Maternal Death The Avoidable Crisis
1 Introduction

Urgent Delivery
Maternal Death:
The Avoidable Crisis

Maternal Death The Avoidable Crisis
2 Contents

Contents

Introduction

4

MSF obstetric programs

5

The critical moment: delivery

7

The causes of maternal death8Complications in conflict

9

Ivory Coast10

Afghanistan

11

Somalia12Pregnant on the run, far from home

13

Kenya

14

Republic of Congo

15

Natural disaster: Spotlight on Haiti

16

Fragile health systems

19

Central African Republic

20

South Sudan

21

Democratic Republic of Congo

22

Pakistan

23

When maternal mortality is the emergency

25

Burundi26

Nigeria27

Maternal Death The Avoidable Crisis
4 Introduction

Maternal Death:
The Avoidable Crisis

Every day, approximately 1000 women die inchildbirth or from a pregnancy-related complication.1
Maternal death can occur at any time in pregnancy,
but delivery is by far the most dangerous time forboth the mother and the baby. The vast majority ofthese deaths can be prevented if access to emergency
obstetric care is ensured.
Experience shows us that at least 15 percent of all
pregnant women worldwide encounter a life-threatening
complication. In a conflict or a crisis, pregnant womenare even more vulnerable because health services havecollapsed, are inadequate or non-existent. But these
women need access to quality emergency obstetric care
whether they live in a conflict zone, in a refugee camp or
under plastic sheeting after a devastating earthquake.
In fact, they need the same help that all pregnant womenfacing a complication need: access to appropriate medical
assistance – skilled medical staff, drugs and equipment –to save their life and the life of their baby.
Médecins Sans Frontières (MSF) makes it a priority to provide
life-saving, emergency obstetric care in both acute andchronic humanitarian crises. In the organisation’s emergency
activities, teams strive to address the five main causes ofmaternal death: haemorrhage, sepsis, unsafe abortion,
hypertensive disorders and obstructed labour.
The provision of emergency obstetric care is at the forefrontof MSF’s work in sexual and reproductive health. Additional
medical care provided to women by MSF includes antenatal
and postnatal care, family planning, assistance to sexual
violence survivors, fistula treatment, post-abortion care, andprevention of mother-to-child transmission of HIV.
This briefing paper details MSF’s approach to delivering quality
emergency obstetric care in five different types of crises:
Conflict
Population displacement
Fragile health systems
Natural disaster
Maternal mortality emergency
Conflict, epidemics, natural disasters, or the complete
breakdown of a country’s health system are crises faced by
MSF’s millions of patients around the world every day.
But a maternal death: that’s the avoidable crisis.
1 Unless stated otherwise, all statistics (except for MSF activities)
are sourced from the World Health Organization.

© Yasuyoshi Chiba/Duckrabbit

Maternal Death The Avoidable Crisis
5 MSF obstetric programs

MSF provides obstetric carein around 30 countries.
In 2010, MSF teams delivered
more than 150,000 babies.
Médecins Sans Frontières
obstetric projects
Afghanistan
BurundiCentral African Republic
Chad
Colombia
Democratic Republic of Congo
Ethiopia
Guinea
Haiti
India
Iraq
Kenya
Liberia
Malawi
Niger
Nigeria
PakistanPapua New Guinea
Republic of Congo
Russian Federation
Sierra Leone
SomaliaSouth Sudan
Sri Lanka
Sudan
UgandaYemen* based on 2010 data – projects withmore than 100 deliveries per year

Russian Federation

Iraq

Afghanistan
Pakistan
India

Haiti

Niger
GuineaSierra Leone

Colombia

Nigeria
Central African Republic
Liberia Republic of Congo

Chad
Sudan

Yemen

Ethiopia

SomaliaSouth Sudan
UgandaKenya
BurundiD emocratic Republic of Congo
Malawi

Sri LankaPapua New
GuineaMaternal Death The Avoidable Crisis
7 The critical moment: delivery

The critical
moment: delivery

Maternal Death The Avoidable Crisis
8 Introduction
The causes of maternal death

A maternal death1 can occur at any
time during pregnancy or up to 42days after childbirth, but delivery is
by far the most dangerous time forboth the woman and her baby. The
majority of maternal deaths occur
just before, during, or just after
delivery, often from complications
that cannot be predicted. At thiscritical moment, a woman needs
access to quality emergency obstetriccare: skilled medical workers who
can identify complications, and drugs
and equipment necessary to takeprompt action to save her life and thelife of her baby.
Taking the emergency medical
approach: Targeting the fivemain killers
When launching an emergency
response to a crisis, MSF concentrates
efforts on medical activity that
directly addresses the main causesof maternal death. Over 80 percent
of maternal deaths are due to direct

obstetric complications that are either
preventable or treatable. The five main
killers – haemorrhage, sepsis, unsafe
abortion, eclampsia and obstructedlabour – account for almost threequarters of all maternal deaths.
In order to have the most immediate
impact on reducing maternal death
during acute and chronic humanitariancrises, MSF has invested significantly
in developing the technical andlogistical capacity to provide life-saving
emergency obstetric and neonatalcare. This care is provided by a skilledattendant, such as a midwife, obstetrician
or doctor, who is trained in promptly
identifying and managing complications.

The causes ofmaternal deathWorld Health Organization,
World Health Report 2005
1 Hussein et al (2011), A review of healthsystem infection control measures indeveloping countries: what can belearned to reduce maternal mortality,
Globalisation and Health, 7:14.

Sepsis (Infection) 15%

Unsafe Abortion 13%

As many as 5.2 million new cases ofmaternal sepsis occur annually andan estimated 62,000 maternal deaths
will result from the condition.1 In
order to prevent infections, it isessential that women deliver ina hygienic environment and if
infection does occur, be treated with
antibiotics. In addition to the threat
to women’s lives, the condition is
also associated with more than one
million neonatal deaths and can also
lead to long term consequences forthe woman such as infertility.

Worldwide, nearly half of all induced
abortions are performed under unsafe
circumstances; 98 percent of these unsafe
abortions occur in developing countries.
Reducing the number of women dying
as a result of an unsafe abortion requiresa multi-faceted approach. Appropriate
care must be available to all women who
present to a health facility experiencing
complications (incomplete abortion,
sepsis, haemorrhage) following an unsafe
abortion. In order to prevent unsafe
abortions occurring in the first place,
women need access to family planningand emergency contraceptives to reduce
the number of unwanted pregnancies,
and also to safe abortion care performedby skilled medical workers in safe andhygienic facilities.

MSF provides life-saving care withskilled staff at:
A basic unit – provides appropriate
drugs for treating infection, eclampsia
and haemorrhage, manual removalof placenta and retained products,
instrumental delivery such as vacuum
extraction and care for the newborn.
MSF also manages a higher level ofcare in hospitals, to which women
can be referred as required:
A comprehensive unit – provides allof the above as well as surgery suchas caesarean sections, safe bloodtransfusion and care for sick and low
birth weight newborns.
1 A maternal death is the death of a woman
while pregnant or within 42 days ofchildbirth or the termination of pregnancy,
irrespective of the duration and site of thepregnancy, from any cause related to (direct)
or aggravated by (indirect) the pregnancy or
its management, but not from accidental orincidental causes (World Health Organization).

