Half the Sky

by Nicholas D. Kristof

  Allan’s own life took a tragic course in 2005. He was diagnosed with ALS and also myasthenia gravis, two diseases that affect motor nerves. He had always been athletic and outdoorsy, but now he found himself increasingly frail. He lost weight, had trouble walking and breathing, and then was consigned to a wheelchair. He worried about being a burden to his family. Yet he went to work every day and even attended international conferences. At the International Women’s Health Coalition banquet in January 2008, he could barely move but was a center of attention, lionized by admirers from all over the world. In October 2008, he died.

  AMDD is now saving lives in fifty poor countries. We saw its impact when we stopped by a clinic in Zinder, in eastern Niger, the country with the highest lifetime risk of maternal mortality in the world. Niger has only ten ob-gyns in the entire country, and rural areas are lucky to have a physician of any kind in the vicinity. The Zinder clinic staff were startled and excited to see a couple of Americans, and they happily gave us a tour—even pointing out one heavily pregnant woman, Ramatou Issoufou, who was lying on a stretcher, gasping and suffering convulsions. Between gasps, she complained that she was losing her vision.

  The sole doctor in the clinic was a Nigerian, Obende Kayode, placed there as part of a Nigerian foreign aid program (if Nigeria can send doctors abroad as foreign aid, so can America!). Dr. Kayode explained that Ramatou probably had eclampsia, a pregnancy complication that kills about fifty thousand women a year in the developing world. So she needed a cesarean section; once the baby was out, the convulsions would end as well.

  Ramatou was a mother of six, thirty-seven years old, and her life was ebbing away in the little hospital waiting room. “We’re just calling for her husband,” Dr. Kayode explained. “When he provides the drugs and surgical materials, we can do the operation.”

  The Zinder clinic, it turned out, was part of a pilot program in Niger arranged by the United Nations Population Fund (UNFPA)* and AMDD to fight maternal mortality. As a result, all the materials needed for a C-section were kept in sealed plastic bags and available if the family paid $42. That was a great improvement over the previous approach of having the families run all over town, spending far more to buy bandages here, gauze there, scalpels somewhere else. But what if Ramatou’s family didn’t have $42?

  In that case, she would probably die. “If the family says they have no money, then you have a problem,” Dr. Kayode acknowledged. “Sometimes you help, with the expectation that you will be paid back. At the beginning, I helped a lot, but then afterward people didn’t pay me back.” He shrugged, and added: “It depends on the mood. If the staff feel they can’t pay out again, then you just wait and watch. And sometimes she dies.”

  Still, the hospital staff didn’t want Ramatou to die with us watching. The nurses wheeled her into the operating room and scrubbed her belly, and a nurse administered a spinal anesthetic. Ramatou lay on the gurney, breathing heavily and irregularly, otherwise motionless, apparently unconscious. Dr. Kayode came in, quickly sliced through Ramatou’s abdomen, and held up a large organ that looked a bit like a basketball. That was her uterus. He carefully cut it open and pulled out a baby boy, whom he handed to a nurse. The baby was quiet, and it wasn’t immediately clear if he was alive. Likewise, Ramatou was suspiciously comatose as Dr. Kayode stitched up her uterus, put it back in her abdomen, and then sewed up the outer cut on her stomach. But twenty minutes later, Ramatou was regaining consciousness, wan and exhausted but no longer suffering convulsions or labored breathing.

  “I’m okay,” she managed to say, and then the nurse brought her baby son to her—now squawking, wriggling, and very much alive. Ramatou’s face lit up, and she reached out with her hands to hold her baby. It truly seemed a miracle, and it showed what is possible if we make maternal health a priority. One doctor and a few nurses in a poorly equipped operating theater in the middle of the desert of Niger had brought a woman back to life and saved her baby as well. And so Allan Rosenfield’s public health legacy included two more lives saved.

  * It was Professor Wall’s campaign that, in the 1990s, first introduced us to obstetric fistulas. Dr. Wall heads the Worldwide Fistula Fund (www.worldwidefistulafund.org) and is finally seeing his longtime dream of a fistula hospital in West Africa being realized. With support from Merrill Lynch and private American donors, the hospital is being built in Niger, although funding is still tight. Professor Wall has truly been a hero in the struggle to help these neglected women.

