c-section

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 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 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 Sherry Wren

“They think of surgery as transplants and plastics and don’t realize that there’s a huge population that has no accessRead 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

Laura Kilduff

“When the baby’s heart rate was dropping I wasn’t worried about me, it was purely about the baby and howRead 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 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

Camila Maglaya

“I always say – we’re not always rich back home – but we do whatever we can, we speak out.”Read more →

2014/03/05

Dr Angela Davis

“There’s a strong cultural message that somehow having an elective C-section is an ‘easier’ way to give birth.” Dr AngelaRead 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

Comfort Osagie-Ogbeide

“You have to buy your life.” Comfort works in hospital administration in London. She is originally from Nigeria. What isRead 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

Judy Mewburn

“The pelvic outlet on a girl of 11 or 12 – you could no more get a baby through thereRead 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

“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

“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 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 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 Sherry Wren

“They think of surgery as transplants and plastics and don’t realize that there’s a huge population that has no access to the most basic, lifesaving procedures.”

Sherry is an Associate Dean of Academic Affairs and Professor of Surgery at Stanford University School of Medicine. She runs clinical and research programs in global surgery, gastrointestinal oncology, and surgical robotics. She is the co-developer of the International Humanitarian Aid Surgery course which has now trained more than 200 surgeons to prepare for work in low resource settings.

Why is safe surgery essential for women’s health?

When you look at the number one killer of women across the world it really is childbirth. And there’s just no way you can impact maternal mortality without having access to safe surgery.

And that’s just from an obstetric standpoint – women also get injured in car accidents, women get appendicitis – all multiple other conditions that need surgical care.

11% of the global burden of disease can be classified as surgically-treatable. I can think of no more important issue, in many ways, than safe surgery.

What, you mean that ‘neglected stepchild’ of public health?

You know I’ve actually only ever read that once, in the Paul Farmer and Jim Kim Kim article – I think it just gets quoted by everyone who keeps waiting for the situation to change.

I’m amazed when I speak to people in the public health domain who talk about the MDGs for maternal mortality or the ‘Decade of Road Safety’ but have an absolute disconnect and don’t recognize that safe surgery must be part of these programs. There will be excess maternal mortality as long as there is no access to safe C-sections, and consider the best road safety programs in western nations where people still get in accidents and need surgeons to take care of them.

Do you have any theories on why that is?

A couple! Surgery in the western world has become so commonplace it’s seen as standard care, assumed safe. To the point that people say “I’m just getting a minor op,” and they forget that before the advent of laparoscopic surgery having your gallbladder out was a 5-7 day hospital stay.

They think of surgery as transplants and plastics and don’t realize that there’s a huge population that has no access to the most basic, lifesaving procedures. It’s a profound disconnect in reality.

I also think that surgeons need to learn how to speak public health language. We need better research data. We need to go to their meetings – but it can be tough to break into a club, and it’s not like there’s a huge amount of funding for these topics.

Do I think the ‘neglected stepchild’ will be part of the family in my lifetime? I hope so. But I’m not going to hold my breath.

You run a training course for high-income setting surgeons going to work in a low-resource setting. What’s the most important thing for them to realize?

The most common area of concern is obstetric emergencies. Surgery in low-resource settings is split roughly in thirds – obstetric, orthopaedics, and everything else, so you have to be prepared – but in the U.S. you can’t just say “I’m going to learn to do some ortho today.” To participate, or even scrub in on a case you have to have malpractice insurance that would cover that kind of surgery. Anyone who’s not an obstetrician is terrified to take care of a pregnant woman because of the litigation risk.

It’s also about preparation. Some surgeons go overseas as as part of a comprehensive group bringing everything – physicians, machines, resources – you’re bringing a piece of your own world with you and parking it somewhere. It’s very different if you actually go work in the context the way it is with the resources on hand.

Does surgery around the world keep pace with advances in education and technology?

If your hospital doesn’t have power, running water 100% of the time it’s very difficult to keep up with where technology has moved.

Technology is a double-edged sword. I look at global surgery and I think the goal is someplace in the middle – a happy medium between over-care and over-testing (as I think we do in the U.S.) and availability of resources populations fundamentally need.

Interestingly educational knowledge is easier to disseminate. I participate in a collaborative programme in Zimbabwe on medical education where trainees have not had the opportunity to use advanced technology but they are knowledgeable about the recent advances and often will say “if we had the ability to perform x, this is what I think it would show.”

Is surgery a growing field for women around the world?