© Nicola Vigilanti

Indirectcauses20%

Other
directcauses8%

Haemorrhage 24%

Obstructed Labour 8%

Haemorrhage (severe bleeding)accounts for approximately a quarterof all maternal deaths and can kill evena healthy woman within two hours.
The majority of haemorrhage cases
occur immediately after delivery andcan be prevented and treated withsimple measures. For example, an
injection of oxytocin given immediately
after childbirth is extremely effective
in reducing the risk of postpartum
haemorrhage. In some cases, theurgent manual removal of the placenta
is required, and some women needa blood transfusion and/or a surgicalintervention. Haemorrhage can result insevere anaemia in the longer term.

Obstructed labour can be the result of awoman’s pelvis being too narrow for thebaby’s head to pass through during birth,by the baby being in the wrong position
or by inadequate uterine contractions.
Without an appropriate medical
intervention, a woman may spend anumber of days in labour and eventually
die of complications of a ruptured uterus.
Commonly, the baby is stillborn or diessoon after birth. Skilled medical workers
can manage many of these problems
before labour becomes obstructed orrecognise slow progress and refer awoman for an instrumental delivery or
caesarean section. If a woman survives a
prolonged obstructed labour, she may beleft with an obstetric fistula (see page 26).

Hypertensive Disorders(Pre-Eclampsia/Eclampsia) 12%
Pre-eclampsia is a pregnancy-induced
hypertensive disorder occurring
during late pregnancy, labour, or afterchildbirth. The last stage – eclampsia– is characterised by seizures. Mild
pre-eclampsia can be monitored during
pregnancy but severe pre-eclampsia
or eclampsia requires urgent care ina hospital. While blood pressure canbe lowered by the use of specificantihypertensive drugs and further
seizures can be prevented withmagnesium sulphate, the only ‘cure’for the condition is the delivery of thebaby, which must be done as quickly
as possible, either by vaginal delivery or
caesarean section.

Maternal Death The Avoidable Crisis

Complications
in conflict
Ivory Coast
Afghanistan
Somalia

Maternal Death The Avoidable Crisis
10 Complications in conflict

Amidst the death and devastation ofarmed conflict, the cycle of everyday
life continues and it is often pregnant
women – the indirect victims of aconflict – who fill MSF’s emergency
rooms. Just like pregnant women
anywhere in the world, they needaccess to quality emergency obstetriccare in the event of a complication. But
while their needs are ordinary, theircircumstances are not.
Secondary level health care is one of thefirst casualties of armed conflict: healthstructures are often damaged, destroyed
or shut down, supplies of medicines andequipment are cut off, and many skilled
medical professionals flee the area to seek
refuge. Insecurity also makes it dangerous,
if not impossible, for women needing
emergency obstetric care to access thehealth facilities that are still functioning.

Delivering care in these volatile andinsecure contexts is inherently difficult
and requires a flexible and pragmatic
approach. It is not always feasible toprovide a comprehensive package ofsexual and reproductive healthcare,particularly during the initial phaseof an emergency, so MSF focuses on
the services that will have the mostsignificant and immediate impact onmortality. Extensive outreach activities
may not be possible due to insecurity,
so MSF utilises the small opportunities
that exist to reach out and let womenknow about the free maternal healthservices that are available at MSF
facilities. Once the situation has
stabilised, it is possible to implement
more wide-ranging and far-reachingactivities, such as health education,
comprehensive postnatal follow up
and family planning.

Ivory Coast

When Ivory Coast dissolved into aviolent political crisis following the
October 2010 national elections,pregnant women in the country’s
largest city, Abidjan, faced a crisisof their own. Fierce fighting forced
the closure of many health facilities
and a huge number of healthprofessionals fled the city in searchof safety, leaving women in needof emergency obstetric care in adangerous position.
At the height of the conflict inFebruary 2011, MSF began providing
emergency medical care to thousandsof wounded patients in a Ministryof Health hospital in Abobo, one of
the areas of Abidjan most affectedby heavy fighting. Confined to thehospital grounds because it was too
dangerous to leave, medical staff faced
a double emergency: multiple influxesof patients suffering from acute trauma
such as bullet and shrapnel wounds;
and at the same time, hundreds ofwomen arriving at the hospital doors
needing a place to deliver their babies
safely. Sometimes overwhelmed by up
to 80 deliveries a day, MSF staff went on
to assist 1400 deliveries in just 56 days.

Caroline Seguin,Emergency Coordinator in
Abobo hospital, Abidjan“In Abobo, the population had noaccess to health services because
all the health structures had closed
because of the fighting. At the heightof the emergency, the scene in thehospital was a mess. The emergency
room (ER) was full of wounded patients
and we had to treat people outside
the ER, on the floor. At the same time,the maternity ward was full of womendelivering. The conditions were very
difficult because we were short ofsome essential drugs and there werelots of emergencies at the same time.
But the team was really proud to help
women give birth in the middle of all
the fighting and death.
It was really hard to manage the trauma
and obstetric emergencies at thesame time. We only had one operating
theatre at the beginning and even after
we opened another one, it was still notenough. We had to prioritise the cases.
Some days we had to deal with sevenor eight caesarean sections plus thetrauma surgery and dressing changes
for the wounded.
The security situation was critical –sometimes the hospital was full ofarmed men from the military and I had
to calm them and ask them to leave
the hospital. Sometimes we received
bullets inside the hospital comingfrom the surrounding fighting. Whenthe fighting in Abobo was too tense,
it was too dangerous for women to
cross the check points and avoid thebullets, so many women could notreach the hospital and they deliveredat home. Some women came toolate and arrived in a bad condition
so unfortunately sometimes we hadmaternal deaths. But we were theonly ones dealing with complicateddeliveries so without MSF’s services, a
lot more women would have died.”© Nicola Vigilanti© Nicola Vigilanti