  * The UN is so wretched at public relations that it can’t even match its abbreviations with its organizations. This agency originally was called the UN Fund for Population Activities, and it remained UNFPA even after it changed its name to the UN Population Fund.

  CHAPTER SEVEN

  Why Do Women Die in Childbirth?

  Would the world stand by if it were men who were dying just for completing their reproductive functions?

  —ASHA-ROSE MIGIRO,

  UN DEPUTY SECRETARY GENERAL, 2007

  The first step to saving mothers’ lives is to understand the reasons for maternal mortality. The immediate cause of death may be eclampsia, hemorrhage, malaria, abortion complications, obstructed labor or sepsis. But behind the medical explanations are the sociological and biological ones. Consider the factors that converged to kill Prudence Lemokouno.

  We found Prudence lying on a bed in the little hospital of Yokadouma, in the wild southeastern corner of Cameroon, in roughly the area where (genetic evidence suggests) AIDS first jumped to humans in the 1920s. A twenty-four-year-old mother of three children, Prudence was wearing an old, red-checked dress that bulged out hugely at the belly; a sheet covered her lower parts. She was in tremendous pain, and she periodically grabbed the side of the bed, though she never cried out.

  Prudence had been living with her family in a village seventy-five miles away, and she had received no prenatal care. She went into labor at full term, assisted by a traditional birth attendant who had had no training. But Prudence’s cervix was blocked, and the baby couldn’t come out. After three days of labor, the birth attendant sat on Prudence’s stomach and jumped up and down. That ruptured Prudence’s uterus. The family paid a man with a motorcycle to take Prudence to the hospital. The hospital’s doctor, Pascal Pipi, realized that she needed an emergency cesarean. But he wanted $100 for the surgery, and Prudence’s husband and parents said that they could raise only $20. Dr. Pipi was sure that the family was lying and could pay more. Perhaps he was right, for one of Prudence’s cousins had a cell phone. If she had been a man, the family probably would have sold enough possessions to raise $100.

  Prudence Lemokouno in her hospital bed in Cameroon, untreated by the staff (Naka Nathaniel)

  Dr. Pipi was short and solidly built, with spectacles, a serious and intelligent manner, superb French—and a resentful contempt for local peasants. He worked diligently, and he was very pleasant to us, but he excoriated the nearby villagers like Prudence who didn’t take care of themselves and didn’t seek medical attention early enough.

  “Even the women who live in town, right next to the hospital, they have their babies at home,” he said. Overall, he estimated, only about 5 percent of local women deliver in the hospital. Supplies are almost nonexistent, he complained, and in the history of the hospital nobody had ever given a voluntary blood donation. Dr. Pipi came across as bitter—angry at the women, and also at himself for being stuck in a remote provincial backwater. He was utterly unsympathetic to their needs.

  We had come upon the clinic by accident and dropped in to inquire about maternal health in the area. Dr. Pipi gave an intelligent assessment of conditions in the region, and then we stumbled upon Prudence in an unused room in the hospital. She had been lying there untreated for three days, according to her family—only two days, Dr. Pipi indignantly told us later. The fetus had died shortly after she arrived at the hospital, and now it was decaying and slowly poisoning Prudence.

  “If they had intervened right away, my baby would
still be alive,” Alain Awona, Prudence’s twenty-eight-year-old husband, said angrily as he hovered beside his wife. A teacher at a public school, he was educated enough to be indignant and assertive at the mistreatment of his wife. “Save my wife!” he pleaded. “My baby is dead. Save my wife!”

  Dr. Pipi and his staff were furious at Alain’s protests and embarrassed at having a woman die in front of visitors. They argued that the problem was a resource shortage compounded by uneducated villagers who refuse to pay for medical services.

  “Most of the time in emergencies, the family doesn’t pay,” scoffed Emilienne Mouassa, the senior nurse, who appeared to have veins full of antifreeze. “They just run away.”

