This post originally appeared on the Action Agenda Blog of the Women’s Refugee Commission.
In June 2008, while I was working in a province of the Democratic Republic of Congo (DRC) that continues to be severely affected by the nation’s protracted conflict, a woman arrived at the hospital, hemorrhaging profusely. She had been pushed to the hospital on a bicycle, from a health center 2.6 miles away. After delivering a healthy infant earlier that day, she had experienced placental retention, a common cause of postpartum hemorrhage and infection. If a provider has been trained to manage this complication, it is treatable. But the nurse who had delivered the woman’s infant could not help her. By pure chance, however, that nurse had heard that—for one day, this particular day only—a doctor would be at a hospital some distance away. The woman’s family had then loaded her onto the bicycle and pushed her, for hours, to the hospital. Fortunately, the rumors had been true: a doctor was available, and he was able to stop the hemorrhaging. Although her situation remained critical, the woman did not die that day. I left before hearing whether she ultimately survived, and I often wonder about her ultimate fate.
This woman’s luck was uncommon. More often than not, if a woman in the developing world experiences complications during birth, she will die. Unless all the stars align—the pregnant woman knows she needs care and is permitted to seek it, transportation is available, she reaches the facility in time, trained health workers are available to provide emergency care and there are adequate antibiotics, sterile materials and other supplies—she has little chance of survival. In a conflict setting such as the DRC, or during the aftermath of a natural disaster, a woman may have even less chance.
I am an African OBGYN and the Technical/Clinical Advisor for the Reproductive Access, Information and Services in Emergencies (RAISE) Initiative. Much of my clinical work has occurred in conflict settings, and I have seen firsthand the widespread lack of vital reproductive health care for refugees and internally displaced persons (IDPs). Indeed, RAISE facility assessments confirm that relatively few health centers and health workers are equipped to meet this need.
WHO has recognized the grave importance of health facilities and health workers in both natural disasters and conflict-related emergencies. To mark World Health Day 2009, WHO has established a cadre of best practices that will improve the safety of health facilities and the efficacy of health workers in all types of emergencies.
But we must go even further.
All actors need to bear in mind that during war and disaster, not all deaths and injuries are directly due to the emergency itself. Death and severe morbidity can often be the result of unmet reproductive health needs, which are frequently critical in the developing world. But all too often reproductive health services were not part of the health infrastructure to begin with. Being prepared to address reproductive health needs in times of crisis can become a catalyst for establishing reproductive health infrastructure.
Much of the vast gap between developed and developing nations is due to extreme inequities in access to emergency obstetric care. To bridge this gap, and save many lives that are now needlessly lost, provisions that specifically seek to prevent and manage obstetric complications must be created and implemented.
Training non-physician clinicians in emergency obstetric care is a crucial step in saving lives, both in emergencies and in times of relative stability. In many areas, only doctors are trained to manually remove the placenta and perform other vital emergency obstetric functions. But most regions in Africa have an intense shortage of doctors. I can personally attest to this reality, as one of only two OBGYNs working in the entire country of Chad for some ten years. Initiatives such as the Health Systems Strengthening for Equity (HSSE) project are now, thankfully, advocating for the important and lifesaving role of non-physician clinicians.
So as we mark World Health Day 2009, let us not forget about the acute reproductive health needs of refugees and IDPs. This basic human right is not only for the “lucky” few, or to be stumbled upon by chance. Instead, we must actively push for the tried-and-true solutions that can save lives around the world.
Grace Kodindo, OBGYN, was head of maternity in Chad for 10 years. Currently the Technical/Clinical Advisor for the Reproductive Health Access, Information and Services in Emergencies (RAISE) Initiative, Dr. Kodindo is featured in a BBC documentary on maternal mortality titled Dead Mums Don’t Cry.