obstetrics

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 →

2014/03/05

Dr Sophia Webster

“The assumption is always that flying a light aircraft, especially a single engine, is a risk.” Sophia is a UK-basedRead more →

2014/03/05

Dr Rebecca Jacob

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

2014/03/05

Morgan Mandigo

“It reminds me of a quote I heard – that in many African countries people will say “I’d rather haveRead more →

2014/03/05

Dr Marianne Stephen

“There might be a more acceptable level of risk, but the grief – that kind of grief is never normalized.”Read 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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Dr Sophia Webster

“The assumption is always that flying a light aircraft, especially a single engine, is a risk.”

Sophia is a UK-based obstetrician who recently flew a small airplane from the U.K. to South Africa, landing in 26 African countries along the way to promote safe pregnancy.

Which is more dangerous, having a baby in a low-resource setting or single-handedly flying a plane over an ocean?

Definitely the baby. Unsafe pregnancy is impacting directly on the safety of the life of mothers and children on a daily basis.

The assumption is always that flying a light aircraft, especially a single engine, is a risk. The fact that it’s comparatively much safer demonstrates the level of risk that women around the world are putting themselves through – not just once, but multiple times through their reproductive life.

I don’t think people realize the extent to which women’s lives are at risk just for the fact that they want a family.

What was the idea behind the journey?

It’s difficult to measure women’s health, there are a lot of different angles. Whereas a fairly simple way of thinking about how healthy a pregnant population is: how many women survive that journey?

Women who are going through pregnancy and childbirth in high-resource countries don’t really understand what their counterparts in sub Saharan Africa have to face. There’s under-recognition even within the professional community.

It’s always difficult to marry what you read and what you see. Generally statistics read true on the ground. But a statistic versus seeing the reality is something different. I compared what I saw and it fired me up. It’s not fair on so many levels.

What is the likelihood of childbirth by C-section?

Most women in their lives will get pregnant. We’re all at risk of the same clinical problems, but only in some countries will they advance unmanaged; only in some countries will you die from them.

For a first pregnancy in the U.K. there’s a 20% risk of having a C-section. The exact percentage varies around the world, but one thing remains the same: it needs to be conducted in a theatre with an anaesthetist and a surgeon. In some of the countries I visited women will be laboring in the village without even a skilled midwife.

What does this mean for the healthcare community?

The local professionals work really hard. They’re swamped, under-resourced, overworked, and at times are limited by what they can do as individuals.

The reasons women are dying in pregnancy are usually associated with haemhorrage. They need blood but there’s no transfusion; they have high blood pressure but there’s no doctor to give medication – or no medication at all. Monitoring is a problem – there’s a functioning blood pressure machine but then you find it doesn’t work.

That becomes exhausting after a fairly short period of time. There’s this idea of wanting a healthy mother and baby, and it’s just not always achievable.

Did you bump into a lot of internationals NGOs along the way?

What really struck me was that some places would have lots of outside donations, and NGOs working in the same places. Other countries were really lacking in that funding and collaboration.

In Darfur I landed on a gravel strip, UN helicopters all around – it was quite a difficult area to get to. But when I arrived, all of the student midwives were lined up with a banner, singing. They’re relatively ignored by the global midwifery community and they wanted to show a great welcome to someone coming to talk to them about maternal health.

What did you notice, switching so often between the sky and the land?

As you travel further south the weather changes – there’s cloud and rain and suddenly over Chad, Sudan, you start to see very good views.

You appreciate the beauty, how small we are in comparison to the earth, the moon the stars. But you also realize quite how remote some of the communities on the ground are. Sometimes I couldn’t believe I was looking down into the Sahara desert and there are villages there. You’re looking for roads, and there are no roads. Of course there will be women, and women having babies – and at some point they will need medical help.

You start to marry that up with the maternal death rate.