  Dr. Pipi said that without intervention Prudence had only hours to live, and that he could operate on her if he had the remaining $80. So we agreed to pay it then and there. Then Dr. Pipi said that Prudence was probably anemic and would need a blood transfusion to get her through a C-section. A nurse consulted Prudence’s records and reported back that her blood was type A, Rh positive.

  Nick and Naka Nathaniel, the videographer, looked at each other. “I’m A positive,” Nick whispered to Naka.

  “And I’m O positive—a universal donor,” Naka whispered back.

  They turned to Dr. Pipi.

  “What if we gave blood?” Nick asked. “I’m A positive and he’s O positive. Could you use that blood for the transfusion?”

  Dr. Pipi shrugged agreement.

  So Nick and Naka handed over some money to send a nurse to town to buy what supposedly were brand-new disposable needles. The lab technician then drew blood from each of them.

  Prudence didn’t seem fully aware of what was going on, but her mother had tears of joy streaming down her cheeks. The family had been sure that Prudence was going to die, and now it suddenly seemed that her life could be saved. Alain insisted that we stick around to see the surgery through. “If you go,” he warned bluntly, “Prudence will die.”

  Emilienne and the other nurses had been arguing with the family again, shaking them down for more money, but we intervened and paid some more. Then the nurses hooked up the blood units on a drip, and blood from Nick and Naka began coursing into Prudence’s bloodstream. She almost immediately perked up and, in a weak voice, she thanked us. The nurses said that everything was ready for Prudence’s surgery, but the hours dragged by and nothing happened. At 10 p.m., we asked the duty nurse where Dr. Pipi was.

  “Oh, the doctor? He went out the back door. He’s gone home. He’ll operate tomorrow. Probably.” It appeared that Dr. Pipi and the nurses had decided to teach Alain and Prudence’s family a lesson for being uppity.

  “But by tomorrow it will be too late!” Nick protested. “Prudence will be dead. The doctor himself said that she might have only a few hours.”

  The nurse shrugged. “That is up to God, not us,” she said. “If she dies, that would be God’s will.” We came close to strangling her.

  “Where does Dr. Pipi live?” Nick asked. “We’ll go to his house right now.” The nurse refused to say. Alain was watching, flabbergasted and dazed.

  “Come on, you must know where the doctor lives. What if there’s a crisis in the night?”

  At that point, our Cameroonian interpreter tugged us aside. “Look, I’m sure we could find out where Dr. Pipi lives if we ask around,” he said. “But if we go to his house and try to drag him back here to do surgery, he’ll be incredibly angry. Maybe he’ll do the surgery, but you don’t know what he’ll do with the scalpel. It wouldn’t be good for Prudence. The only hope is to wait for morning, and see if she’s still alive.” So we gave up and headed back to our guesthouse.

  “Thank you,” Alain said. “You tried. You did your best. We thank you.” But he was crushed—partly because he knew the hospital staff was doing this to spite him. Prudence’s mother was too angry to speak; her eyes glowed with tears of frustration.

  The next morning, Dr. Pipi finally operated, but by then at least three days had elapsed since Prudence had arrived at the hospital, and her abdomen was severely infected. He had to remove twenty centimeters of her small intestine, and he had none of the powerful antibiotics that were necessary to fight the infection.

  The hours passed. Prudence remained unconscious, and gradually everybody realized that it wasn’t just the anesthesia; she was in a coma. Her stomach expanded steadily because of the infection, and the nurses paid her little heed. When the bag of urine from her catheter overflowed, no one changed it. She was vomiting lightly, and it was left to Prudence’s mother to clean it up.

  As the hours passed, the mood in the room became increasingly grim. Dr. Pipi’s only comments were criticisms of Prudence’s family, especially of Alain. Prudence’s stomach ballooned grotesquely, and she was spitting up blood. She began fighting for her breath, in huge, terrifying rattles. Finally, the family members decided that they would take her home to the village to die. They hired a car to take them back to the village, and they drove back, somber and bitter. Three days after the surgery, Prudence died.

  That’s what happens, somewhere in the world, once every minute.