Maternal Death The Avoidable Crisis
11 Complications in conflict

Maternal Death The Avoidable Crisis
12 Complications in conflict

Lenet Kajogi, Medical Focal Point /acting field coordinator, Ahmad
Shah Baba hospital, Kabul“From our hospital, we can reach a big
part of the population of Kabul so thatwomen do not have to make long
journeys to reach medical care. The factthat all medical care is completely freeat our hospital means that we also reachsome of the poorest people who can’t
afford expensive private clinics, which
for many is the only other option in thisarea. We are trying to reach all women of
reproductive age in Ahmad Shah Baba,
but as word of the hospital has spread,
we are seeing more and more womenfrom the surrounding areas and villages.
In many families it is still not acceptablefor women to go to a hospital alone, or atall. Most women still give birth at home inunhealthy conditions, and are not awareof the benefits of going to a hospital toget help from medical professionals. It
is also very difficult to convince women[who deliver at the hospital] to comeback for postnatal follow up. Out of 500
deliveries, only about ten come back for
postnatal care, but it is something we areworking on improving through healthpromotion and talking to our patients.
Busy days can get really busy. We usually
perform around 25 deliveries every day
and if there are many deliveries at once
it can be challenging for the staff. Since
opening the project, we have almost
doubled the number of deliveries – in2009 there were 3588, and in 2011 there
were more than 6000. We have offeredextensive training to the staff here, tothe point that Afghan MSF midwives can
now supervise the maternity without
assistance from international staff.
There is one patient that I will neverforget. She was a 25-year old woman
who came in just before delivery
with severe pre-eclampsia. We were
all convinced that she was too ill tomake it, but we managed to reduce
her blood pressure and performed avacuum-assisted delivery. After threeintense days, she was sitting up withher baby in her arms and chatting. It
was really amazing to see, and evenmore encouraging that she was one of
the mothers who later came back forcheckups after her delivery.”© Ton Koene

Afghanistan
Afghanistan is one of the mostdangerous places in the world fora woman to give birth. Decades ofconflict continue to take a huge tollon the availability and quality of
medical services in the country; thepopulation suffers from a generallack of access to medical treatment,
particularly to secondary level
health care, including emergency
obstetric services. Insecurity meansthat many women are hesitant
to make the long, dangerous
and often expensive journey tohealth facilities offering quality
maternal healthcare. The private
healthcare sector in Afghanistan iswidespread, but it is unaffordable
for many Afghans, and the qualityof care on offer is questionable.
The country also faces a shortageof qualified female staff and the
supply of drugs and medical
material can be inconsistent.

© Oscar Sanchez-Rey

Somalia
The tripling of the population of thecapital Kabul over the last ten years
reflects a migratory trend towards
urban areas, and includes displaced
persons fleeing conflict in more
insecure regions in Afghanistan andreturnees from refugee camps inPakistan. In Ahmad Shah Baba, a
growing district on the outskirts ofeastern Kabul, MSF works alongside
existing hospital staff to provide
healthcare in all areas of the hospital,
including a comprehensive maternal
healthcare package that includes
antenatal, delivery, emergency
obstetric, postnatal and neonatal care.

After more than two decades ofcivil war combined with frequent
drought, Somalia maintains its status
as one of the world’s most intractable
humanitarian crises. In addition tothis ongoing emergency, every day,a Somali woman must face startling
statistics: the country has someof the highest maternal mortality
rates in the world at twice the global
average and a woman has a one inthirteen lifetime chance of dying as aresult of pregnancy or childbirth.
Today, Somalia is one of the mostcomplex places where MSF isdelivering assistance. A context ofhigh insecurity prevails throughout
most regions, leading to immense
challenges in safely and efficiently
providing humanitarian aid. Accessfor international technical support
staff is still largely restricted due tothe level of security risk and also due
to imposed restrictions, so projects
are run primarily by Somali staff,
supported by teams of specialist
staff based in Nairobi who visit the
projects when possible. The ongoing
conflict has caused health services
to crumble, leaving the vast majorityof the country without access tobasic services. Emergency obstetricservices are limited or non-existent in
the majority of the country, and it isfrequently unsafe for women to travel
to access care, leaving those who© Otavio Omati

Hawa’s story
suffer complications during pregnancy
and labour extremely vulnerable.
One of the regions where MSF is
responding to this crisis is Middle
Shabelle, in central Somalia. Teams areproviding a comprehensive packageof maternal healthcare through a
network of four health centres, in therural districts of Jowhar and Balcad.
Through mobile and fixed clinics,
staff also offer general healthcare,treatment for malnutrition and an
extended immunisation program. All
services are provided free-of-charge.
One of MSF’s objectives is to ensurethat women do not arrive too lateto deliver at the hospital. In 2011, theMSF team registered five maternal
deaths of women who delivered in
the community but came to Jowhar
Hospital too late with complications.
In this hospital, 90 kilometres north of
Mogadishu, 1834 women delivered
their babies, including 291 who
underwent complications. Some 126
women delivered by caesarean section.

Hawa, a 21 year old woman, had beenin labour for three days before she
was finally referred to MSF’s hospital in
Jowhar, 18 kilometres from her village.
She was examined by medical staff
and diagnosed with obstructed labour
due to cephalous-pelvic disproportion
with foetal distress. An emergency
caesarean section was planned, butconsent could not be provided by herhusband because he was too young
to give it. Therefore Hawa’s brotherwas asked but refused to provide it
because he thought the child’s life
should not take priority over Hawa’s.
Following advice and counsellingfrom doctors and midwives, the older
brother consented and the caesarean
section was performed – a distressedbaby boy was delivered and needed
resuscitation, but fortunately Hawa
and her baby survived theentire ordeal.

Maternal Death The Avoidable Crisis
13 Introduction

Pregnant on therun, far from home
Kenya
Republic of Congo

Maternal Death The Avoidable Crisis
14 Pregnant on the run, far from home

The risks faced by women during
pregnancy and childbirth arecompounded when they are forced
to flee their homes due to violence
or instability. Along with children,
women are the most vulnerable
group amongst a refugee or internallydisplaced population, and pregnancy
amplifies this vulnerability. After days
or weeks of walking, pregnant womenare often in a weakened state by thetime they reach safety. The living
conditions that may greet them –lack of access to adequate shelter,
nutritious food and clean water, as well
as exposure to communicable diseases
like cholera and hepatitis A – only
intensify the danger. For many women,
the place where they have sought

refuge is also affected by insecurity,
so accessing the care that does exist
involves an often perilous journey.

Dr Josiah Oyieke, Maternity WardManager, Dagahaley Hospital

Assessing and addressing emergency
obstetric needs is an integral part of
MSF’s response in both acute andprotracted situations of displacement.
Depending on the facilities andservices that are already available,
MSF may establish a network ofhealth posts throughout a camp or
area where people have settled, from
where women needing obstetric carecan be referred to a hospital, which
deals with complications if necessary.
To ensure as many women as possible
are aware of, and can benefit from theservices, proactive communication
with community leaders, other healthproviders and the women themselves,is paramount.

“One of the main challenges we facehere in the maternity ward is the issueof obtaining consent from patients inemergency situations. Often the womenin need of emergency interventions are
not in a position to give consent for therequired procedure, and need to obtain
permission from family members – notjust husbands, but other relatives too.

© Reuters

Kenya
Dadaab, Kenya. The world’s largest
refugee camp. Home to around halfa million people, the vast majority ofwhom have fled conflict or hunger
in neighbouring Somalia.
Already in a dire situation, refugees
living here are now facing an evenbigger crisis. In October 2011,
following the kidnapping of two MSF
workers and an increase in insecurity,
humanitarian aid was scaled backsignificantly. MSF remained however,running its 300 bed hospital in
Dagahaley – one of the five campsthat make up the complex – atfull capacity. The maternity ward,
which offers emergency obstetriccare including caesarean sections
if necessary, today sees around 350
deliveries per month.
Around 20 percent of the refugees
living in Dadaab are women of
reproductive age. In an average 24hour period, eight to ten babies areborn in MSF’s maternity ward. The
ward is also supported by a network offour health posts situated throughout
Dagahaley, where women can receive
antenatal care. Medical staff at thehealth posts will also immediately
refer patients to the maternity ward
if they have complications during
pregnancy or are suffering any otherobstetric problems. In 2010, MSF teams
delivered over 2300 babies in
the hospital.

