anaesthesia

2014/03/06

Margaret Bugyei-Kyei

“You’ve got to wear white for three months.” Margaret is a senior ODP at Great Ormond Street Hospital in London.Read more →

2014/03/06

Aisslta Bissang-Kondet

“I’ll tell you the story of a 9 year old girl I can’t manage to forget.” Aisslta – known toRead more →

2014/03/05

Dr Rola Hallam

“About a year ago in Syria I met an obstetrician who was delivering women on her kitchen floor.” Rola isRead more →

2014/03/05

Dr Zipporah Gathuya

“The surgeons were screaming they needed to get the baby out.” Zipporah is a Consultant Anaesthetist working in Kenya. Her areaRead more →

2014/03/05

Dr Rebecca Jacob

“Patient on the ground, instruments boiled over a kerosene stove by the light of a hurricane lamp.” Rebecca recently retiredRead more →

2014/03/05

Dr Sandra Leal

“Latin America shares many things, among them a strong regard for family – which constitutes the center for society” SandraRead more →

2014/03/05

Janet Dewan CRNA, MS

“I cared for a woman who had been suffering as an outcast for 25 years, since her first baby. ItRead more →

2014/03/05

Dr Jane Fitch

“The comparison between resources can make anaesthesia a very different experience. It makes you realize how wasteful we are, howRead 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 →

2014/03/05

Dr Eva Hanciles

“Often the first time a pregnant women come to hospital is when she’s been trying to deliver at home withoutRead more →

2014/03/05

Dr Angela Enright

“Women are the glue that hold the family together. If the mother dies in childbirth, it is a catastrophe forRead more →

2014/03/05

Dr Ronke Desalu

“Safe surgery is tied up with the socio-economic status, political participation and education of women.” Ronke is an Associate ProfessorRead more →

2014/03/05

Dr Queeneth Kalu

“They say ‘Abasi Akan uman ikwa,’ meaning ‘God forbid delivery by knife!’” Queeneth is a Senior Lecturer and Chairman,Medical AdvisoryRead more →

2014/03/05

Dr Nneka Anaegbu

“In the coming decade we’ll be on the frontier and at the helm.” Nneka is a Consultant Anaesthetist at LagosRead more →

2014/03/05

Dr Kelly McQueen

“Women with cancer in the early stages with the hope of treatment and cure often have no access to anRead more →

2014/03/05

Dr Michelle White

“It’s powerful to see how generous they are in their love and affection for each other.” Michelle is Head ofRead more →

2014/03/05

Dr Jannicke Mellin-Olsen

“Anaesthesia and surgery go hand in hand – it is difficult to do surgery if the patient is in pain.”Read more →

2014/02/05

Dr Amy Keightley

“In the UK we have swabs with a radio band so that if you lose one in the body duringRead more →

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Margaret Bugyei-Kyei

Margaret Bugyei-Kyei

“You’ve got to wear white for three months.”

Margaret is a senior ODP at Great Ormond Street Hospital in London. She trained as a nurse and then in anaesthesia in Ghana.

How do you celebrate a safe C-section in Ghana?

It’s a big celebration! You’ve got to wear white for three months. There has been so much fear that you won’t make it through alive, so everyone is celebrating, rejoicing. “Thank God you’ve come out of surgery successfully,” everyone tells you.

Here you don’t have that tradition – it’s just an everyday fact of life.

Is surgery so unsafe?

There’s a lot of fear, anxiety. People believe that you go into surgery and you don’t come back – because really that happens a lot.

They think it’s the operation that killed you, but surgery is essential when you need to do it. It’s education, transportation, poverty – all these things that delay treatment. By the time you’re ready it’s too late.

What are the barriers to safe surgery for women in Ghana?

Resources, equipment – poverty. Most patients come and they have nothing – but they still need to provide everything. Relatives are sent to the cash and carry to buy the medications, they have to donate the blood before any treatment takes place.

In the U.K. you get emergency care without hesitation. If you need something in the theatre your hands reach out to it, there it is. We have monitors; we have drugs; we have a cupboard of machines to help with difficult intubation, or locating a vein. What do I do back home? How do I get help?

Is equipment a big issue?

Most of the equipment sent to Africa is second-hand – some isn’t even working but it’s dumped on us. There’s a lack of everything. We reuse everything.

Patients die for lack of basic monitoring equipment. Women go into labour and they don’t even have a place to rest their head – a bed is like equipment to put their heads on.

What is it like to deliver care in this setting?

It’s tragic. Tragic for the patient and tragic for the nurse. You are going to let a patient lose their life for no reason – you could have saved them easily with the right equipment, access. So you withdraw; your spirit is demoralized.

And telling the families is so hard. It’s difficult enough to get a surgery. They get there and think – please, now it’s going to be ok.

Why did you train in anaesthesia?

First I trained in nursing. I’m the type who really loves caring for people. But at the time I was working in theatres we didn’t have enough anaesthetists – so I decided I could be a role model for my colleagues. At the time I was the only female who trained as a nurse anaesthetist on the course.

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Aisslta Bissang-Kondet

Aicha Bissang-Kondet

“I’ll tell you the story of a 9 year old girl I can’t manage to forget.”

Aisslta – known to everyone as Aicha – has been a senior anaesthetic and resuscitation technician in Lome, Togo since 1993. She’s a member of many organisations and has held the position of president and secreatary general. She is married with 3 children, and loves to exchange ideas and experiences.

Selon vous, pourquoi l’accès à la chirurgie est-il essentiel pour la santé des femmes? / Why is access to safe surgery essential for women’s health?

Les femmes ont recours à la chirurgie pour 2 grandes raisons. Une: parce qu’elles sont malades et le traitement est obligatoirement chirurgicale, et deux: elles sont en bonne santé mais elle cherche à devenir mère ou au moment d’un accouchement par césarienne ou alors à la suite d’un traumatisme suite à un viol.

Women need surgery for two main reasons. One: because they’re sick and like anyone else they need surgical treatment, and two: they’re in good health but require obstetric care, like a C-section for pregnancy or following a rape trauma.

Quels sont les obstacles qui empêchent les femmes à obtenir les soins dont elles ont besoin? / What are the obstacles that stop women from getting the care they need?

Brièvement: l’ignorance; les moyens financiers dans les familles; l’absence de structure de santé à proximité.

In brief: lack of awareness; financial resources of the family; lack of any reachable health facility

Que souhaitent faire les jeunes filles dans votre entourage lorsqu’elles seront adultes ? / What do young women in Togo want to be when they grow up?

