midwives

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

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 →

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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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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.