© Brendan Bannon

Despite the presence of maternity
services within Dagahaley, it isestimated that an average of 20–30
women deliver at home each month,leaving them prone to develop
complications at a later stage,
especially infections. To reduce
the number of home births andto encourage women to deliver inthe safe, controlled environmentof the hospital, MSF is providing a
special service called the ‘Mama Taxi.’
Expectant mothers are given thenumber of a driver they can call when
they are in labour, avoiding themtrying to find transportation at night
when insecurity in the camp can beheightened, or having to walk too far
to get to the hospital.
1 Female genital mutilation results in a highmorbidity (sepsis, bleeding and urinary
retention) and has disastrous long termcomplications. It is on these objective medical
grounds that MSF is strictly opposed toits practice and does not supply drugs orequipment for its purpose. MSF of course
provides care for girls and women suffering
the medical consequences of this practice andmakes no related judgment of the practice.
To alleviate the risk of complications
during pregnancy for women who haveundergone infibulations, it is necessary tounstitch the vaginal opening so that the
infant can pass through (disinfibulation).
MSF has a policy of refusing to stitch thegenital lips back together (reinfibulation)and MSF teams explain to communities the
medical reasons for this.

Time that is lost in waiting for consent
from the woman’s family can be thetime between life and death. For
example, one woman arrived at theward in the late stages of pregnancy
with bleeding and high bloodpressure. She declined a caesarean
section and went home despite thebaby having already died inside theuterus. Eventually she came back to
the ward with severe complications
and associated blood clotting. She
finally underwent the operation, but somuch severe damage to her uterus wascaused during the delay that the entire
uterus had to be removed and she
won’t be able to have children again.
Female genital mutilation is almost
universal in the population we aretreating here, and it is the mostextreme type-three form. This can haveserious consequences for childbirth, as
the passage is too small for delivery
and the area needs to be disinfibulated
in order to allow the birth to takeplace. The MSF protocol is to leave
the women disinfibulated without
refibulating after they have given birth.1
The best thing about this job, andabout MSF, is that the facilities areavailable to enable me to give mothers
the best possible care. I do not need toworry about getting the equipment I
need to ensure the highest standard ofcare. I know MSF will provide it.”
Suleiman’s story
Suleiman is a patient who gave birth toa baby girl in MSF’s maternity ward. She
arrived at the hospital with the helpof the Mama Taxi service. “The child is
now doing well. I felt my labour in theevening and my mother and I have thenumber of the taxi. We called and hecame immediately, after 20 minutes.”Maternal Death The Avoidable Crisis
15 Pregnant on the run, far from home

Republicof Congo

Maternal Death The Avoidable Crisis
16 Pregnant on the run, far from home

Republic of Congo is home to someof the highest maternal mortality
rates in Africa, with women having
a one in 22 lifetime risk of dying due
to pregnancy or childbirth.
Added to this is the dynamic of alarge population of refugees whobegan fleeing from neighbouring
Democratic Republic of Congo at
the end of 2009. Many have settled
along the Ubangi River in Likouala
Province, and MSF has been working
since November 2009 in the town of
Bétou, providing emergency obstetrichealthcare in the 25-bed maternity

unit, alongside other services. As
well as working in Bétou hospital,
to reach the more remote refugeesettlements, mobile MSF medical
teams travel up and down the river byboat, providing general consultations
and antenatal care. Congolese nurses
in the five health centres from where
MSF runs these mobile clinics arealso trained to attend to normaldeliveries, and to monitor basic
elements in pregnancies and labour
so abnormalities can be diagnosed
quickly and referred to the hospital.
In 2011, MSF performed 12,472
antenatal consultations, 2642
deliveries and 207 caesarean sections.
There were no maternal deaths in
Bétou hospital.

Natural Disaster:
Spotlight on Haiti“The one shining light in all thisphysical and emotional sufferingis the birth of healthy little babies.
Eight healthy little new ones
arrived today under the blue tarpof our hospital. We all need themto breathe new life and hope into
this torn country.”
21 January 2010,
Isabelle Jeanson, MSF Communications Officer

© MSF

© MSF

© Kadir van Lohuizen / NOOR

Maternal Death The Avoidable Crisis
17 Natural Disaster

The massive earthquake thatdevastated Haiti on 12 January2010 killed approximately 200,000
people and left one million
homeless. The disaster led to MSF
launching what would become theorganisation’s largest emergency
response in its 40 year history.
Images of makeshift medical
facilities being inundated bythousands of injured patients and of
surgeons desperately carrying out‘open-air’ operations under plastic
sheeting were broadcast around theworld. But amidst the unrelenting
cases of acute trauma, the everyday
emergency of giving birth in Haiti
continued amongst the rubble.
In the 12 months following theearthquake, more than 15,000
women gave birth in MSF clinics
and hospitals. In some facilities,
obstetric-related surgery made up
60 percent of all surgical activity.
Even before the earthquake struck,
pregnant women were at risk in
Haiti – the country has the highest
maternal mortality rate in the Western
hemisphere. Since 2006, MSF had
been providing emergency obstetricservices in the Delmas slum area of thecapital Port-au-Prince, where many
women could not access care because
it was unavailable, unaffordable orinaccessible due to violence andinsecurity in the slum. Up to 60
percent of Haiti’s health facilities wereMaternal Death The Avoidable Crisis
18 Natural Disasterseverely damaged or destroyed in theearthquake, including MSF’s obstetricfacility – Maternité Solidarité.
As a result, MSF started providing
human resources, drugs and obstetrics
expertise to the Ministry of Health’smaternity hospital Isaïe Jeanty,
which had not been damaged in
the earthquake. The hospital was
overwhelmed with women coming
to deliver, many of them with serious
complications. And with thousands offamilies sleeping on the streets, many
women faced the added difficultyof having no homes to bring theirnewborns to following a safe delivery.
“We’ve delivered so many prematurebabies as a result of trauma”, said
MSF midwife Eva de Plecker at thetime. “Women are coming to us withpre-eclamspia or eclampsia – serious
conditions exacerbated by stress.
Though Haiti had an extremely
high rate of pre-eclampsia before
the earthquake, the massive toll of
this disaster has probably further
aggravated the condition. After a few
days, the maternity ward here reachedfull capacity. Women with serious
complications need a longer time torecover after birth. At the same time, we
still have to keep making space for new
mothers and babies that need our help.”
As the cases of acute trauma slowed
to a trickle in the weeks following theearthquake, the need for emergency