Si je fais le tour des jeunes filles dans ma propre famille ”africaine” sur 11 filles qui sont au lycée 3 veulent la santé et 2 veulent être médecin mais pas de chirurgie. Les autres c’est finance, gestion ou droit. Oui il y’a un obstacle : l’importance des études (les matières sont exclusivement scientifique) et la durée de la formation très longue

If I look at the young women in my own ‘African’ family, of 11 girls who are at school, three want to go into health and two want to be a doctor – but not surgery. The others – finance, management, law. But obviously there is an obstacle: the importance of education and the long period of training.

Pourriez-vous nous raconter l’histoire d’un patient qui vous a marqué? / Can you share the story of a patient that has stuck in your mind?

Je vais raconter l’histoire d’une fillette de 9 ans que je n’arrive pas à oublier. La fillette pendant les vacances et les jours où il n’y a pas l’école aide sa mère à vendre des oranges. Les oranges sont dans un plateau et elle se promène avec. Tous les passants peuvent l’interpeler et acheter. Alors un monsieur lui dit qu’il veut acheter tout le plateau et lui demande de le suivre chez lui car il n’a plus d’argent sur lui. Arrivé chez lui il dit à la petite de venir prendre son argent à l’intérieur de sa chambre. De la, il viola sérieusement la petite qui a perdu connaissance. Comment a-t-il fait, personne ne sais mais la petite a été retrouvée non loin du petit marché de son quartier et transportée à l’hôpital en état de choc. Les gynécologues ont réussi à faire l’hémostase et avec la réanimation bien conduite l’enfant a la vie sauve mais avec d’important dégât FRV +FVV (vagin vessie et rectum sont confondu). Il a fallu une intervention chirurgicale pour que cette petite soit sauvée.

I’ll tell you the story of a 9 year-old girl that I can’t manage to forget. When the girl didn’t have school or during the school holidays, she would help her mother sell oranges. She’d take a tray of fruit and walk about with it, so that passers by could see. One day a man told her he wanted to buy the whole tray – but she’d have to follow him home, because he didn’t have any money. He called for her to take the money from his bedroom where he raped her. She was found unconscious near the market and taken to hospital in a state of shock. Doctors managed to revive her and stop the bleeding, but they had to repair her bladder and rectum as she’d received a traumatic fistula. It’s only because of surgery that this little girl was saved.

Quel est votre objectif de feminisation de la profession médicale dans les prochaines décennies? / What is your goal for women in the medical profession in the coming decades?

Faire aimer les matières scientifiques aux jeunes filles en proposant des prix d’encouragement ; en soutenant financièrement leurs études afin qu’elles n’arrêtent pas parce que les parents n’ont plus les moyens Pour les femmes qui travaillent déjà organiser des rencontres internationales d’échanges, encourager les promotions professionnelles ou organiser des voyages de perfectionnement pour améliorer leurs prestations.

I want incentives for girls to love science subjects; financial support for their studies so that they don’t have to stop when their parents can’t afford it. For women already working in the field I want to organise international meetings, encourage them to learn and push themselves and develop their skills.

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Dr Rola Hallam

Dr Rola Hallam

“About a year ago in Syria I met an obstetrician who was delivering women on her kitchen floor.”

Rola is a British-Syrian doctor in anaesthesia and intensive care. Since the beginning of the Syrian crisis, Rola has been working on health advocacy and the delivery of humanitarian and medical aid.

Is access to surgery really such an issue worldwide?

It’s a huge, huge problem. But we don’t talk about it very much. I think people underestimate how many incidences in our life we do need surgery, partly because it’s something we take for granted in this country. But for millions and millions of people around the world that’s simply not the case. They don’t have it at all, or it’s unsafe. Which means people are dying unnecessarily.

Is this the case for people in Syria right now?

Very few conflicts resemble each other, especially from a health perspective. Some don’t affect the system that much – and some unfortunately, as in the case of Syria, involve systematic targeting of healthcare and health professionals.

Just two weeks ago a hospital in Aleppo was destroyed with what’s called ‘intelligent’ missiles – a three-bedded intensive care unit, three ORs, 20 beds, newly-furbished by an NGO. It killed five patients, relatives, and injured 14 people.

70% of the hospitals and clinics have been destroyed or are non-functional; it’s near total destruction of the system.

What does this mean for the healthcare workers?

Healthcare providers are either killed, imprisoned or have left the country.

And so Aleppo – the largest populated city in Syria, which had just over 5000 doctors before the conflict – now has about 30.

You’re talking about a staggering reduction and therefore a massive burden of care on the remaining doctors.

A recent assessment of need in Syria found that the health sector is the biggest emergency and biggest priority in Syria, just ahead of food security. It shows just what a massive problem this is.

What does this mean for women?

We have a very high proportion of children and women in Syria – approximately 70% of the population, and we used to have relatively good antenatal and maternal care. Now public health becomes a massive issue, primary health becomes a massive issue – and of course, maternal health is significantly compromised.

And we haven’t even talked about the violence itself. If you were a civilian under constant bombardment you’d think twice before traveling to see a doctor – especially when you can’t afford to pay for medication because there’s huge unemployment.

You can’t collect data easily under the conflict, but there’s a huge amount of anecdotal evidence of harm to women and children.

So where are women giving birth?

About a year ago in Syria I met an obstetrician who was delivering women on her kitchen floor. There was no health service nearby but people knew she lived there. They’d literally go knock on her door and she had no choice – she closed the kitchen and turned it into a little birthing centre.

We’ve been hearing about women who set off over long distances in the last month of their pregnancy, under the shelling, to get to areas of slightly better healthcare.

It’s devastating. In any nice world you’d be sitting down and getting excited about your new arrival. Instead you’re crossing really scary military barricades, questioned for hours perhaps – and then you’re essentially homeless. You have to find somewhere to live, guns and bombs going off around you.

Are their babies surviving?

We’re seeing a huge rise in premature birth, which may well be due to poor nutrition and health of mothers. Some are in the siege area, where food and medicine aren’t allowed in. There’s a lack of clean water.

Some people think it might also be to do with their mental state. If you’re heavily pregnant and suddenly bombs are falling around you, and your neighbours are being killed and your house destroyed – a lot of them are delivering early from the stress.

And because the healthcare system is so inadequate, a lot of babies are dying. If not from lack of facilities, from the lack of baby milk. We’re finding – again, anecdotally – that women under these stressful and malnourished circumstances don’t have adequate breast milk.

I must have heard tens of these cases – it only leads me to believe there must be hundreds, if not thousands.

What can people be doing?

Under humanitarian law it’s absolutely illegal to be targeting and destroying healthcare structures. We’ve heard it condemned but there hasn’t really been anything concrete on that, so we need serious pressure on a policy level.

