childbirth

2014/03/06

Sandra de Castro Buffington

“Storytelling can help women to know what best practice looks like – and empower them to demand it. It’s probablyRead more →

2014/03/06

Alisa Swidler

“Too many people don’t even know what fistula is, because they don’t experience it as an issue.” Alisa is aRead 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 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

Kathleen O’Neill

“In terms of treating breast cancer – even when it’s not curable – the impact of surgery is still immeasurableRead 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 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 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

Evelyn Felicia Somah

“Back home they have this thing – if you’re going to surgery, you’re going to die.” Evelyn is a seniorRead 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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Sandra de Castro Buffington

“Storytelling can help women to know what best practice looks like – and empower them to demand it. It’s probably the most effective tool we have to reach people with new ideas and information.”

Sandra is the Founding Director of the Global Medical Center for Social Impact at UCLA’s Fielding School of Public Health, leading social change through storytelling and entertainment.

You worked in family planning and reproductive health in low-resource countries for more than 20 years. Was surgery an important aspect?

I remember that over 80% of admissions were obstetric and gynaecology. Women are absolutely the majority coming in through the emergency rooms for emergency surgery, and it’s a multiple crisis when a woman in a low-resource country loses her health and her wellbeing.

Oftentimes the father doesn’t have the will or the wherewithal to raise a family. Her life is on the line, but so is theirs.

When I was 19 I moved to northeast Brazil, to a very small fishing village. There was a family across the road with nine children, the mother pregnant with her tenth. She died in childbirth. And those children – they became orphans.

The Global Media Center for Social Impact raises awareness and action for health issues through storytelling. How can narrative help women in need of safe surgery?

Storytelling can help women to know what best practice looks like – and empower them to demand it. It’s probably the most effective tool we have to reach people with new ideas and information.

People have to care – you have to entertain, engage and empower, in that order.

But everything from intention to action can change when we’re transported by a story.

And it’s not about story v statistics in my experience. Once writers are inspired on a topic they often incorporate statistics into storylines, so that people never actually realize they’re learning something.

Surgical safety sounds like a dry concept. How could storytelling bring it alive?

It already has! A few years ago when the WHO Surgical Safety Checklist was being launched, I took Atul Gawande as an expert on surgical safety to speak with a couple of TV show executives here in Hollywood. And I asked him, on the way over, to start with a story.

He took a case study from medical literature – a complex case about all the really important and timely steps that were taken to save a child’s life, and won our full attention. We cared deeply about this little 3-year old girl who had drowned, and her parents – we lost our bearings and arrived in a new world. And once we were there, we were so open to learning.

Did it translate to television?

When Atul bought the Surgical Safety Checklist into the story it was so interesting to us. The creator of the TV show ER ended up writing a storyline about how it saves the life of a beloved character, and the audience really cared.

It aired on a Thursday night and Friday morning at 6 a.m., surgeons were being gathered together to watch the episode. Many were so moved they ended up adopting the Checklist for their own practice; patients were coming in and asking if they used the Checklist before surgery; it actually bought global attention to the issue.

What is the long-term impact?

It’s so interesting – you have art imitating life and life imitating art, bringing it into popular culture where it becomes more widely accepted. The stories can strike how you create the future.

There are so many challenges to safe surgery, particularly in low-resource settings where you don’t have equipment to sterilize instruments, or disposal for surgical waste. We can help to create demand for safe surgical practice if we show what a healthy cycle looks like, and inspire women and me around the world to demand it.

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Alisa Swidler

“Too many people don’t even know what fistula is, because they don’t experience it as an issue.”

Alisa is a leading philanthropist and campaigner for human justice and health issues.

How has motherhood changed your perspective on maternal health?
Comparing levels of care during childbirth – it can get pretty dire. In the U.S. they really hold your hand, they walk you through the tests, the vitamins, the questions. Then you go to a hospital in a low-resource setting and there are no bed sheets in the hospitals, just old torn mattresses. Women deliver, if they make it to hospital, on a cold metal frame.

We talk about health all the time with our children – we’re so lucky when it comes to that.

What’s your greatest frustration when it comes to women accessing healthcare worldwide?

It’s not always a priority for everyone.

I think there could be more focus on it – we should come up with better ways of addressing certain issues, and even exposing them.  Too many people don’t even know what fistula is, because they don’t experience it as an issue.

When did you first learn about obstetric fistula?

About eight years ago, through Richard Branson and Virgin Unite.

That was after I had all my children.  So I actually didn’t know it was a risk; it was not even a concern while I was pregnant.  That’s how it should be, because no one needs to suffer that trauma.

If it does happen – because transport is an issue, because a woman in labour can travel days to get to a hospital – we need to see that it’s not a taboo, that they get the surgery they need.

What can people do about it?

Ask questions.  I’ve been on so many boards in the last 20 years and I’m always the one who won’t stop asking questions.  About accountability, about the specifics, about how money is being spent.

There’s a lot of duplicating efforts in global health and it really bothers me – because there are so many areas, like access to safe surgery for women, that still need attention.

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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

“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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Kathleen O’Neill

“In terms of treating breast cancer – even when it’s not curable – the impact of surgery is still immeasurable in how much it can affect someone’s life in a positive way.”

Kathleen is a research associate at the Program in Global Surgery and Social Change at Harvard Medical School. She is also a 4th year medical student at the University of Pennsylvania. She recently returned from working at Hôpital Universitaire Mirebalais in their surgery department for six months in Mirebalais, Haiti. She plans to begin a general surgery residency program following graduation next year.