obstetric care – and secondary level
healthcare more generally – remainedin Port-au-Prince. In recognition ofthis need, MSF built the Centre deRéférence en Urgences Obstétricales(CRUO) in the Delmas area to replace
the destroyed Maternité Solidarité. The
new 130-bed facility began treating
patients in March 2011 and provides 24hour free care for women experiencing
serious and often life-threatening
complications. Since opening, morethan 4000 women have delivered
at CRUO; 70 percent of which werecomplicated deliveries. The hospitalis staffed primarily by Haitian healthprofessionals and support staff andis equipped with its own laboratory,
blood bank and pathology department.
MSF also provides care to newborns in
a dedicated neonatal department.
At the epicentre
In Léogâne, west of Port-au-Princeand very close to the epicentre of theearthquake, MSF began providing
emergency medical assistance after
80 percent of the city was destroyed.
While the project was initially set up
to treat patients wounded in theearthquake, MSF quickly identified
a huge need for obstetric andgynaecological care. Even before theearthquake, women in Léogâne had
to travel to Port-au-Prince to reachthe nearest hospital to give birth orreceive emergency obstetric care.
MSF decided to stay well beyond the© Ron Haviv/VII

Roseline, 34, was five months
pregnant when the earthquake
struck. She delivered her first baby
at the Isaïe Jeanty hospital fourmonths later.

© MSF

emergency phase and, by September
2010, the makeshift tent hospital was
replaced with a semi-permanent
structure made out of containers.
Obstetric/gynaecological activities
now make up more than half of all
medical activities at Chatuley hospital,
with five gynaecologists and twenty
midwives assisting the delivery of
up to more than 700 women eachmonth. The hospital provides a full
package of sexual and reproductive
health services including antenatal care,postnatal care and treatment for sexual
violence victims. Two years after theearthquake, the 160-bed health facility
remains the only health structureoffering free emergency medicalcare to a population of approximately
300,000 inhabitants in Léogâne and thesurrounding area, and has become areferral centre.
Pregnancy and the cholera
emergency
On 20 October 2010, cholera broke out
for the first time in Haiti, prompting
MSF to open 70 cholera treatment
centres and units throughout thecountry. When cases began appearing
in Port-au-Prince, pregnant womenstarted arriving at MSF facilities
suffering from the disease andexperiencing obstetric complications
or premature labour as a result.
Cholera affects pregnant women thesame way it affects other people, withdehydration, diarrhoea and vomiting,but for some pregnant women, theirbaby is at critical risk. The mother’s
dehydration means the baby will notreceive enough oxygen, blood flow, orthe necessary nutrients, which causes
distress and can bring on prematurelabour. In Isaïe Jeanty hospital in
Port-au-Prince and Chatuley hospitalin Léogâne, MSF set up obstetriccholera treatment units (CTU) to
isolate pregnant women. The care
was organised so that the pregnancy,
delivery and postpartum period could
be supervised within the CTU byspecialised staff, with the possibility ofreferral to the maternity ward in theevent of complications. In Léogâne,
MSF undertook a study among the
102 pregnant women who received
treatment for cholera at the hospital
between 13 December 2010 and 28
February 2011, in order to measure theeffect of this specialised approach on
the outcome for the mothers and theirbabies. Previous research has shown
the maternal mortality rate amongcholera-affected pregnant women
to be up to 25 percent and the foetal
mortality rate to be between 12 and54 percent. However, there were nomaternal deaths recorded among thepatients in MSF’s study and there wasa foetal mortality rate of 13.8 percent,half of which had occurred before
admission. The study illustrated thatthe setting up of a specific care unit
meant that specialised staff could
successfully manage both the obstetricand neonatal aspects of care as well as
the cholera at the same time.

“When the earthquake happened I was
afraid I would lose the baby as I ran
outside the house. I was so scared forhim. Afterwards, I talked to the baby
inside me and explained to him what
happened. The pregnancy went well
but the birth was a bit difficult. I had
a lot of pain and I needed a caesarean
section. I knew that the services
would be free here, that’s why I came.
It all finally went well, and here isAngely, my first baby. I am very proud
to finally be a mother. We thoughtthat life was done. But no, we take it
back, step by step.”
Crisla, 19, was readmitted a day
after giving birth to twins at Isaïe
Jeanty hospital.
“I developed eclampsia the day
before I delivered and I realise that’s
serious. During my pregnancy, thedoctors advised me to stay calm sothat my blood pressure would not
rise. However, the day before I gavebirth, I had a problem at home. I got
angry and I fainted. When I woke up
the next day, I realised that I was in
the hospital with the two babies next
to me. Then they told me that I had
developed acute eclampsia and thatthe babies were born by caesarean
section. I was making a good recovery
until I went home and began to bleed
again. I came back to the hospital rightaway. The doctors realised that I still
had blood clots in my belly, so they
operated again to clean everythingout. They [the twins] are so pretty, but
I can’t take care of them yet. I have toomuch pain.”Maternal Death The Avoidable Crisis

Fragile healthsystems
Central African RepublicSouth Sudan
Democratic Republic of Congo
Pakistan

Maternal Death The Avoidable Crisis
20 Fragile health systems

No matter what the context, pregnancy andchildbirth is always going to be a significant andconstant demand on a country’s health system.
When this system is dysfunctional, damaged or
non-existent, pregnant women are in a dangerous
position. It is the life-saving, secondary level
care that is most affected when a healthcare
system is not functioning. Protracted conflict or
instability means that infrastructure is basic or
may not exist at all, drug supply is erratic at best,and skilled staff may have left for urban areas, or
have left the country entirely. With health services
concentrated in the capital city and major towns,
women living in remote areas find it particularly
difficult to access emergency obstetric care when
they face complications. They must travel long
distances, often with limited transport options, toreach facilities that may not even have the skilled
staff, adequate drugs or equipment necessary to
manage their delivery safely. Depending on needs
and feasibility, MSF may create a health structurefrom scratch, support existing health facilities or
upgrade a primary level heath structure into asecondary level facility. To ensure that patients
receive the best quality of care and that this levelof care can continue after the organisation has
handed over the project, MSF invests significantly inthe training of national staff.

Central African
Republic

The Central African Republic(CAR): a country in a state ofchronic medical emergency. Fiveseparate retrospective mortality
surveys carried out by MSF
and other researchers in 2011highlighted excess mortality
above the emergency thresholdin areas accounting for the
majority of the population.
Pregnant women do not escapethese statistics – a woman has a one
in twenty-five lifetime risk of dying
as a result of pregnancy or childbirthin this country. One of the biggest
barriers women face is access tohealth facilities: distances to travel
to a hospital are often huge, roads
are in poor condition, and transport
options may be nonexistent or
unaffordable. A dearth of trained
medical staff in outlying areas, alongwith a significant lack of equipment
and medication, makes it extremely
difficult to access quality obstetriccare in the event of a complication.
MSF provides emergency medicalcare in nine hospitals and 36 healthposts throughout CAR. In Paoua, in
the northwest of the country, MSF
provides emergency obstetric care,including access to caesarean sections
if necessary. In 2011, more than 1400
women delivered their babies in MSF’s
maternity ward at Paoua Hospital.