Everyone needs to do their bit. Governments, NGOs, individuals – whether you adopt a health center to rebuild it, provide security and salary support for doctors so they stay, antibiotics for arriving patients.

You have to be specific about what you need. Hand in Hand for Syria went back to the obstetrician’s kitchen and we built a small children’s and women’s facility in the excavated basement, generously funded by the public. It’s amazing what can happen with willpower and staff and incredibly dedicated colleagues on the ground. It can be done, it is being done, and people can engage with that. I hope so, anyway.

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Dr Zipporah Gathuya

Dr Zipporah Gathuya

“The surgeons were screaming they needed to get the baby out.”

Zipporah is a Consultant Anaesthetist working in Kenya. Her area of interest is Paediatric Anaesthesia and anaesthesia education.

Why is access to safe obstetric surgery essential for women?

Women are the carers for the family, especially in low-income countries. There are always other people who they are taking care of, despite having just had a baby. And there is certainly not much income to spare for complications.

Most women go for delivery being healthy. For them to continue in that health is paramount.

And if they don’t get it? What is the impact on the baby?

When the mother has a difficult labour the child risks hypoxia [oxygen starvation] or another complication like cerebral palsy, which has such a high infant mortality rate. These children can become a big burden on the whole family, and usually have miserable lives.

I have also seen many children whose mothers died at delivery and whose relatives never came to pick them from the hospital. It is very sad for that child, who will never quite appreciate maternal love.

Is there a particular case that sticks in your mind?

When I was training a mother was brought to the labour ward with severe pre-eclampsia [a life-threatening complication of pregnancy]. She was 33 years old, on her third pregnancy but had no living baby.

Just as she was wheeled into the operating room for an emergency C-section she had a seizure and began vomiting. The surgeons were screaming they needed to get the baby out.

We delivered a live male infant, but the mother went into renal shutdown. It took her three weeks to recover, and she went home with her son after a month.

Access to safe anaesthesia was essential to her survival. Though it has been more than 10 years, the scenario is still very vivid in my mind.

What is the role of education here?

The impact and importance of education to the mothers on access to antenatal care cannot be overemphasized. Caesarean sections are now more acceptable, whereas initially women would have the notion that a Caesarean section was a sign of weakness.

Education and skill advancement of both the anaesthesia and surgery providers will go along way towards minimizing the risk of many mothers dying or suffering complications.

Let’s talk again about the positive aspects of safe obstetric care. What is the long-term legacy?

If the mothers are sure that they will have safe pregnancy, delivery and child survival; even the issue of family planning will be more widely acceptable.

A healthy mother is a healthy community.

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Dr Rebecca Jacob

Dr Rebecca Jacob

“Patient on the ground, instruments boiled over a kerosene stove by the light of a hurricane lamp.”

Rebecca recently retired as a Professor of Anaesthesia at the Christian Medical College in Vellore, India. She now works as a consultant anaesthetist in Bangalore. Her focus is on paediatric anaesthesia and, in particular, working with children with clefts with the Smile Train charity.

Why is access to safe obstetric surgery essential for women?

No brainer! Everyone wants to be safe, even when the surgery is minor – let alone when there are two lives at stake.

You’ve helped to develop a training programme for students going out to work in a rural setting. What are their biggest concerns?

They feel very much alone. They’ve trained in a protected environment, with the safeguard of senior mentors. That doesn’t exist in the rural areas.

Suddenly, as well as gaps in their knowledge and poor support services, they have to worry about things we take for granted in the city such as uninterrupted water, electricity, suction – its an immense responsibility.

An operation can become very dangerous, very quickly – but really you don’t have a choice.

Can you give an example?

A student and her husband went to take up their new post in rural North East India. That same night a woman with prolonged obstructed labour was bought to them. Her only chance was an emergency Caesarean section.

With no electricity they performed the operation – patient on the ground, instruments boiled over a kerosene stove by the light of a hurricane lamp.

What changes would you like to see?

Those students came back to Vellore, obtained post grad degrees and went back to the same area. They set up a good hospital with three operating theatres, a sterilizing machine for instruments, generators for electricity. The only problem is that their oxygen and supplies have to come by boat – or four hours by road from the nearest airport!

So we need better training opportunities for our doctors and nurses. Improved facilities – hospitals, drugs, electricity, water, equipment in rural areas. Better salaries, housing and schools for the families and children of health care workers so that they will want to continue to work in rural areas.

This is the greatest loss we in developing countries suffer – we spend a lot on the education of our doctors most of whom leave to work in ‘greener pastures.’

What do you tell your students?

Don’t ever stop caring. No matter how little each of us can achieve, that little bit could still make a difference in one life.

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Dr Sandra Leal

Dr Sandra Leal

“Latin America shares many things, among them a strong regard for family – which constitutes the center for society”

Sandra has been anesthesiologist at the Social Security Maternity Hospital in El Salvador for 20 years. She is past president of the Anesthesiologists Association of El Salvador.

How does safe surgery for one woman have a positive impact on more than one life?

Latin America shares many things, among them a strong regard for family – which constitutes the center for society.  In this context women are acknowledged as the bond that holds this nucleus together, and more often than not, are the sole providers of the family income.

Many an individual, call it parents, spouse or offspring, depend on her either emotionally, economically or even both.  Under this perspective, it can be understood why their safety and well-being becomes so important, why safe healthcare is a vital cornerstone.

Access to safe surgery and anaesthesia is essential, though not always possible.

Latinoamérica comparte muchas cosas, entre ellas resalta un fuerte vínculo con la familia, la cual constituye el centro de la sociedad. En este contexto las mujeres son reconocidas como como el lazo que mantiene este núcleo unido, y con frecuencia son el único sostén económico familiar; a menudo muchos individuos, entre padres, cónyuges e hijos, dependen de ella emocionalmente, económicamente o más aún ambos. Bajo esta perspectiva, puede comprenderse por que su seguridad y su bienestar se vuelven tan importantes, y proveerla con servicios de salud seguros es un pilar para ello.

Why is that?

Resources are relatively scarce and sometimes just not available; distances are in many instances broad, or transportation is an issue, which can mean that access to surgery, even if safe, comes too late or doesn´t come at all.

In El Salvador, anaesthesia still plays a significant role in many adverse events for women; most surely, without safe, solid, anaesthesia equipment and anaesthesia provider, no surgery can come out a success.

