“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.