© Talia Bouchouareb© Ben Milpas

Dr Anne Marie Pegg, Medical
Referent, Paoua“Pauline arrived at the hospital latein the afternoon. It had been overan hour’s drive on the back of a
motorcycle taxi. She had alreadybeen in labour for over 24 hours.
This was her fourth pregnancy – she
had had three previous caesarean
sections, but none of those babies
were delivered alive. During herantenatal visits, she had been strongly
counselled to make her way to thehospital at the onset of labour.
Her labour had started early in themorning. Knowing how important it
was to get to the hospital, she started
her search for a way to make the trip.
This wasn’t easy – she needed to findsomeone with a motorcycle who
could take her. No small task in an area
without mobile phone coverage, andwhere motorised forms of transport
are not widespread. After an entire
day and night of searching, she foundsomeone. She was reassured by the
movements of the baby within.
On arriving at the hospital, she wasquickly assessed by the midwife, whothen notified the doctor on call. Wellaware that a caesarean section wasnecessary, the surgical team was
summoned. Within an hour, Pauline’s
baby daughter was born, pink andscreaming, into the world.”

Maternal Death The Avoidable Crisis
21 Fragile health systems

Maternal Death The Avoidable Crisis
22 Fragile health systems

Janet Fields, a nurse-midwife who
has worked in Aweil tells the story ofa woman who suffered postpartum
haemorrhage, the leading cause ofdeath during childbirth:

Dr Raghu Venugopal, Mweso“A mother came in for what we assumed
was a normal delivery. She had a quick
labour and delivery and within 30
seconds of the delivery of the placenta,
she started bleeding. We had alreadygiven her oxytocin, a drug which helps
with bleeding, but as the bleeding
didn’t stop, we immediately had to giveher another medication in her leg, andalso start an intravenous line on her. We
also did a lot of uterine massage. It took
a long time for the bleeding to stop,
but eventually it did.
The thing that is scary about thatstory is that this woman would mostcertainly have died in the village. Thiswoman has four other children to takecare of. Because she was here, her life
was saved.”
Katie Hutchinson, midwife, Agok
“It’s just horrific that so many womenare still dying in this country, especiallybecause there are simple proceduresthat can be done to prevent maternalmortality both in pregnancy anddelivery. Access to life-saving surgery is
extremely important for these women,
and MSF is now providing this in Agok.
During delivery there are some hugerisks that women face here if they are
not in the hospital.
But we can also do things that are not so
difficult, and that really can save women’s
lives. Every single week in maternity, we
save somebody’s life. It’s an amazing
thing to do, but it also makes me a little
upset that it’s not a difficult thing to do.
Women in South Sudan, as everywhere,
should have the opportunity to have asafe delivery. We haven’t had a maternal
death since I’ve been here, and thatis certainly my nightmare. A maternal
death is not acceptable, and I hope it will
stay like that.”© Marcell Nimfuer / Fischka.Com

South Sudan
In July 2011 a new nation wasborn, and with it, hope that abetter future would be paved fora country torn apart by decadesof civil war. But the prospect for
women in South Sudan remains
alarmingly unchanged. Women
still have a one in seven chanceof dying as a result of pregnancy
or childbirth during their lifetime,and it is not uncommon that they
will have to walk for days, andoften weeks, to reach an adequate
health facility to give birth. South
Sudan’s health system has been left
shattered by years of conflict, anda lack of trained and skilled healthstaff and adequate facilities, leaves
three quarters of the population
without access to even the mostbasic form of healthcare.
MSF, working in eight of ten statesof the country, is running some of its
largest obstetric programs in South
Sudan in response to this crisis. The
organisation runs the maternity
department in the bustling Aweil Civil
Hospital, in Northern Bahr El Ghazal
State, and in 2011 there were morethan 3000 deliveries, of which, around
10–12 percent were complicated.

An increasing number of women are
coming to the hospital to deliver theirbabies, in the knowledge that theirbirths will be safer with the assistanceof a skilled health professional
and access to drugs and the rightequipment if necessary.
In Agok, a town in the transitional
area of Abyei located in the borderarea of Sudan and South Sudan, thematernity team is carrying out anaverage of 66 deliveries per month.
MSF has been working here since2008, running a comprehensive
hospital program serving a
population of around 100,000. An
operating theatre that opened
in Agok in 2011 now means thatemergency caesarean sections, aswell as other surgical proceduresfor pregnancy complications, areavailable for women if necessary. In
2011, the maternity team delivered
802 babies.

© Ben Milpas

Democratic
Republic of CongoIn the Democratic Republic of Congo(DRC), a woman has a one in thirteen
lifetime chance of dying as a resultof pregnancy or childbirth. This isa country that has been ravaged
by more than a decade of violent
conflict, and years of neglect of thehealth system have contributed tothis high rate of maternal mortality.
In 2010, MSF staff assisted more than
19,000 births in DRC, accounting for thelargest number of deliveries in any of thecountries the organisation is working in.
One of MSF’s many programs throughout
the country is situated in Rutshuru
Hospital, in North Kivu in the east of
the country. Since 2005, alongside the
Ministry of Health, MSF has been working
in the 280-bed hospital supporting
various services including the maternity.
More than 400 women give birth eachmonth in this ward, and in early 2011,nearly half of these deliveries were bycaesarean section. Due to the dangers
that such an intervention can pose to
women in their future pregnancies, one
of MSF’s objectives has been to reduce
the rate of caesarean sections.
Enrica Bentivegna,
MSF obstetrician/gynaecologist“The rate of caesareans needs to be
reduced in order to avoid futurecomplications for the women. If awoman of 15 years of age has acaesarean, she will likely need tohave them for her other births, anda long list of complications therefore
accompanies this, for example, uterine
rupture and postpartum haemorrhage.
Also, a child born by caesarean section
is more exposed to respiratory distress.
In less than a year we’ve been able tosuccessfully reduce the rate from 46
percent to 32 percent. Some caesarean
sections can be prevented by instead
doing an instrumental delivery. The
training of health workers in thispractice has been a key element in the
reduction of the rate.”
MSF is in the process of handing over
the responsibility of the maternity unitof Rutshuru Hospital to the Ministry of
Health, but will continue to train staff in
the management of both normal andcomplicated deliveries. Also in NorthKivu, MSF is working in Mweso healthzone in collaboration with the Ministryof Health, assisting a large and dispersed
population who during times of violence
and instability are displaced. At the 170bed Mweso Reference Hospital, teams areproviding safe deliveries to mothers who
might otherwise give birth in unsanitaryand unassisted conditions in their villages.
In 2011, more than 3500 deliveries wereattended to by the MSF teams.