El acceso a cirugía y anestesia seguras es esencial, pero no siempre posible. Los recursos son relativamente escasos y a veces simplemente no están disponibles, las distancias en muchos casos son amplias, o el transporte es difícil, lo que puede ocasionar que el acceso a la cirugía, aún si es segura, sea alcanzada con retraso o no pueda accesarse en lo absoluto. En El Salvador,la anestesia todavía juega un papel importante en muchos eventos adversos maternos: indudablemente, sin un equipo y un proveedor de anestesia sólidos y seguros, no puede haber cirugía exitosa.

What are some of the other barriers to safe surgery?

To this scenario, we have to add cultural issues, in many instances so strongly attached that they will work against any conscious and well-intended attempt to deliver good quality healthcare.  This raises the stakes and potentially turns what could have been a routine and relatively safe procedure, into high risk, full blown major surgery and/or anaesthesia for which neither the personnel nor the patient are prepared.

These type of settings are more frequent in rural areas, where education is poor, sanitary facilities are few and hospitals almost always lack even the basics.  It is here where young doctors and paramedics start their practice, which raises their main concern: who or where to go for consultation, and what to do when the resources needed are not available?

A este escenario, debemos agregar aspectos culturales en muchos casos tan fuertemente arraigados que actuarán en contra de cualquier intento consciente y bien intencionado de proveer salud de alta calidad, elevando los riesgos y potencialmente volviendo lo que pudo ser un procedimiento seguro y rutinario en una cirugía y/o anestesia de alto riesgo y grandes proporciones, para la cual ni el personal ni la paciente suelen estar preparados.

Este tipo de situaciones son más frecuentes en las áreas rurales, donde la educación suele ser pobre, las instalaciones sanitarias escasas y casi siempre carecen incluso de lo básico. Es aquí donde los jóvenes médicos y paramédicos inician su práctica, lo que da paso a su principal preocupación: a donde o a quien acudir por apoyo o para consultar, o que hacer cuando los recursos necesarios no están disponibles?

What can we do to change this?

To address these issues we have to understand that it is essential to provide not only the much needed equipment , but also to stimulate a continued medical education program.  Together with a public-oriented education program, this will allow all parties involved to work together and make the most of what they have at hand.

Para poder abordar estos tópicos primero debemos comprender que es esencial proveer no solo el tan necesitado equipo, sino también estimular un programa de educación médica continuada junto con un programa de educación orientado hacia la población que permita a todos los involucrados trabajar juntos y sacar el mejor partido de lo que disponen.

 

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Janet Dewan CRNA, MS

Janet Dewan

“I cared for a woman who had been suffering as an outcast for 25 years, since her first baby. It only took us 30 minutes to repair her fistula.”

Janet is a nurse anesthetist based in Boston, U.S.A. She first worked in Niger in the 1970s and has returned there many times, and now works regularly in Rwanda with the International Organization for Women and Development, an organization that provides fistula repair surgery to women suffering from this condition.

Is there a gender imbalance in access to surgical care?

When there are shortages in healthcare, women and babies are often the ones least advantaged.

It’s not at all unusual to find in the maternity section that the monitoring or anesthesia equipment is inferior to what’s used even for minor surgery in the same hospital. Childbirth is something that is considered just a natural process. But without a skilled birth attendant, and access to resources such as safe surgery if a c-section is required, it carries a high mortality with it. There is a vast global disparity in maternal and infant mortality statistics between well resourced and developing health systems.

What is an obstetric fistula, and how does it happen?

There are two types that we see. The first is obstructed labour – the woman is in labour for days without progress. The baby’s head pressing against her pelvic organs, so that no blood flow can get through, causing ischemic tissue damage.. The baby may die before the women receives help , and by the time it passes she has developed an ischemic hole, either between the vagina and the bladder or the vagina and the rectum.

Fluid freely flows out, of her vagina and she becomes incontinent.

The second type of fistula we see results from damage to pelvic organs after surgical interventions, Ceasarian Section. These injuries tend to be higher, involving the bladder and uterus or in the cervical region and often require open abdominal surgical repairs.

Can access to surgical services reduce the risk of fistula?

Absolutely. Fistula is a direct result of lack of available maternity and obstetric care, and the rate of C-section in some low-resource settings is very low, in others skilled health providers and other resources are not available for surgical and anesthesia care. when C-section is indicated.

Lack of personal and capital resources contribute to surgical care being performed under less than the safest circumstances. Some women do not have access to skilled services. Without an adequately trained birth attendant who recognizes the need for intervention and knows how to get a mother to it, complications are either not treated or treated too late so that complications , such as obstetric fistula result.

My own specialty, anesthesia, is not always available to care for the mother and infant. Anesthesia care goes beyond simply administering a spinal anesthetic. Monitoring the mother, so the earliest signs of serious complications are detected while they are correctable, is probably the most important anesthesia function. Anesthesia personnel also care for fragile infants. Anesthetists need to recognize their role in safe surgery goes beyond the technical. Current anesthetists should have the opportunity to participate in continuous education opportunities so they can be mentored in current principles of safe practice, interpretation of monitoring and appropriate interventions,.

Without the training and the resources it’s impossible to meet global targets for safer surgical care.

Does fistula ever occur in wealthier countries?

It does happen occasionally with urgent or repeat sections or can occur following pelvic radiation therapy.. At our hospital in Boston a woman suffered a fistula following a second urgent C-section – but we were able to repair her, with all that fancy equipment and skilled personnelwe have. She’s fine, the baby’s fine. Of course she wasn’t happy to have the complication, but that’s how treatable fistula is, how little suffering should go with it. Two weeks after her injury she was repaired and home caring for her healthy baby and toddler.

On the other hand I cared for a woman in Niger who had been suffering as an outcast for 25 years, since her first baby. It only took us 30 minutes to repair her fistula under spinal anesthesia

What can women around the world do about this?

I see quite a large number of female medical students these days – in Rwanda I have met many outstanding female medical students and I think this is likely to make a difference. Nurses and midwives also have an important role if they educate women about their bodies and normal birth and empower them to seek the appropriate care they deserve. Safe maternity care is a core component of the right to health.

It’s estimated that up to 500,000 women are suffering with the condition with 50,000 new cases at year. With our current resources we have the capability to treat barely 12,000 of these cases every year. The fact that fistula is a too common obstetric complication that occurs almost exclusively in the poorest countries, speaks to the global disparity in access to health care, including health personnel and other resources. Fistula is almost completely preventable and if it occurs it is treatable. The global capacity to eliminate this scourge exists,

And nobody should be suffering for any length of time.

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Dr Jane Fitch

Dr Jane Fitch

“The comparison between resources can make anaesthesia a very different experience. It makes you realize how wasteful we are, how disposable everything is for us.”

Jane is President of the American Society of Anesthesiologists.

