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 →


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 →


Camila Maglaya

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


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 →


Judy Mewburn

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


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.


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.


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.



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.



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.