“We see a lot of complications here.
Post-partum haemorrhage, retained
products and malpresentation of
newborns resulting in the impossibilityof a normal delivery are daily needs
here. The day before yesterday, awoman in labour presented with aruptured uterus. The child was safely
delivered during emergency surgery
and is doing well, but the motherbled very heavily. Our Congolese
doctors, operating late into the night,
sent a guard to wake me up to help
them find blood to transfuse into themother. We quickly mobilised our MSF
logistics and medical team, foundblood for the mother, and she lived.
Even when safe deliveries occur,children often suffer the effects
of pre-term labour. Many healthproblems among mothers, including
the hard lives they live where theywork in agricultural fields until thetime they go into labour, result inearly childbirths. Other problems
include newborn infections, including
tetanus. These medical conditions
result in our neonatology ward being
constantly full of mothers and theirnewborns. Neonatology is one of
the most complicated and difficult
aspects of our work, as prematureand ill newborns are very fragile
patients. However, our carefully
designed protocols and constant closemonitoring of such patients means
they receive a real chance at survival.”Maternal Death The Avoidable Crisis
23 Fragile health systems

Pakistan

Maternal Death The Avoidable Crisis
24 Fragile health systems“Most of the women’s deliveries
do still happen at home. They
don’t come to us because theyoften don’t have or can’t afford thetransport… We do a lot of healtheducation, about the importanceof antenatal care and coming here
for a safe delivery.”Jannicken Troemborg,
MSF midwife, Kuchlak, Balochistan

Pakistan has one of the highest
rates of maternal mortality in
Asia: women have a one in 93
lifetime risk of dying as a result ofpregnancy or childbirth. Limitedaccess to quality emergency
obstetric care, a shortage of
qualified female medical staff,
compounded by social andeconomic barriers, mean womenface significant risks duringchildbirth. In areas affected byconflicts and sectarian clashes,insecurity and travel limitation
make it even more difficult for
women to access quality obstetricand gynaecological care. Many
pregnant women who need
services are either refugees,
internally displaced or too poor to
pay for private clinics.
Emergency obstetric care is only
available in urban areas of Pakistan,often because of a severe shortage oftrained female staff. And many womentraditionally give birth at home,
especially in rural areas. In Balochistan,
Pakistan’s largest and least developed
province, violence, displacement,
lack of economic development
and poverty have limited people’s
access to healthcare. This often
leaves pregnant women who needemergency obstetric care in an evenmore vulnerable situation.
To improve access to emergency
obstetric and gynaecological care forinternally displaced women, as well as
to the local population of Nasirabad
and Jaffarabad districts, MSF has beenworking in Dera Murad Jamali District
Hospital since 2009. It is the only
medical facility in the district providing
free-of-charge, quality comprehensive
obstetric care, including caesarean
sections and antenatal and postnatalcare. In 2011, MSF conducted 990
deliveries – 517 of which werecomplicated cases, including 146 that
required caesarean sections.

© I sabelle Merny/MSF

In the town of Kuchlak, home to
many Afghan migrants and refugees
as well as nomads and a hostpopulation, MSF runs a mother andchild healthcare clinic with a birthing
unit that runs 24 hours a day, sevendays a week. The all-female staff inthe birthing unit offers free-of-charge
and much needed obstetric care.
For complicated cases that requirecaesarean sections or other specialised
medical care, MSF provides anambulance service to refer patients to
hospitals in Quetta. In 2011, the MSF
team assisted 2114 deliveries, 308 of
which were complicated. There were
197 women referred to hospitals for
caesarean sections. The team also
provided 3488 antenatal consultations
and 2159 postnatal consultations.
In Khyber Pakhtunkhwa (KP) province,
MSF is supporting the District
Headquarter Hospital in Timergara
and Tehsil Headquarter Hospital in
Dargai to provide free-of-charge
emergency obstetric care to a total
catchment area of over one million
people. In Timergara in 2011, there
were 4568 deliveries, 708 of whichwere complicated cases, including 616
caesarean sections.
In Dargai, as well as antenatal andpostnatal care, MSF also provides healthpromotion to male family members
in order to explain the importance ofantenatal care and the risks of delivery,
to encourage them to send their wives
and daughters to the hospital. In 2011,
2580 women successfully deliveredat the facility, 844 of whom hadcomplications. MSF teams performed
264 caesarean sections.
To respond to the significant need for
emergency obstetric care in Peshawar
district, MSF opened a Women’s
Hospital in May 2011. The 30-bed,
private reference hospital focuses on
managing complicated pregnancies
and deliveries. MSF also supports
Basic Health Units run by the local
authorities in Peshawar district withantenatal and postnatal care. A medical
referral network has been establishedwith refugee and internally displaced
persons camps and ten Basic Health
Units. The hospital also receives referrals
from other MSF projects in Hangu in
KP province and in Kurram Agency
in the tribal area, where clashes andinsecurity are always a concern. In 2011,
there were 156 deliveries conductedin the Women’s Hospital, including
58 caesarean sections. There were nomaternal deaths.

Jannicken Troemborg, midwife,
Kuchlak, Balochistan“It’s a very poor area of Pakistan, witha main population of about 100,000
that live there constantly. There arealso nomadic people who stay here insummer months, and in winter, they
go to Sindh province in the south.
Though there is medical care available
in the private sector, people here arevery poor and they really can’t afford
it. And there are limited health facilities,
especially for women.
Most of the women’s deliveries do still
happen at home. They don’t come tous because they often don’t have or
can’t afford the transport or they needto have a man to come with them. They
choose to come to us because theymight have had a traumatic delivery
before, or they often come when they
have given birth to twin number one
and they wait four or five hours but
twin number two hasn’t come. So thenthey seek help. So we do deliveries, butalso general maternal and infant health.
We do a lot of health education, about
the importance of antenatal care andcoming here for a safe delivery.”Razia, a patient at Tehsil
Headquarter Hospital in Dargai,
Khyber Pakhtunkhwa province“I have eight children and all of them arealive. I have given birth to four of mychildren in hospital, and four at home.
I have a blood weakness so I camehere for my delivery. The deliveries in
the hospital have been much easier. I
also come here because we get freetreatment and we cannot afford it
otherwise. This is a good facility.”
Annabelle Djeribi, Project Co-ordinator,
Women’s Hospital, Peshawar“We have decided to have a hospitalwhere as far as possible we have female
staff only. We allow only females to
go inside the hospital and that means
women feel more confident. They areaccompanied by female caretakers andit also gives some confidence for the
male who is waiting in the visitor room
outside. He knows that it is a place thata woman can find a secure and safe
environment to deliver.”Maternal Death The Avoidable Crisis
25 Introduction

When maternalmortality is the
emergency
BurundiNigeria

Maternal Death The Avoidable Crisis
26 When maternal mortality is the crisis

In some places, the maternal mortality
rate is so high that MSF considers thesituation to be an emergency in itself
and launches a dedicated obstetricprogram with the objective of reducing
maternal mortality within a specificarea. Unlike in an acute emergency,
where the situation evolves rapidly
and it is difficult to plan beyond justa few weeks, in these more stable
contexts, MSF is able to commit to alonger-term project with a dedicatedand streamlined focus. This allows for
significant investment in staff training,
infrastructure, strengthening referral
networks and outreach activities,
which has obvious benefits for women

who would otherwise not have accessto this kind of specialist care. In thisenvironment, it also becomes possible
to investigate and document problems
over a longer period of time, implement
comprehensive strategies to resolve
them and measure whether a particularapproach could be successfully appliedin other contexts. In countries such as
Nigeria, Chad and Burundi, MSF has alsodecided to complement its emergency
obstetric activities with fistula repair
programs [see opposite]. The approachis two-pronged: to repair existing
fistulas, but also to try to prevent new
fistulas from occurring in the firstplace by providing access to quality
emergency obstetric care.
© Francois Dumont