  It wasn’t only Prudence’s ruptured uterus that was responsible for her death. There were four other major factors.

  Biology. One reason women die in childbirth has to do with anatomy, arising from two basic evolutionary trade-offs. The first is that once our ancient ancestors began to walk upright, too large a pelvis made upright walking and running inefficient and exhausting. A narrow pelvis permits fast running. That, however, makes childbirth exceedingly difficult. So the evolutionary adaptation is that women generally have medium-sized pelvises that permit moderately swift locomotion and allow them to survive childbirth—most of the time.

  The other trade-off is head size. Beginning with our Cro-Magnon ancestors, human skull size expanded to accommodate more complex brains. Larger brains offer an evolutionary advantage once a child is born, but they increase the chance that a large-headed fetus will never emerge alive from the mother.

  Humans are the only mammals that need assistance in birth, and some evolutionary psychologists and evolutionary biologists have argued that as a result perhaps the first “profession” to emerge in prehistoric days was that of the midwife. The risk to the mother varies with anatomy, and human pelvises are categorized by shapes that reflect alternate evolutionary compromises: gynecoid, android, anthropoid, and platypelloid. There is some disagreement among specialists about how significant the pelvic distinctions are, and The Journal of Reproductive Medicine has suggested that they reflect childhood environmental factors as much as genetics.

  In any case, the most common pelvis for women is gynecoid, which is most accommodating of the birth process (but is not found on great women runners) and is particularly common among Caucasian women. In contrast, the anthropoid pelvis is elongated, permits fast running, and is more likely to result in obstructed labor. Data on pelvis shapes is poor, but African women seem disproportionately likely to have anthropoid pelvises, and some experts on maternal health offer that as one reason maternal mortality rates are so high in Africa.

  Lack of Schooling. If villagers were better educated, Prudence would have had a better chance, for several reasons. Education is associated with lower desired family size, greater use of contraception, and increased use of hospitals. So with more education, Prudence would have been less likely to have become pregnant and, if she had become pregnant, would have been more likely to deliver in the hospital. And if the birth attendant had been better schooled, she would have referred a case of obstructed labor to the hospital—and she certainly would not have sat on Prudence’s stomach.

  Education and family planning also tend to leave families better able to earn a living and more likely to accumulate savings. The result is that they are better able to afford health care, and educated families are also more likely to choose to allocate savings to the mother’s health. Prudence’s family, if educated, would therefore have been better able to a
fford the $100 for her surgery, and more likely to consider it a wise expense. The World Bank has estimated that for every one thousand girls who get one additional year of education, two fewer women will die in childbirth. As we’ll see, such studies sometimes overstate the power of education, but even if the magnitude is exaggerated, an effect is clear.

  Lack of Rural Health Systems. If Cameroon had had a better health care structure, the hospital would have operated on Prudence as soon as she arrived. It would have had powerful antibiotics available to treat her infection. It would have had trained rural birth attendants in the area, equipped with cell phones to summon an ambulance. Any one of these factors might have saved Prudence.

  One of the impediments to constructing a health system is the shortage of doctors in rural Africa. Dr. Pipi was unsympathetic, but it’s also true that he was a hard worker who was hugely overburdened—and Cameroon just didn’t have enough physicians to post a second one at the hospital in Yokadouma. Doctors and nurses in rural Africa get ground down by the relentless hours, lack of supplies, and difficult conditions (including the dangers to their own health), so they try to move to the capital. Very often, they also emigrate to Europe or America, amounting to a kind of foreign aid from Africa to the West and leaving women like Prudence without anyone to operate on them.

  One problem with our proposal for donor countries to invest heavily in maternal care in Africa is that those countries lack the doctors—at least those willing to serve in rural areas. It’s far easier to build an operating theater in a rural area than to staff it. One sensible response is to start training programs in Africa that produce many more health care professionals, but in two- or three-year programs that don’t grant MDs that allow the graduates to find jobs abroad. Africa would be better off graduating fewer doctors if the trade-off were that more health professionals would be forced to remain in their home countries. The purpose of medical training isn’t to fuel emigration but to address health needs at home.