People don’t always recognize the role of anaesthesia in safe surgery. What can you tell me about it?

There are very few medical specialties where you can literally take care of people from birth – and actually, pre-birth – all the way to end of life. Anaesthesia cares for everyone, and everything in between.

What about in lower-resource countries where you’ve worked?

The comparison between resources can make anaesthesia a very different experience. It makes you realize how wasteful we are, how disposable everything is for us.

In the U.S. we have all kinds of fancy warmers for giving blood products and fluid. In Egypt we draped it across some lights to get the ambient heat. Working in China in the late 1980s you’d see rooms chock full of inoperable equipment. Purchased or donated, it was broken and there was no one who could maintain it, no spare parts.

We know that 70,000 operating rooms around the world don’t even have a basic pulse oximeter [a monitoring device essential for safe anaesthesia]. Literally a couple of billion people don’t have access to safe anaesthetic and surgical care.

How important is access to safe surgery for women’s health?

It’s critically important. The medical care of women during their childbearing years – the majority of their lifetime – is primarily obstetric and gynecological. It’s critical that all around the world, women have access to these surgical procedures.

And when safe surgery isn’t available?

There are complications that have a huge personal and social impact on a woman and her family.

If she doesn’t have appropriate care during childbirth she risks damage to the birth canal and development of fistula that can lead to incontinence. A woman in low-resource settings without the ability to have this repaired can be ostracized from her family, her social network, her employment.

And the mom’s status clearly impacts and somewhat determines a lot of what the child’s life will be like.

What can we do to support safer anaesthesia around the world?

Nicholas Greene, one of the ‘founding fathers’ of modern anaesthesia, recognized early on the constraints that low-resource settings have in being able to provide safe surgical and anaesthetic care. His focus was on training and education, and our Global Humanitarian Outreach committee and Charitable Foundation have really taken off from there in the last decade.

What is your hope for the future of women in global anaesthesia?

It’s only in the last 40-odd years that we’ve moved away from a 25-30% female minority in the field of anaesthesia in America. I hope that women will realize the critical role that we do play in the U.S. and beyond – women all over the world are vital for providing the safest anaesthetic care possible.

We all need surgery and anaesthesia at some point – but in particular I’ll go back to the fact that we know that women really need obstetric care at certain times to prevent complications that will negatively impact themselves, their children and their families. It’s just critically important.

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Dr Isabeau Walker

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.

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Dr Eva Hanciles

Dr Eva Hanciles

“Often the first time a pregnant women come to hospital is when she’s been trying to deliver at home without progress. She’s in urgent need of a Caesarean section.”

Eva is a Fellow of the Faculty of Anaesthetists of the Royal College of Surgeons in Ireland and of the West African College of Surgeons. She at present heads the Intensive Care Unit at the only Tertiary Hospital in Sierra Leone and lectures Nurse Anaesthetists in that country

Let’s talk about anaesthesia. Why is access to safe anaesthesia important for women?

Anaesthesia isn’t considered a lucrative and fashionable option for post-graduate doctors, but without safe anaesthesia – which also includes post-operative care – there’s increased morbidity and sometimes mortality.

It’s of vital importance to women, especially in low-resource countries. Often the first time a pregnant women come to hospital is when she’s been trying to deliver at home without progress. She’s in urgent need of a Caesearean section.

Can you talk us through how you handle a case like that?

I recall a patient who had been in prolonged labour at home and presented at hospital in a collapsed state. We couldn’t get her blood pressure and her pulse was weak and thready. We could only get a line in through the internal jugular vein.

It was obvious we were dealing with a ruptured uterus.

This is something you would never see in a country with wider access to surgical services and we had to do surgical intervention and resuscitation at the same time because her heart was so unstable.

Of course a dead foetus was delivered and the bleeding was stemmed only after a hysterectomy. But the mother’s life was saved.

What changes have you seen over your career that have made anaesthesia safer?

The greatest change to safe surgical care has been the widespread use of spinal anaesthesia. In settings where there is no oxygen supply, little or no monitoring, poor power general anaesthesia is out of the question – it’s very risky and can contribute to high maternal mortality rates.

Let’s talk about anaesthesia.  Why is access to safe anaesthesia important for women?

Anaesthesia isn’t considered a lucrative and fashionable option for post-graduate doctors, but without safe anaesthesia – which also includes post-operative care – there’s increased morbidity and sometimes mortality.

It’s of vital importance to women, especially in low-resource countries.  Often the first time a pregnant women come to hospital is when she’s been trying to deliver at home without progress.  She’s in urgent need of a Caesearean section.

What changes have you seen over your career that have made anaesthesia safer?

The greatest change to safe surgical care has been the widespread use of spinal anaesthesia.  In settings where there is no oxygen supply, little or no monitoring, poor power general anaesthesia is out of the question – it’s very risky and can contribute to high maternal mortality rates.

Who is it important to educate?

Everyone.

In rural Sierra Leone, anaesthesia services are provided by nurses, who must be constantly updated.  Failure to provide continuing education can make anaesthesia very unsafe.

At the same time, further education of pregnant women to encourage them to visit ante-natal clinics would lead to further reductions in mortality.

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Dr Angela Enright

Dr Angela Enright

“Women are the glue that hold the family together. If the mother dies in childbirth, it is a catastrophe for her and for the children.”

Angela is Head of Anesthesia for Vancouver Island. She’s a past president of the World Federation of Societies of Anaesthesiologists and the Canadian Anaesthesiologists’ Society, and a trustee of Lifebox Foundation.

Why is access to safe surgery and anaesthesia an important issue for women’s health?

In low-income environments, emergency obstetric surgery such as Cesarean Section and ruptured ectopic pregnancy constitute a large part of the surgical volume. Women also endure other surgical conditions such as trauma, cancers and bowel obstructions that require surgical intervention.

Often they present late to the hospital and are in a high-risk state. The rate of complications such as severe blood loss is high.

But if a woman in a low-resource setting needs a surgery?

The challenges are huge. Poor transportation, long distance from a surgical facility, lack of money to pay for surgical care, distrust of the care available and late presentation all affect the ability of the patient to access timely and appropriate surgical care.

In addition, women may have cultural issues which may prevent them going to a hospital for surgery – such as requiring a husband’s permission, which may not be freely given or delayed if he works away from home.

Has global surgery kept pace with developments in medical knowledge and technologies?

There are improvements in some areas – for instance education of women, which makes them more aware of what they need and how to access it. Provision of local health care workers, such as in Malawi, has improved care and resulted in earlier referral to a surgical or obstetrical centre. Cesarean section is now most frequently performed under spinal anesthesia. That provides a measure of safety over poorly managed general anesthesia.

