Saving Mothers, One at a Time

Sue Makin , the newest contributor to this blog, is an American Presbyterian missionary doctor working at a 190-bed mission hospital in southern Malawi. She has been working in Africa for the past 18 years. According to a 2007 study of global maternal mortality rates, more than two-thirds of deaths among Malawian women of reproductive age are linked to pregnancy or childbirth – a larger proportion than in any of the 171 countries in the study.

In spite of – or maybe, because of – the grim statistics on maternal health here in Malawi, a wonderful part of my job is training younger clinicians who will carry on the work after I have left. The lifesaving skills demonstrated by Sam Matandala, a clinical officer in training at our hospital, were a great encouragement to me last month. Clinical officers are the “doctors” who provide most of the care for all the people in Malawi, including emergency obstetrical care. In our district in southern Malawi, which has a population of over half a million people, there are three trained medical doctors, graduates of medical schools. I am one of them, with specialty training in obstetrics/gynecology. The other two are general practitioners and are medical directors of the two hospitals in our district, one a government hospital and the other a mission hospital. Any woman in Malawi with a life-threatening obstetrical emergency needing immediate attention will likely be attended to by a clinical officer or nurse midwife. Medical doctors are few and far between.

On the night in question, Sam ran up against a health-care problem just as typical here as chronic under-funding and dearth of supplies, but perhaps less obvious to Westerners when they think of conditions in Africa: Women are definitely second-class in Malawi.

Around 8 p.m., a nurse midwife called Sam to the maternity ward where he saw a woman covered in blood mixed with soil, unconscious and deathly pale. Her extremities were cold, her pulse faint and her blood pressure an abysmally low 76 over 28. This woman, a mother of three, perhaps in her late 20s, had been three months pregnant with a fourth child. That morning, she had begun bleeding vaginally. Instead of coming to the hospital, her husband had decided to take her to a traditional birth attendant. She stayed with the attendant for nearly six hours, bleeding all the while. After she lost consciousness and the midwife grew frightened, the pregnant woman’s relatives loaded her onto a bush-bicycle ambulance and walked with her for about two hours to get to the hospital. She continued to bleed on the journey to the hospital.

As Sam rightly points out, women in Malawi, regardless of age, are not empowered to make decisions about their own health. When they are sick or giving birth, they must wait for their husband or other male relatives to decide when they should be taken to the hospital. This leads to delays – particularly when the decision-making man has gone far away from the village – and many women who come to the hospital at all come late, when complications have already set in.

In this case, Sam had to act quickly to save the woman’s life. (Calling for me to come from home would have wasted precious time.) He and the nurse midwife started IVs in both arms and drew blood for type and crossmatching. They looked for her relatives in the hope that someone among them would donate blood, but they had run off after dumping her at the hospital, perhaps thinking that she was already dead. Luckily, the lab technician, called from home, found a unit of compatible blood in the blood bank, and a transfusion was started for the woman. The ultrasound by Sam showed that the woman had a partial miscarriage and needed to have all of the products of conception removed from the uterus to stop the bleeding. Due to the woman’s poor condition, going to the operating theater and doing the evacuation of the uterus under full anesthesia was out of the question. So Sam did it right there in the maternity ward under Pethidine, an analgesic like Demerol, and followed up with Pitocin, for her uterus to contract and the bleeding to stop. The next morning, only some nine hours later, the woman was walking around and even asking to go home.

Some have described obstetrics in sub-Saharan Africa as a roller coaster of highs and lows, sometimes terrifying and sad, sometimes unpredictable, always interesting, and very rewarding to those of us who are privileged to participate in the drama of childbirth. This particular story had a happy ending. But the poverty in this area is compounded by poor education. Illiteracy rates are alarmingly high, and girls often drop out of school early. The prevailing belief in this area is that the role of a female in society is to marry, have many children, raise the children, and look to her husband for guidance in all matters. Even as we train more clinical officers and try to improve our medical services to women, we must remember that the environment we work in does not allow the women themselves to have a voice in their choices of health care or where and when they will seek medical help.