Why is global surgery essential for women’s health?

The average person in the U.S. has eight operations in a lifetime. If you’re living a long and productive life, it’s likely that at some point you’ll need access to surgery. Because of the risks of childbirth, women are more at risk of needing a life-saving surgery than the average man – particularly in low-resource settings where fertility is usually higher and more pregnancies means more risk.

But it’s not just about reproductive health. A lot of the work I was doing in Haiti was around the issue of breast cancer – and surgery is absolutely necessary as part of that treatment.

Is there much access to surgical care for cancer in Haiti?

It’s similar to many low-resource countries in that very few centres treat surgical disease and people generally live far away from them. I interviewed patients getting chemo at the hospital and most had been seeking care for a year or more.

Cost is a huge factor. Just the process of diagnosis is incredibly difficult and the cost of surgery could range from a few hundred dollars to a few thousand. Any money they had saved was gone very quickly.

Is the surgery generally safe?

Safe and effective surgery isn’t just a question of availability, but integration. Surgery in Haiti isn’t really plugged in to a larger system of treating cancer, and there’s limited pathology or chemotherapy. A surgeon might remove a lump and hope it was benign, but it’s difficult to know what they’re cutting out.

You see women going severely in debt for surgery that wasn’t a definitive cure. Four years later they have metastatic disease.

What is the impact of this?

Having this life-threatening illness, searching for so long for treatment – the whole process affects the family. The majority of women getting treatment usually had several children, and they’d be struggling to take care of them. Often kids became the breadwinners of their family, taking care of their moms. An illness like that doesn’t just affect one person, it affects the whole family.

So a lot of what we talked about during our interviews was how grateful they were to find care – to finally have someone taking care of them. The entire oncology team at the hospital is composed of women – nurses, physicians, led by a Haitian physician trained in oncology, Dr Ruth Damuse. It’s a wonderful place, women taking care of women.

What is the chance of survival?

Women would notice the lump in their breast relatively early but, particularly at the lower socio economic level, delay and delay care. They say ‘I don’t have the money to be able to do that, I can’t leave my family.’ It has to be something that affects their lives to a very large extent before they seek care, so often the lump isn’t only noticeable to them, but grossly obvious to everyone.

Unfortunately in Haiti whenever we were diagnosing it was rarely a question of ‘is this breast cancer’ – by the time the woman presented, it was very obviously so. And that is a very difficult thing, because the chance of cure becomes so small.

Does that mean the surgery isn’t worthwhile?

In terms of treating breast cancer – even when it’s not curable – the impact of surgery is still immeasurable in how much it can affect someone’s life in a positive way.

When you can remove a fungating mass on their breast so it’s no longer infected or at risk of bleeding, you remove the stigma. The ability to move about and not have to daily worry about this gaping open wound that won’t heal, which cancer ultimately turns into – it confers a level of dignity to patients that I think is lost in the standards ways we measure outcomes. It’s life-changing.

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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 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

“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 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 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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Evelyn Felicia Somah

“Back home they have this thing – if you’re going to surgery, you’re going to die.”

Evelyn is a senior staff nurse at Great Ormond Street Hospital. She was born in The Gambia, and trained in the U.K.

Why did you train as a nurse?

My grandma was a midwife, my mum was a nurse – it’s part of me. When I grew up my dad said – and you listed to your parents! – nursing doesn’t pay here, you need to study something else. So I trained as a secretary, I was working with the UN in The Gambia.

But when I moved to the U.K. I saw technology was changing – you don’t really need a secretary, you’ve got a computer. So I’m going to do what I love to do, what I wanted to do when I was a child.

Tell me about access to surgery in The Gambia.

In The Gambia, healthcare is the biggest issue. People are just dying from things that they shouldn’t, and women are suffering the most. They don’t have the right equipment, they don’t get emergency obstetric care. I know of a cousin who just died giving birth back home. They couldn’t stop the bleeding.

So where do you go if you need surgery?

I have an uncle who nearly died – he had fluid on his lungs, but he was rushed to Senegal, because they couldn’t diagnose him in The Gambia. Half an hour flight away – but he would have died if he’d stayed; he would have died if he wasn’t working for a bank which paid for him to go.

When people have money they can rush to Senegal. But when they don’t – you have lost your life.

Do people worry about unsafe surgery?

Back home they have this thing – if you’re going to surgery, you’re going to die. Take medication, go to the doctor – that’s fine. But if they’re putting you to sleep?

It’s because they haven’t seen successful surgery. People aren’t diagnosed soon enough, so the surgery is much more complicated. My dad – we lost him – when you’d talk about an operation he’d say “oh no, no – I don’t want anybody to cut my body.”

My mum, too, was diagnosed wrongly. She’d had the problem ten years, and by the time we were able to get her to America she only had two weeks. They used to give her cough mixture, but her heart was gone. The doctors couldn’t believe she had traveled so far.

How does this change?

People need to be educated. They need to be informed that surgery will help. For me, since I’ve been here, I’ve really changed my perspective. We were never taught that surgery could do that.

Both my parents gone because they couldn’t get diagnosed properly; they couldn’t get treated in time.

So many people visit Gambia, they can see all this. But it’s a tourist place for them. They go for the holiday and everything else is just put aside.

 You have so many difficult stories. I’m sorry to make you go through them all again.

I enjoy caring for people; I enjoy it so much. That’s why I’m in this field. I like helping people and I like education. I do health checks at my local church, and I always encourage women to take care of their health.

It’s ok. If telling stories can help to let people know what’s happening – if it can make a difference – then I want to share them.

 

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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.