But you need early access, resources and skilled providers to be able to treat these patients successfully. This is still a problem, as well as practical issues, like a functioning blood bank for life-saving transfusion during a crisis.

Does surgery in these conditions become unsafe?

Yes!

What are the repercussions?

Women are the glue that hold the family together. If the mother dies in childbirth, it is a catastrophe for her and for the children and also for the husband, who now has to figure out how to care for his family whilst trying to work to support them.

Many women have ‘cottage’ jobs – something they can do from home which brings in some money, like weaving baskets sold to tourists. This type of income often pays for the children’s education.

Late management of surgical problems such as breast cancer results in increased morbidity and early mortality for the woman. Often other problems such as an enlarged thyroid may be left until it presents a major airway problem. Bleeding from untreated uterine fibroids can result in severe anemia and a mother bereft of energy and the ability to care for the family.

Do women play a role in delivering care too?

I would say that women provide the backbone of care in anaesthesia and nursing. Most surgical care is still provided by men.

Does this crisis get much recognition?

There is a belief that surgery is expensive and unaffordable but that is not the case. Routine surgical conditions should be treated early to return people quickly to the workforce.

Major agencies such as WHO have invested much time and effort dealing with public health issues and communicable infectious diseases. Obviously these need attention but much has been done to improve their status and it is time to turn some attention to surgery.

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Dr Ronke Desalu

Dr Ronke Desalu

“Safe surgery is tied up with the socio-economic status, political participation and education of women.”

Ronke is an Associate Professor and Consultant in Anaesthesia at the Lagos University Teaching Hospital. Her sub-specialty interests are paediatric anaesthesia and Training in CPR. She is happily married with 2 grown-up children.

Why is access to surgery essential for women’s health?

A third of the 4500 surgeries performed at my hospital in Lagos last year were related to women’s reproductive health. This is a substantial percentage for one ‘special group,’ and emphasizes the importance of ready access to safe surgery for women.

Yet not all women are lucky to get this professional treatment; the maternal mortality rate in Nigeria is approximately 585 per 100,000 live births.

Why did you become an anaesthetist?
I always wanted to be a doctor, even as a young girl growing up in Lagos in the 1960s. With two aunties showing that women were just as capable as men, and could be doctors, my mind was made up.

I’m passionate about helping the vulnerable and the sick, and it gives me great satisfaction to see the outcome and the value one person’s actions can have on another person.

Can you tell us about one of your most memorable cases?
I’m in a profession that has its fair share of risks, but I like to look on the positive side of my work, the good we do and the relief we bring.

Many years ago we treated a 5-year-old child with a large cystic hygroma [a growth that appears on a baby’s neck]. The surgery was difficult, and afterwards she was unable to breathe on her own. We admitted her to our intensive care unit, which didn’t have a functioning ventilator at the time.

The trainees and technicians took turns to manually ventilate her for 100 days.

The case emphasizes the importance of teamwork, perseverance – and above all, commitment to your patient.

What is the government doing to reduce maternal mortality?

In the last six years, the Lagos State Government opened six specialized maternal and child health hospitals, with full surgical facilities. This means more theatres, more surgeries, more training and better health service delivery.

What is the role of women in the surgical ecosystem?

Safe surgery is tied up with the socio-economic status, political participation and education of women. We need to support groups that advocate for women’s health issues – women shouldn’t have to travel such long distances for basic care.

I take as one of my critical roles in life, to uplift and raise the bar for young women. To show them that it is indeed possible to have both a happy home front and a sky that is the limit in their career.

 What is your goal for women in the medical profession?

I want them to realize that they’re part of a unique team. Many organisations assume that women can’t cope with the top positions and we need to change that mindset. We need to be amongst the counted when it comes to doing our job well.

Women need to be fully involved in the implementation and management of healthcare, as well as in the policy and mapping of future health plans for their community – and indeed the world.

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Dr Queeneth Kalu

Dr Queeneth Kalu

“They say ‘Abasi Akan uman ikwa,’ meaning ‘God forbid delivery by knife!’”

Queeneth is a Senior Lecturer and Chairman,Medical Advisory Committee at the University of Calabar Teaching Hospital in Cross River State, Nigeria.

Do women recognize that surgery can play a life-saving role in safe childbirth?

In my locality they say ‘Abasi Akan uman ikwa,’ meaning ‘God forbid delivery by knife!’ When it comes to childbirth, most Nigerian women prefer a vaginal delivery, meaning going to hospital is a last resort.

This translates to late presentation after laboring for hours in the traditional birth attendant’s home. They commonly arrive with obstructed labour, severe preeclampsia, foetal distress, haemorrhage – conditions requiring surgical intervention to save mother, baby or both.

The importance of safe anaesthesia in these emergency patients, arriving in suboptimal states into our very challenging health service system, cannot be over-emphasized.

What kind of challenges?

As a trainee anaesthetist I once had a patient who needed a Caesarean section at night. As soon as I gave her the spinal anaesthesia, there was a public power outage.

There was no back up power supply in the theatre. W e had no automated patient monitors at the time. We put on the small light of the laryngoscope, checked blood pressure every 5 minutes, palpated the pulse, kept communication with the patient and waited in the theatre till the anaesthesia receded.

We’re familiar with occasional power outages during surgery and will usually carry on with torchlights until power from the generator or public supply is restored. In this case we felt it was too risky, so we returned the patient to the ward and surgery was done the following morning. These are not things we are proud of but the reality in Africa is: we work in a challenging environment.

Does experience of working in other countries change your perspective?

I witnessed a case of placenta acreta [a sever complication of pregnancy that often requires surgery] during my obstetric anaesthesia fellowship at Wolfson Medical Centre in Israel.

The early diagnosis and preparation of equipment, blood availability, personnel – obstetricians, anaesthesiologists, interventional radiologists, perfusionists, nurses…it was amazing. Such a sharp contrast to what’s available in our environment when we see the same condition.

I realised why our maternal mortality rates are so high and theirs so low. I realize that saving a woman’s life in an obstetric emergency situation, especially where there’s bleeding is more or less a warfare and must be treated as such. All hands must be on deck.

What are your goals for women in the healthcare profession?

My joy is that I have found my passion for public health being fulfilled along my career path, and I encourage women to rise to professional excellence.

They should strike a work life balance. Make the most of the opportunities that come their way, engage in community development projects. Share their knowledge through health education programs in churches, market places, media houses.

I pray that in the coming decades, women will not be looked upon in terms of gender but will be seen as too relevant to be ignored.