In the U.S., absolutely. About 40% of new surgical trainees are women, 50% of medical school graduates. There are still some barriers, areas that are still more commonly within the male domain but it’s rapidly going away – as opposed to when I started training and it was me and 17 guys!

In some places I would say that the issue of women in the profession is still many years behind. I believe there are cultural and biases, both conscious and unconscious– on rounds when I’m working in Africa I’ll ask a doctor if he’s going to encourage a bright young female student on a surgical track and he’ll say “oh no, you know women don’t want to be surgeons.”

But I’ve got a group of female students in Zimbabwe who are so excited to be surgeons. Why? Because they see that it’s possible.

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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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Laura Kilduff

“When the baby’s heart rate was dropping I wasn’t worried about me, it was purely about the baby and how we were going to get him out safely.”

Laura Kilduff is 33 years old and lives in Oxfordshire, U.K. She is a Chartered Occupational Psychologist and runs her own business from home. Her first child, Charlie, was born by emergency caesarean section last year.

What were your concerns going in to your pregnancy?

The main thing – which must be similar to every woman around the world having their first child – was fear of the unknown. You can ask what a contraction feels like, but no one can properly describe it. Everyone seems to have a different experience. So at night, when you can’t sleep, you’re on your iPhone Googling questions – and the answers are always the worst.

You wind yourself into this ball of tension and worry about what is going to happen.

How did you prepare? Was the possibility of C-section discussed?

I took an antenatal course. That environment of women together, sharing fears and experiences, it was so important. But the option of caesarean section was mostly glossed over – we focused on that ‘ideal’ natural birth.

It’s something cultural we seem to be going through in the U.K. at the moment – births have to be natural and if it’s not natural the sense is that it’s unnatural.

So I went into it not really thinking a C-section would happen. Everyone talks about the candles, the birthing room, the pool! All this lovely stuff. Although in the end – with nine in the group – only one had that ‘ideal’, everyone else had a lot of intervention.

What happened at the hospital?

I went into labour the night before I was scheduled to be induced, two weeks past my due date. They put me in a room at the hospital and I said, “I don’t think I need an induction, I think labour is on its way!” They put a monitor on my tummy to check the baby’s heart rate – it kept dropping suddenly, and he was obviously in a bit of distress.

I was there three hours, four hours, contractions getting painful and stronger. But whenever I had a contraction the baby’s heart rate dropped, and they didn’t know why. At this point the consultant looked at all the print outs and said there’s a possibility you may need a C-section.

We’re lucky in this country in that we have some fantastic anaesthetists, great surgeons and nurses, and you have to trust that they know when it’s needed, necessary. I’m not medical, but I could see and hear the beeps of when the baby’s heart rated dropped – I knew something was wrong.

And then…

I was on a gurney and on the way to theatre in less than five minutes. It turns out the baby’s head was pressing on the cord, so during contractions he wasn’t getting enough oxygen.

You have to be strong. You’re in tears because of the pain, so you look to the people around you, to reassure you.

Although what you’re not really prepared for is the number of them. At least two anesthetists, two surgeons, the midwife, a couple of nurses, my husband. You’re in pain and surrounded by all these people, most of whom you’ve never met before – you just have to trust them. Half an hour max and he’ll be with you.

What was it like after the operation?

You don’t realize how debilitating it is; the first night you can’t really move at all. I couldn’t pick up the baby, and I was only just about ready to walk by the time we left the hospital. The recovery is much longer than you think as well. You stumble down the road and turn back after five minutes, exhausted. You can’t push the pram because it puts pressure on the stitches. And you need a lot of time for your muscles to recover.

Then there’s that question of a second baby – because of the incision there’s more of a risk, so do you have to have another C-section?

Has this experience changed the way you think about the issue of women’s health worldwide?

You hear stories in the media of women who haven’t survived, or had stillbirths. You can’t imagine it. And thank god I didn’t have to. When the baby’s heart rate was dropping I wasn’t worried about me, it was purely about the baby and how we were going to get him out safely. And whether he would be ok when he came out.

After the birth a lot of people said ‘oh, you had an emergency C-section – it must have been awful’ – but childbirth is pretty horrific generally, for the child and the mum! You need that awareness that it isn’t an easy thing to do – there’s going to be pain and upheaval whether or not you have an operation.

It was the right thing for me. The baby came out in 10 minutes. He was fine, cried quickly. They stiched me up and then we went back to the delivery room to bond with him.

Actually, nine months later it’s almost hard recalling it – you mentally block out a lot of what happens, that’s nature’s way.

You can’t forget if you don’t have the baby there.