The first clinic she gets to might not have a theatre or surgical staff; by the time she gets to a place where she can have a C-section, she’s often moribund and the baby’s often dead. If women can’t access a safe place to give birth, what is their chance of a successful delivery?

What’s the change you’re hoping to see?

There was a poster on the wall of a hospital in Zambia that said “no woman should die because she gives life.” You want to see a change in attitude – a fight. I hope the communities I visited will be inspired to make a stand – that it’s not good enough that our women are dying. What can we do at local and national level.

We need to think more about the problems that are happening. Even when it’s not hugely local to us we need to think about it on a wider scale – because effectively it’s a war against woman that so many are not surviving.

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Dr Rebecca Jacob

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

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

Why is access to safe obstetric surgery essential for women?

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

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

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

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

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

Can you give an example?

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

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

What changes would you like to see?

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

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

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

What do you tell your students?

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

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Morgan Mandigo

“It reminds me of a quote I heard – that in many African countries people will say “I’d rather have HIV than cancer” because it’s much easier to get plugged in to treatment.”

Morgan is a fourth year medical student in the Department of Global Health and Social Medicine at Harvard. She’s currently based in Haiti.

Why is safe surgery essential for women’s health?

The obvious answer is obstetrics – but what I didn’t fully appreciate until I came to Haiti was the magnitude of the cancer problem. We see case after case after case after case of devastating breast cancer, and a huge portion of the general surgeries we do are mastectomies.

Who is affected?

It strikes women at such a young age in low-resource countries, and we really don’t have a good understanding of why this is. But it seems to be that more and more women in their late 20s, early 30s are presenting with cancers that progress very quickly.

We always use maternal mortality as the example of trickle-down effect on the children, the community, the economy, but more and more we’re going to see the same argument playing out here.

The cancers that only affect men hit at a much later age – in the U.S. more men die with prostate cancer than from it – so women’s cancers can have a bigger impact on the children and families.

Why are the cases so devastating?

The presentation is so late. Some academic articles estimate 80-90% of breast cancer in low-resource countries is diagnosed at stage 3 and 4 – that is lymph node involvement, metastases.

Cancer treatment requires so many things – surgery, chemo, radiation, pathology. When you don’t have access to all of those tools, often surgery is the only option. But there is a very real threat of doing unsafe surgery when you haven’t been trained in oncology.

Why is there such late diagnosis?

Because there are such high barriers to actually receiving care. The geography, the logistics, the money – the day’s work you’re losing traveling to the hospital, sleeping outside on the ground so you have a good place in line the next morning, all the while not knowing if the doctor will even be able to help you.

That’s an awfully big set of challenges to overcome for a little lump in your breast that may not cause you any pain.

How does surgery become unsafe?

Oncology surgeries can be dangerous because tumors are so vascular. You could run into significant bleeding problems if you’re not properly trained.

There’s also the risk of not getting all the cancer, or even worse, of spreading the cancer. Cancer ultimately starts at the cellular level, and if you’re not using proper surgical techniques you can miss the margins; or you can risk seeding that cancer into other cavities in the body.

Even when you have the ability to do safe surgery, you don’t always have what you need to fully treat the cancer.

Can you give an example?

A few months ago a woman arrived with a mass growing out of her face – it was roughly a quarter of the size of her own head. It was a very rare tumour that had obliterated her vision on one side. The only thing available to help her was surgery.

The team did the best job they could to remove the tumour, but we don’t have pathology, the biomedical resources we’d have in the U.S. Your natural inclination is to try to take out a tumour like that – it’s so public, and you could see the suffering on her face from the stigma of carrying it around. But it was a very tricky surgery to do.

The team was able to resect the tumour successfully but they couldn’t be sure they had removed it entirely, and last Friday she came back. The tumour was bigger than before. This time it was also more vascular and had invaded more of the bone in her face, and though we wanted to be able to help her, we knew this time it would be unsafe.

It highlights the importance of safe surgery and knowing when you can operate and when you shouldn’t, but also what else we need to be able to do to provide better cancer care – to have a more positive impact.