 

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Dr Nneka Anaegbu

Nneka Anaegbu

“In the coming decade we’ll be on the frontier and at the helm.”

Nneka is a Consultant Anaesthetist at Lagos State University Teaching Hospital, Nigeria.

Why is access to surgery essential for women’s health?
The woman’s role is vital in the maintenance of the family. Since the family is the smallest unit of the society, their function is essential for society at large.

Inability to get access to safe surgery can lead to unnecessary demise of a woman, a tragedy and a great disaster to her children and husband. Children who lose their mothers are negatively affected psychologically, which may affect their behavior in the society.

Does a woman’s role in society affect her ability to get surgical care?
There are various challenges that women face while trying to access health care. They include financial, educational, cultural, gender inequality, poor governance and religion.

In my culture the young girls are usually at a disadvantage due to gender inequality – their parents may not send them to school because they believe it is a waste of resources. Girls are soon married out to end up in a man’s kitchen, seen and not heard.

This leaves women financially dependent on their husbands for every need, including healthcare support. A woman whose husband does not provide money for her to access healthcare when needed is a woman at risk.

Is surgery seen as a safe option?

Education about safe surgery is vital, and sometimes lacking.

In our environment some women run away from Caesarean section for various reasons. Some believe they may die during the surgery, others feel that their family and friends will look down on them for not delivering naturally. Others feel that it means that they are not prayerful enough.

I remember a woman who was pregnant and attended antenatal care at the hospital. The doctors noticed that she had pre eclampsia, therefore she was told that she would require surgery to deliver her baby. Instead she went to a traditional birth attendant to deliver.

She eventually developed eclampsia, and by the time she came to the hospital the baby was dead. She still had to have a Caesarean delivery and died in intensive care after about 10 days.

What can women around the world do to support safer surgery?
Women should strive to educate their girls to enable them have a brighter future and be independent. Many of the young girls I know want to be professionals in various fields, and have a passion for healthcare. But there are many barriers –parents lack the financial capacity, while some girls get pregnant in secondary school and can’t further their education.

Women should be supported by other women to achieve their goals. My aim for women in the medical profession is that in the coming decade we’ll be on the frontier and at the helm of activities in the industry. Taking decisions that will favor women, in order to improve women health and prevent avoidable eventualities that may affect women.

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Dr Kelly McQueen

Dr Kelly McQueen

“Women with cancer in the early stages with the hope of treatment and cure often have no access to an exam or biopsy”

Kelly is Associate Professor, Department of Anesthesiology and Director of Vanderbilt Anesthesia Global Health & Development Affiliate Faculty at the Vanderbilt Institute for Global Health, and president of the Global Surgical Consortium.

How is surgical need related to gender?

The health of men and women over a lifetime is associated with risks specific to their gender and to their roles in society.  For women, there are several unique periods in her life when the availability of safe anaesthesia, and emergency surgery is vital – the most obvious time frame is during childbirth.

The biggest risk to mothers worldwide is peripartum haemorrhage, often requiring surgery.  In low-income countries the risks are even greater because they relate to a lack of access to an emergency cesarean section for obstructed labor and for seizures related to high blood pressure.

Access to surgery and safe anaesthesia for these conditions – haemorrhage, obstructed labor and eclampsia – will save the lives of mothers and babies, and prevent related complications such a vaginal fistula and stroke.

Is it just about reproductive health?

Cancer affecting women specifically also illustrates the important relationship between certain surgeries and gender.  Cervical and breast cancer often require a biopsy for diagnosis, and frequently surgical intervention for treatment, palliaton and cure.

Cervical cancer when diagnosed early has a very good prognosis.  But when diagnosed late – often when the kidneys are blocked, or the tumour is so large that it protrudes from her body – there is little hope of treatment.

The later is a common outcome in the poorest countries, and the unnecessary death of a women often leaves children in need of care behind.

Why is this a global rather than local concern for women?

Disease for the most part knows no geographical boundaries.  But the prevalence of surgical disease does correlate with increased non-communicable disease such as heart disease, trauma and cancer that we’ve been seeing for many years in higher-resource countries.

Recently in low-income countries, non-communicable disease has been increasing and therefore the need for safe surgery and anaesthesia has as well.  The needs for these same services are commonly required by women all over the world, and so women from every country must engage to create awareness about the role of surgery and safe anaesthesia in our good health.    

What is the reality of the situation faced by a woman in need of surgery when she lives in a low-resource setting? 

In the lowest-income countries, need for surgery has never been greater.  Sadly it’s in these same countries that access to safe anaesthesia and surgery is most often unavailable.

Organizations such as the The Global Surgical Consortium are committed to revealing the unmet need, and advocating for availability: in many hospitals surveyed we note a lack physicians and other providers, the absence of essential medicines including oxygen, and the absence of safety equipment and basic surgical supplies

This means that many women who need an emergency Caesarean section never receive one or are delayed until after the baby has died and the mother has birth trauma – which will affect her the rest of her life.  Women with cancer in the early stages with the hope of treatment and cure often have no access to an exam or biopsy, and therefore are diagnosed very late in the disease when it is too late to provide definitive care.

What role do women play in delivering healthcare worldwide?

Of course women in every society are often engaged in care-giving.  In lower-resource countries this is especially true within the home, and also in the nursing profession.  They’re also physicians, but many fewer of them have the opportunity for the extended education that is required and available to their higher-resource counterparts.

More women should be given the professional opportunity to work in health care for one very important reason we’ve seen. Women are much less likely to leave their families to seek higher pay or new opportunities outside their community – the retention of women in professional roles in the low-income countries is higher than for men.   

For someone who has never worked in a low-resource setting hospital, or thinks safe surgery is a luxury –

Just a few hours in a hospital of a low-income country bears witness to the vital role of safe anaesthesia and surgery in the lives of women.

Women die in childbirth everyday because of a lack and unsafe practice of anaesthesia, and limited or no access to a life-saving surgical intervention when they need it.  Their babies die too because of the mothers excessively high blood pressure or being stuck in the birth canal with no availability of a cesarean section.

Walking in the halls you see women with large tumors protruding from their breasts, or large thyroid goiters taking over their neck.  Visiting the Emergency Department you see women – mothers, sisters, aunts – morning the loss of a husband or son, because there is no access to emergency anesthesia and surgery for trauma.

Safe anaesthesia and basic surgery can be provided in a cost-effective and appropriate manner. There is no doubt that the lives of women around the world are impacted daily by lack of access to it.

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Dr Michelle White

Dr Michelle White

“It’s powerful to see how generous they are in their love and affection for each other.”

Michelle is Head of Anaesthesia on the MV Africa Mercy, the largest floating hospital NGO in the world. She is currently docked in Congo.

