Obstetrics on the Frontline

Dr. Benjamin BlackBy Dr. Benjamin Black

Central African Republic (CAR). Before I came here the name conjured up for me dark scenes of civil war, senseless killing and grueling poverty. I was nervous. Not least because I would be living and working using my basic French. I did my research, read back through the news stories of the last few years and various opinion pieces; it was almost unanimously grim.

When I told friends and family where I’d be going the common response was “Oh Central Africa, but which country are you actually going to?”

Despite being one of the most volatile countries in the world, CAR remains largely unknown and in some ways a forgotten emergency. Forgotten by some, but not all. Médecins Sans Frontières (Doctors Without Borders) has been here since 1997 and, with 16 projects in the country, is a leading healthcare provider. Impressive, but also a reflection of the depressing state of affairs in a country larger in size than France and Belgium together.

The project that I am working in is a town on the CAR side of the border with Democratic Republic of Congo. It has previously been a flashpoint for armed rebels who have left their mark on the town. 

In the hospital is the maternity ward, where I spend most of my days and the occasional night. The cases are the usual mix of normal deliveries, emergencies and surprises. The midwives here manage to get these babies out though.

Whether they are coming head first or breech, they will encourage and motivate until the little thing is screaming its lungs out. In sub-Saharan Africa, a Caesarean section can be lifesaving, but is also a scar that will be carried for life. The risks of complications in future pregnancies (here women often have over 10 pregnancies in their lifetime) make it a decision to be taken with caution, and usually only once alternative options have been exhausted.

Much more challenging than getting these babies out is the situation with unwanted pregnancies -- a subject often considered as taboo, but responsible for a high proportion of maternal deaths. On my very first day in the capital, Bangui, a woman presented to the hospital with an abortion. Already in septic shock, she died.

Woman holding a young girl (Photo: hdptcar on Flickr)

The reality for women here, where contraception is either hard to access or not accepted (for example, by a husband or mother-in-law) is that abortion is the other form of birth control, but one that comes with high risks. Often performed in the community by “traditional” methods, the abortion attempts result in the women coming to us with signs of poisoning, trauma, or overdoses of conventional medicines. The illegality of all this means that getting any reliable history from the patient is like getting blood from a stone, leaving us to make presumptions and guesses. And at the end of it all, the pregnancy often remains.

Together with my midwife counterpart we are training the staff here to recognise and react to the women presenting with abortion complications. Having workshops for our national colleagues on the signs of sepsis and emergency treatment, running regular drills in the department, and increasingly giving the responsibility of management to them.

Together we are making sure that, whatever the reason, these women get quick access to lifesaving treatment and procedures. And just like getting those babies out, this is met with genuine enthusiasm, so much so that we have now accomplished a major milestone; national staff providing training to the other staff. Skills not just learnt, but being transferred too.

Yes, CAR is volatile and challenging. But dark, no. For the women who make it to us, there is care and compassion. And though I am just a passing ship, I remain proud to be witness to the light that shines out.

For more information on Obsterics on the frontline, visit the MSF/Doctors Without Borders Blog "May the forceps be with you."

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