Why do you think that cancer treatment has been so slow to develop in low-resource settings?

If you ask a dozen people on the street ‘what is global health’ they’ll say HIV, tuberculosis, malaria, malnutrition. By focusing our efforts so much on particular diseases, rather than seeing health itself as a human right, we risk creating this dichotomy where we see other diseases running rampant, untreated.

It reminds me of a quote I heard – that in many African countries people will say “I’d rather have HIV than cancer” because it’s much easier to get plugged in to treatment. For cancer there’s often nothing.

But we know what to do about it?

We know what needs to be done, but it’s the how that is difficult. We need to prioritize the development of surgical infrastructure around the world and ensure that there is equitable access to safe surgery. The trend towards a high burden of non-communicable diseases will continue, and many of them are treatable with surgery. But in the meantime, women bear a huge burden.

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Dr Marianne Stephen

“There might be a more acceptable level of risk, but the grief – that kind of grief is never normalized.”

Marianne is an obstetrics and gynaecology registrar who has worked with Médecins Sans Frontières in Pakistan and on the border of Myanmar and India.

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

Women of childbearing age are a unique group of patients in that they’re usually well when the come to you. Childbirth is one of the unique circumstances where an operation is performed on someone who is not sick, making the decision to do so very important.

For a woman in this country it’s important to think: if this was your daughter, your mother, your sister, going in healthy to hospital to have a baby, how much of a tragedy it would be if they died. The tragedy is the same wherever you go in the world. There might be a more acceptable level of risk, but the grief – that kind of grief is never normalized.

How does surgery in a low-resource setting become unsafe?

The problems are so complex, on many different levels, from bureaucracy at the top end to the grassroots clinical level where local healthcare staff can be extremely overburdened, often working in an environment lacking support and training. It can be very disheartening, on call 24 hours a day, seven days a week; going home and waiting for the phone to ring them back to an ill-equipped theatre with lack of staff and little recovery care.

These people may be the only healthcare professionals for miles around and as a result their work takes over their lives.

The working environment itself presents a challenge. An unreliable electricity supply can mean performing a caesarean by torchlight with very poor visibility or in the blistering heat with lack of fans or air conditioning. This results in a very difficult operating environment for the surgeon. Poor lighting makes it difficult to see what you are doing and a hot operating theatre is an infection risk, not to mention the surgeon can barely stand by the end of the operation.

And when that reality is also conflict zone?

One of the first things to collapse is the structure of healthcare, although despite this women will continue to have babies.

A distressed population will present with many different medical problems, some like trauma are linked directly to conflict but what persists in any affected population are the problems in maternal and child health. Aid workers going into an emergency zone will find themselves performing many caesarean sections and the decision to operate on someone in such circumstances can be a difficult one.

Can you describe a case that stayed with you?

Probably the first post-partum hysterectomy I did for a woman with uncontrollable bleeding following delivery. The staff were able to recognize very quickly that she was unwell, which was the first life saving step. We used our small but well equipped field theatre which had just enough of the right surgical instruments to perform the operation. She had been bleeding for a week before she got to hospital and without the surgery would have died very quickly.

Looking back I can see that it was really good teamwork but at the time it felt a little like a miracle. I came in the next morning and she was sitting up in bed, nursing the baby and eating biscuits.

What’s the role of the visiting healthcare worker?

It’s extremely important not to go in, do operations and then leave again, without leaving any legacy. That’s even more disruptive.

An obstetrician performs about 5 key procedures regularly, all of which are potentially life saving, in a safe surgical setting. By teaching someone to perform a safe caesarean you allow them to go on and teach 5 more, which is important in building a lasting healthcare structure in resource poor settings.

Healthcare workers in ‘developed’ countries have so much to learn from working in low resource settings. The current trend in our training is moving away from the question ‘did you ever do any work abroad’ and towards asking ‘why didn’t you?’. This can only help to broaden our horizons.