BurundiIn Burundi, giving birth can be
dangerous – the country has oneof the highest rates of maternalmortality in the world. The healthsystem is still suffering from theconsequences of the civil war that
plagued the country from 1993 to
2006. As there is no functioning
referral system for emergency cases
and many women cannot afford
to pay for services, only about halfof pregnant women in Burundi
receive assistance from trained
health workers during delivery. The
emergency obstetric care that does
exist is not always accessible and thequality of the services is poor.
MSF opened the CURGO (Centre
d’URgence Gynéco-Obstétrical) in
Kabezi, just south of the capital
Bujumbura, in 2008 to provide free,specialised care for women withcomplications. Now, there are about
250 babies born at the facility every
month. MSF has put in place a 24
hour / seven days a week referral
system, by which women suffering
from, or at risk of complications, aretransferred by ambulance from healthcentres throughout the province
to the CURGO. The main obstetriccomplications treated at the CURGO are
haemorrhage, infection, rupture of theuterus, prolonged or obstructed labour,
ectopic pregnancy and eclampsia.

© Francois Dumont

FistulaFor every woman who dies inchildbirth, a further 20 are left withlifelong debilitating complications
such as obstetric fistula. Without skilled
medical assistance to intervene during
an obstructed labour, the soft tissues ofa woman’s pelvis can be compressed
between her baby’s head and herpelvic bone for days. With the blood
supply cut off, the tissue dies and she
is left with an opening between thevagina and the bladder, the vagina andthe rectum, or both. Without treatment,
the injury results in permanent
incontinence and women with fistulas
often suffer in silence and isolation,
rejected by their husbands, families
and communities and forced to live as
outcasts, some for decades.
There are an estimated two million
women worldwide living with a fistula,with between 50,000 and 100,000
new cases occurring each year. MSF
has permanent fistula repair projects
in Nigeria, Burundi and Chad and also
runs short-term fistula repair camps inunstable contexts where the condition
is prevalent but the possibility for repair
is absent, such as in the Central African
Republic, Democratic Republic ofCongo and Somalia.

© Sune Juul-Sorensen

Mary, 30, is one of thousandsof women who have received
emergency obstetric care at the
CURGO in Kabezi.
Today, drops of sweat are running
down her neck, but her eyes are lit
up. Mary is recovering at the centre
four days after giving birth to a little
girl here. Even before she went into
labour, Mary was hospitalised ather local health centre because she
was severely malnourished. She wastransferred to the MSF facility in an
ambulance when she urgently neededa blood transfusion and her local
centre could not provide it. When
she was born, Mary’s daughter wasanaemic and underweight. Initially,
she was vomiting a lot, but she hassince improved markedly, as has Mary
herself. Her lips have regained colour
and swelling in her legs has decreased
to the point that she has started
walking again today. “If it weren’t for
MSF, my children wouldn’t have amother,” says Mary, who now has fivechildren. She has named her daughter
Nduwakeza, which in Kirundi, the local
language, means ‘Good news’.

Maternal Death The Avoidable Crisis
27 When maternal mortality is the crisis

Nigeria

Maternal Death The Avoidable Crisis
28 When maternal mortality is the crisis“The growth in the project has
been amazing. When we firststarted working here, women
would not come to the hospital
because they thought it was aplace where women died. It wasdifficult to change that stigma.
Now they trust us and they come.”
Dr Damayanti Zahar,
MSF obstetrician/gynaecologist© Penny Bradfield

With a one in 23 chance of dying
from pregnancy or childbirthrelated complications over thecourse of her life, simply being
pregnant can be life-threatening fora Nigerian woman. This is especiallytrue in the north of the country,
where many women lack access toeven basic obstetric services.
In Jahun in Jigawa state, MSF has beenworking alongside the state Ministry of
Health and running a 35-bed maternity
ward and 57-bed fistula repair ward
since 2008. Through word of mouthand visits from the MSF outreachteam, people in even the most remotevillages now know about the freeobstetric services available at Jahun
General Hospital. More and more
women are coming to the facility todeliver: there were 4092 deliveries in2011 compared to 1640 in 2009. With
the availability of skilled staff and thenecessary drugs and equipment, thematernal mortality rate in the hospitalhas been dramatically reduced, from six
percent when the project opened in
2008, to 1.5 percent today.
Dr Damayanti Zahar, MSF
obstetrician/gynaecologist© Penny Bradfield“The growth in the project has beenamazing. I’ve seen the national staff
growing more confident and many more
women coming to the hospital to deliver.
When we first started working here,
women would not come to the hospital

because they thought it was a place
where women died. It was difficult tochange that stigma. We needed to help
them to have confidence in the hospital.
Now they trust us and they come.
We see a lot of complications here. We
see women who have been labouring
at home on their own for two or threedays and the baby has not come.
When we first opened the project,
we had women coming in with an
obstructed labour and then refusing acaesarean section and actually leaving
to go home. It’s already a big decision
to come to the hospital and then if weneed to do surgery, it’s another hugedecision. They think if they go to theoperating theatre, they will die. They
also believe that if you don’t deliver
your baby normally, you’re not a real
woman. But it’s gotten better. Now
people are more open to surgery andtrust us.
But caesarean sections are only one
part of the solution. As an obstetrician,deciding to do a caesarean section in aplace like Jahun is really a big decision.
Women here have a high number ofpregnancies and we don’t know for surethat the next time she is pregnant she
will come to the hospital for her delivery,
which she really needs to do because
she’ll be at greater risk of uterine rupture
and other complications.”© Penny Bradfield

Binta, 16, was brought to Jahun
General Hospital after trying todeliver for two days at home.
Her labour was obstructed, but thedoctors were able to do a vacuum
delivery and Binta safely gave birth toher first child. In order to prevent anobstetric fistula from occurring, staff
have inserted a urinary catheter, which
will help the damaged tissue heal.
“I was frightened because it was myfirst pregnancy and I was going into
the unknown. There were four womenencouraging me to push and they gave
me some herbs to drink, but when thebaby still had not come, they decided
to take me to the health centre. At thehealth centre, they didn’t know what
to do so they sent me here to Jahun
Hospital. I was so tired from being
in labour for so long that I couldn’t
push anymore. If I had not been able
to come to the hospital, I would havesuffered and the end result would havebeen death for both me and my baby.
When I held my baby for the first time, I
was very happy.”

First published March 2012
© Médecins Sans Frontières
www.msf.org
front cover: © François Dumont