6 June 2012

Somalia: The Risks of Childbirth

press release

Dr Hamida Shakib Mohamed just helped deliver a healthy 3.6 kg boy. It's a good thing the mother made it to this health center; it was a difficult labor and she needed the assistance of a skilled birth attendant using a vacuum device to complete the delivery. She lives in a village about 110 kilometers north of here, but her father insisted she make the trip. He appreciates the Médecins Sans Frontières (MSF) supported services here after his wife was treated for post partum hemorrhaging just a few months ago. We give the "right care," as Dr Hamida puts it, "so people come to us."

MSF expanded its medical services in Galkayo North last December by adding maternity and obstetric care. The number of deliveries has since boomed to about 200 per month, many coming from increasingly far away. Dr Hamida is happy about that. She's Somali, educated in the 1980's in Mogadishu, but holds a foreign passport and has lived abroad for most of the past two decades. Now that her children are grown, she says "I'm free and I want to give my energy to the Somali community." She couldn't be more needed.

Insecurity in Somalia prevents MSF and others from keeping international staff on the ground for very long and some places are completely inaccessible. So MSF relies on its Somali staff for the bulk its work. It's a challenge to keep standards up, but through intensive training courses, on-the-job coaching during "flash" visits, and advice from experts based outside Somalia, dedicated staff like Dr Hamida keep the quality up. Dr Hamida says she recently delivered a baby - whose head got stuck during labor - using forceps for the first time with the step-by-step telephone assistance of our more experienced doctor based in Nairobi.

Most of the patients are happy to be here. Almost all of them echo Shamso, who gave birth to her third child last night. She says "I know I can get good health care here." It's also free of charge, a factor that weighs heavy in most of the women's choices. Shamso is lucky. She comes from Galkayo and she didn't have any complications before or during labor. Somalia has amongst the highest maternal mortality rates in the world and the trials faced by so many other women are immense.

A woman in the next room is curled up with sunken bloodshot eyes holding the child still in her belly. She is not sure how she got here. She only knows she fell unconscious with pre-eclampsia some time ago and guesses that relatives organized the three hour trip to get her here. She feels pain but the doctor says she and her unborn baby are ok now.

Down the hall, a very young and sad looking woman recovers after losing her child. She arrived two days ago in labor with eclamptic fits. A caesarian section was indicated, but in Somali culture such a procedure cannot occur without the consent of the husband. He could not be found in the displaced persons camp on the outskirts of town where they live, and although mobile phones are common in Somalia no one had his number, not even his wife who now sits quietly next to her daughter. An uncle showed up but he could not give consent because he was from the mother's side of the family. Finally, after twelve hours another uncle from the father's side consented, but the baby was dead by then.

In another room lies a woman who came from Ethiopia yesterday after a four day labor, which was too much for the baby who died shortly after birth. It may have been too much for her too. She lies in a delirium, chest heaving unevenly, not sure where her baby is. She's passing urine unchecked and the midwife thinks she may also have a fistula.

Vaginal fistulas are common in Somalia, leaving women in pain and incontinent. The tearing can occur for different reasons, often from obstructed labor, and sometimes from rape. An unaccompanied woman came to Galkayo a few weeks ago from Mogadishu. On the way, she was taken by five men, held for three days and repeatedly raped. She came in five days later after relatives from the displaced persons camp told her she could get help here. She was too late to receive precautionary prophylaxis for HIV, but we could still counsel her, prevent pregnancy and sexually transmitted infection, and address her fistula.

Traditional practices can also sometimes complicate childbirth. Female circumcision is common in Somalia and sometimes increases childbirth risk, either through obstruction or bleeding. A mother recently having her first baby sought the help of a traditional birth attendant (TBA) who cut her badly in an attempt to extricate the baby from a circumcised and narrowed passageway. By the time she arrived at the MSF clinic she was in shock and needed a blood transfusion and extensive repair. MSF is now trying to work more closely with TBA's, providing some training on early recognition of complications and encouraging early referral for high risk deliveries.

Having children can be risky in Somalia, but delivering them can be too. "Security is shaky," says Dr Hamida. Last Friday she was called in at night to assist with a retained placenta. On the way to the hospital, a drunken policeman stopped them waving his AK-47. He told everyone to "get out," but luckily after pleading that the doctor was needed for an emergency at the hospital the policeman waved them on. After a blood transfusion, she was able to stabilize the patient. Despite the danger, Dr Hamida is happy to be here and she likes that it's so busy because "you are achieving something." She smiles and says she's "paying back to the community."

Without the dedicated work of employees like Dr Hamida, MSF could not continue to run programs in Somalia. Maternal care is only one of MSF's numerous medical activities throughout the country, but Somalia has extremely high maternal mortality rates - est. 1200/100,000 live births according to various sources, in other words, more than one mother dies for every hundred children born - so maternal care is an essential part of MSF's health care package. Having children in Somalia is a dangerous activity, made slightly less so by the huge effort of MSF's Somali staff.

MSF has been working in Somalia continuously since 1991. MSF relies solely on private charitable donations for its work in Somalia and does not accept any government funding.

In the period from May to December 2011, MSF was running 22 projects in many different parts of Somalia and in refugee camps for Somalis in Ethiopia and Kenya. In this period, covering the height of the crisis, the medical organisation treated over 78,500 patients for severe malnutrition and over 30,000 for moderate malnutrition, over 7,200 patients for measles and vaccinated over 255,000 persons against disease in the Horn of Africa. MSF assisted in over 6,000 deliveries and provided over 537,500 out-patient consultations.

The war in Somalia is now going into its 21st year. After the drought and the enormous crisis of last year, people survive and live from hand to mouth, and are still highly vulnerable to infections, disease and malnourishment.

Inside Somalia, MSF will not step up its activities or open up new projects until its two colleagues - Montserrat Serra and Blanca Thiebaut, abducted in Dadaab and held in Somalia since October 2011 - are reunited with their families.

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