Are women at a disadvantage when it comes to access to surgery in low-resource countries?

Any money usually goes to the men, to the children; women are the neglected person in the family unit, often the poorest of the poor.

But with a lot of women’s health issues – uterine prolapse, obstetric fistula – there really is no other alternative to surgery. So it’s important that they get access to surgical care, that it’s safe – and that it’s effective. Obstetric fistula has a high rate of cure if you get it right first time, dropping dramatically with each further attempt.

Is it hard not to get emotionally involved in these cases?

It’s certainly a very moving surgery to be part of. These women have been ostracized completely from society – very often they’re barred from home, left in an outhouse and someone brings them food. Corrective surgery restores their dignity and their place in society. They can socialize, take a bus, go to market. They can finally get rid of the stench of stale urine.

How do the women respond to this second dramatic change in circumstances?

We try to have a ceremony on the ship for the ladies who have had successful fistula surgery, as a way of showing that they are valued, appreciated. We give them a new dress, symbolizing a new start. There’s applause and dancing – it’s incredibly moving, after the many years of hardship they’ve suffered.

And it’s powerful to see how generous they are in their love and affection for each other. The women who haven’t had successful surgeries nearly always participate. They know how much it means, and their hope of that is so great that they are still willing to rejoice.

What’s the reality for surgery on the mainland, when you leave the ship’s hospital?

It’s not only about access to surgery – people also have to survive their operation, and there are some very practical problems. Many hospitals don’t have access to clean running water or electricity to sterilize the equipment. They don’t have antibiotics, everything disposable is reused.

Everything compromises the safety of surgical care, even the unreliable lighting – it’s very difficult to do a good repair when you can’t really see what you’re doing.

What does this mean for someone with a surgically-treatable condition?

It means they endure with pain, exhaustion, incontinence. For the woman particularly there are economic and social implications – if her husband takes another wife he may reject the infants from the first wife. If she takes the children she may not have the means to look after them.

There’s a lot of social stigma attached to disability, but if we turn a mirror back on ourselves we can see that we take a similar view in the west – we just hide it better.

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Dr Jannicke Mellin-Olsen

Jannicke Mellin-Olsen

“Anaesthesia and surgery go hand in hand – it is difficult to do surgery if the patient is in pain.”

Jannicke is a Consultant anaesthesiologist at Baerum Hospital, Norway, and Deputy Secretary of the  World Federation of Societies of Anaesthesiologists. She is secretary of the European Society of Anaesthesiology, Vice Chairman European Patient Safety foundation, Past President European Board of Anaesthesiology, on the board of the European Society of Anaesthesiology.  She has participated in several international missions with the UN and Red Cross.

Why is access to safe surgery an important issue for women’s health? 

Safe surgery is important to both men’s and women’s health, but as females are the ones giving birth – a very high-risk situation – they are overall at greater risk than males.

People don’t always think about anaesthesia in relation to surgery.  Why is it essential?

Anaesthesia and surgery go hand in hand. Some form of anaesthesia is required for almost all surgical procedures, both because it is difficult to do surgery if the patient is in pain, and because pain provokes reactions in the body that are negative for the wound healing process.

What changes have you seen within access to safe surgical care over the course of your career? 

In my context, surgical care has been getting safer across the last almost 30 years. If you are a trained and experienced clinician, then you can do a lot with your eyes, ears and fingers. The major problem worldwide is the lack of trained personnel. In addition, major steps towards improved safety can be achieved by introducing simple monitors. In my setting, these devices are required for all general anaesthetics, and this is far from available globally.

Why is it important to talk about this issue?

For those that live in areas where anaesthesia and surgery is unsafe, it is important that their situation is made known. They should be invited to report their needs if they feel that it has been ignored in their setting.

For those of us who have drawn the golden ticket and live in areas where anaesthesia services are available and safe, we should share our knowledge, competence and resources with others. For some, it is difficult to know how.  Then a donation to Lifebox would be a good way to support a reliable, well documented programme to improve access to safe anaesthesia and surgery in every corner of the world.


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Dr Amy Keightley

Amy Keightley

“In the UK we have swabs with a radio band so that if you lose one in the body during the operation you can identify it.”

Amy is an Obstetric and Gynaecology Registrar, recently returned from Hoima Hospital in Uganda, currently working at Lincoln County Hospital.

C-sections make up an enormous proportion of all surgeries in low-resource settings.

Yes, but the C-section rate in Uganda, if you look at the place as a whole, is actually very low. There’s not a lot of access to healthcare, and then you arrive at these facilities with a high volume of operations being done in a relatively small space – pockets of high-risk women, clumped together.

Without the training and experience of managing difficult labour, you can end up seeing C-section as a safer way out – without addressing the long-term consequences, and how risky the operation is itself.

So you get this situation where lower-risk women get surgery, and women who needed a C-section three days ago are waiting, waiting, waiting for days, because the theatre is always full.

What are the immediate risks?

Horrible post-natal infection; risk that the surgeon will pick up HIV or hepatitis because they don’t have the right equipment or training.

Resources are a huge problem. In the U.K. there’s someone whose whole job it is to look after the surgical instruments, keep track of equipment. And you can use swabs with a radio band so that if you lose one in the body during the operation you can identify it.

In low-resource settings there’s much smaller theatre teams, and the surgeon may not have someone to assist. The swabs are much smaller and harder to count, and one maternal death we saw was from a swab left in the abdomen – she died of sepsis.

Is the anaesthesia dangerous?

9 times out of 10 the anaesthesia is absolutely fine – but when something goes wrong, it suddenly makes the whole thing very dangerous.

When I arrived, a woman died of a high spinal – an anaesthetic that goes too far up the spine so that the patient can’t breath – because the anaesthesia provider hadn’t been trained to manage the emergency. In the U.K. that would never happen; the patient would be intubated, ventilated, or the anaesthesia would be reversed. Instead, a woman came in for a C-section and died from spinal anaesthesia.

And the long-term consequences?

There’s the impact for the next baby. In the U.K. we can offer mothers a second C-section if they choose, or monitor the second pregnancy closely to make sure that her scar doesn’t rupture.

But in Uganda, what will she do when she goes back to her village, three days walk away, and is laboring with the next one? Who will monitor them when the baby is obstructed? Who will be there to deliver her safely?

What is the impact on hospital staff?

We had two doctors running 4000 deliveries a year, 24 hours a day – no breaks, no weekends. We were losing about 5 women a month, roughly, we were losing babies every day. It’s crisis mode the whole time, and you could never even find half an hour to sit with everyone together because the workload doesn’t ever stop.