 99% of these deaths occur in low-resource countries and could be avoided.

Is global surgery keeping pace with technology?

As we develop ever more sophisticated equipment to improve patient safety in high-income countries, patients in low-income countries are denied even the most basic of surgical care. The gap between what we know and what we can deliver in poorer parts of the world seems to be widening.

Does that mean available surgery becomes unsafe?

Yes, definitely. A number of publications in the last few years have surveyed facilities in rural hospitals in sub-Saharan Africa, and found that they are not staffed or equipped to deliver even basic surgery. So there is poor access to surgery, and when surgery is provided, the essential equipment to provide safe surgery is often not there.

What are the repercussions?

When a young woman dies during childbirth, it is a tragedy for the whole family. The health, education and economic prospects for the entire family are affected, and the risk of the surviving children dying is increased. An effective way to make a difference is for patients to stand up and tell their stories, and to demand better services. Sadly, these women’s voices are rarely heard, so it is particularly important on International Woman’s Day that we tell their stories in solidarity.