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Janet Dewan CRNA, MS

“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 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

“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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Camila Maglaya

“I always say – we’re not always rich back home – but we do whatever we can, we speak out.”

Camila is a senior staff nurse at Great Ormond Street Hospital. She moved to London from the Philippines a few years ago.

How hard is it to get a caesarean section?

It’s not easy to have surgery unless it’s really urgent. Even when it is urgent. Sometimes there’s nothing to do but surgery – like for a woman in obstructed labour – but if you don’t have the money, you don’t have the C-section.

Or if you can get to a hospital that caters to the really poor people, you have to get through a lot of red tape, pass a process, meet the criteria, how urgent are you really…It’s tedious and it’s dangerous. Before you can be seen you’re at the end point already.

How do people handle this?

Some families will just accept it. This is what I’m receiving because I’m poor. They’re used to it. They have that mentality ‘I’ll always have the second type of services.’

But some of them of course still fight for what they deserve. For their mother, their sister, their child. They will go to the complaint system. But it’s a long process.

And when you lose someone you love, and you know they could have been saved – the grief is still the same, the loss is still the same. Whatever standard of life you live, you go through the same process.

What can you do to change the system?

You can only fight for it – you don’t know if you’re going to change the result, even if you get the surgery.

I always say – we’re not always rich back home – but we do whatever we can, we speak out. Then at least you’ve done what you can, and you pray and hope that the next time it happens there will be a better outcome – if not for your family, for someone else.

Why is access to surgery so important?

It’s the difference between rich and poor. It’s poverty, isn’t it. If you have money, you can do everything.

But health should be the ultimate equal opportunity. Rich or poor, a woman or a man. Whatever standard you are in life, you should have an equal chance at this. If one needs surgery – it should be given.

 

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Dr Angela Davis

“There’s a strong cultural message that somehow having an elective C-section is an ‘easier’ way to give birth.”

Dr Angela Davis is a historian at the University of Warwick, interested in motherhood, parenting and childcare.

Your research has focused primarily on 20th century Britain. Is it possible to talk about universalities of childbirth beyond a particular place or time?

Yes there is universality in the process of birth – but it’s also something which is quite contextually-specific. For women giving birth in the U.K. it’s still a leap into the unknown, the fears are there – but it’s very different to when you’re giving birth in a time or place with a high maternal mortality risk.

Even women giving birth in the U.K. sixty years ago – their mothers’ generation would have had a much more risky experience. They knew those stories, that much more striking association with death which we haven’t really had for he last 40, 50 years.

How have access and attitudes towards Caesarean sections changed since the 1900s?

Small numbers of C-sections were done for hundreds of years but without antibiotics, without blood transfusion, usually resulted in mothers dying. Being able to do a safe C-section was a dramatic improvement and for certain groups of women – for instance those with complicating factors (like rickets, which can deform the pelvis) who were never going to have a good outcome, it was transformative. It allowed them to have a healthy pregnancy and birth.

Rates in the U.K. climbed throughout the second half of the 20th century with a dramatic increase in the last decade, for reasons that aren’t just medical.

When they’re used routinely – perhaps unnecessarily, like as a matter of protocol for a second birth following a C-section delivery – you need to question the evidence-base more closely.

Why do you think this has happened?

Misinformation. Not on a medical level but on a cultural level; the threat of litigation, the influence of the media. There’s a strong cultural message that somehow having an elective C-section is an ‘easier’ way to give birth. When of course the fact is – in this country or any other – it’s major surgery.

If you talk to a woman who has had one the idea that it’s easier – risk of infection, complications with breastfeeding – there’s a gulf between the image and the reality.

Obstetric fistula is a traumatic consequence of obstructed labour – did you come across much discussion of this in your research?

It’s constantly present in women’s stories, but not something that was frequently talked about.

There are many accounts of women living with the legacies of frequent childbirth, but these are the things that really changed after the introduction of the National Health Service (NHS). Suddenly in the 1940s there’s a huge rush of people getting all these conditions they’d been living with for a long time, fixed.

One woman I spoke to had a very difficult experience with fistula. But it was picked up after the birth, she had the surgery and went on to have more children successfully. It was weeks, rather than a lifetime.

Is it helpful to look at the global context?

There are big questions that apply everywhere – the importance placed on reproduction, the resources that are made available, and the relationship between women and the high-level policy decisions that are being made about a women’s issue. Because if it concerned men, the whole thing would be treated very differently everywhere.

And there’s a lot that we can learn from one another – not just taking a ‘western’ approach and applying it on a global scale, but vice versa, seeing what works well in different contexts. Still, you need to be cautious.

Why is that?

There’s an element in the U.K. that goes against women and those who criticize their care. It’s easy to say that if you were in this or that country you’d really have something to be concerned about. When the point is – no one should be in that scenario to begin with.

You need women to be well-informed, empower them to know their bodies, their choices – but you need a system that empowers them as well.

What impact do you think personal storytelling can have in changing opinion and practice?

It’s so important. Most of the effective campaigning groups – AIMS, NCT – started with women sharing their stories. There’s an immediacy that touches people in ways that statistics can’t.

Stories are part of the universal, the global context. We can identify with stories of women giving birth in other places, even if you know the context is different – there’s something about having a child you can identify with. These personal stories are really vital.

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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

“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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Comfort Osagie-Ogbeide

“You have to buy your life.”

Comfort works in hospital administration in London. She is originally from Nigeria.

What is your experience of surgery?

Well it saved my friend’s life. She needed a caesarean section for her second baby, and she survived. But it was very difficult.

Why is that?

The attention she needed wasn’t really there, due to lack of financial resources and unavailability of the right equipment in Government hospitals. She decided to go private but lacked the initial deposit. If you don’t have the money, you don’t get the treatment.

There’s so much pressure on the family. The price they may charge is huge, and of course if she’s pregnant the lady hasn’t been working. It pains you to see this happening – women dying from illnesses that are not supposed to take them. You have to buy your life.

So is it hard to trust in surgical care?

Recently I heard about a young lady who died from an incomplete operation. Not immediately – she went for a surgery to deliver a stillbirth and they left some products behind. She kept going for follow up, kept complaining that she had pains. She wasn’t wealthy, and her life didn’t get enough attention. She was neglected until she developed sepsis, and she died.

From a stillbirth. A tragedy followed by a tragedy. It is really difficult to trust surgical care.

Surgery is that line between life and death, and it’s the common belief that if you go into surgery you’re not likely to come back.

Has your attitude changed since you moved to the U.K.?

Here at least they’ve got the right equipment to look after the patient. I’ve come to realize that there’s nothing inherently dangerous about surgery when you need it and you do it safely.

It’s when you need it and they don’t have the resources for that. My friend and her baby almost wasted away. It’s just a nightmare. You don’t want to talk about it.

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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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Judy Mewburn

“The pelvic outlet on a girl of 11 or 12 – you could no more get a baby through there than the moon.”

Judy is a registered nurse who has worked for many years with nursing communities across Africa, delivering training and supporting the vital role of nursing in safe surgery.

Why is a C-section necessary?

Surgery is essential because it’s life-saving. Women die without one. But with this one operation you’re saving two lives.

You always need a C-section for obstructed labour or prolonged labour, and sometimes for breech. And of course for the younger ones, whose pelvises are not big enough. The pelvic outlet on a girl of 11 or 12 – you could no more get a baby through there than the moon.

Why don’t women in low-resource countries get the operations they need?
When you look at a C-section it’s a relatively straightforward procedure – incision, muscle, uterus, get the baby out. But so many hospitals don’t have the right equipment, or the only surgeon isn’t there. Or there’s an even worse case ahead of you.

These hospitals deal with a huge catchment area, and the women are far away. They’ve been laboring for days before they walk in – or wheel in, if they’re lucky enough. The mother arrives exhausted (goodness, you try walking a few miles in labour). And the foetus will be incredibly distressed, if not dead.

On my last visit I saw a woman who had been in second stage labour for two days, lying there, saying “that’s it. I can’t push anymore.”

What happens if you can’t get a C-section in time?
After prolonged obstructed labour the baby dies in utero and starts to decompose. The mother becomes toxic and her body tries to push it out.

Depending on how many children she’s had, her uterus may burst, in which case there’s bleeding – so much bleeding their blood won’t clot any more, and without the right transfusion or a hysterectomy they’ll bleed to death.

I saw a case like that recently in Ethiopia. Holding the mother’s hand, I didn’t speak the language – but there’s a body language that is universal, isn’t there.

What happens next?

For the mother? She’s shattered. Nine months of pregnancy and she looses the baby. She cries. She goes home. Life is pitched against you.

And if she dies but the baby survives? Devastation visited on the family. Who is going to look after the children?

What about when it goes right?

When a baby is delivered safely – in two minutes it’s as though it were born with clothes! They wrap it up – nappy, blanket, second blanket, this big rolled wodge, and the mother carries it around with a little face poking out. It’s the start of everything.

So yes, safe surgery is a women’s issue. But really, it’s a world issue.

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Dr 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.