After only a month in Ethiopia, we headed to Ghana for a week. The timing was fortuitious as there was a major international meeting in Accra, the capital city of Ghana, February 12-14. The meeting was called The 1,000+ OB-Gyn Project, sponsored by the Bill and Melinda Gates Foundation through a grant to Dr. Frank Anderson at the University of Michigan. The goal is to set in motion a trans-continental chain of African and American university partnerships to produce another 1,000 obstetrician-gynecologists for sub-Saharan Africa within the next decade.
The meeting was co-chaired by my old friend, Dr. Kwabena Danso, whom I have known for 20 years.
Just after he completed residency training in Ghana, he came to the OB-Gyn Department at the Louisiana State University School of Medicine in New Orleans, where I was a faculty member in charge of developing the urogynecology fellowship program there. We have been good friends ever since.
A look at basic statistics tells you it is tough to be a woman in Africa. Although Africa has only 20% of the world’s births, the continent accounts for 40% of the world’s maternal deaths. According to WHO statistics, across the continent of sub-Saharan Africa a woman’s lifetime risk of dying from a pregnancy complication is 1 in 39, whereas in the developed regions of the world, the risk is only 1 in 3,800–a nearly 100-fold risk of maternal mortality.
There are a lot of reasons for this: high fertility and lack of access to adequate contraception, a desire for large families (fueled, in part, by high infant and childhood mortality—it is difficult to have a small family if your livelihood depends on agricultural labor and your children die before they can contribute to family finances), poor transportation and communication infrastructure, poorly-developed and poorly-managed medical intrastructure, and a lack of political will to address medical problems that are largely seen in many places as “only a woman’s issue.” (One of the great political challenges for women’s health in Africa is to make men aware of the huge stakes that they themselves have in the lives of their mothers, sisters, wives, and daughters).
But one of the major problems is a lack of skilled manpower–both obstetricians and midwives–to address acute obstetrical emergencies and to develop a maternal health care system that works.
According to the magisterial historical research of Irvine Loudon (I highly recommend his book Death in Childbirth for those wanting to research these issues in more detail), maternal mortality in Europe and the United States was at contemporary African levels (if not higher) at the turn of the 20th Century. Then, over the course of only 50 years, rates of maternal death plunged to fantastically low levels that had never been achieved before anywhere in the world. This happened simultaneously across North America, Western Europe and Scandinavia. Maternal mortality has fallen even lower in the last 75 years and has remained so low that most pregnant women in the West never even contemplate the possibility of dying from a pregnancy-related complication. (If you read women’s journals and letters from the mid-19th Century, you will find that women were often obsessed with the possibility of pregnancy-relate death, and with good reason).
Why did this happen? Two theories are often propounded. One I like to call the “rising tide lifts all boats” theory, which holds that it was rising prosperity and improved standards of living that led to this event. The other theory I call the “heroic doctor theory,” which states basically that it was life-saving medical interventions by “heroic” doctors, nurses, and midwives which made the difference. Which one was it?
The answer is The Heroic Doctor Theory.
Lest I be accused simply of self-serving adulation (I am, after all, Professor of Obstetrics & Gynecology at Washington University), let me explain why is the case. I fully acknowledge that the two theories are interrelated: it takes a developed infrastructure and economic prosperity to give doctors, nurses, and midwives the enabling environment in which they can do their work. But the answer is actually straightforward from a medical point of view.
To understand why maternal death plummeted, you have to understand why women die in pregnancy and childbirth, and what can reasonably be expected to prevent this from happening. The major causes of maternal death around the world have not changed too much in the last 200 years (the one exception would be the rise of HIV infection as a cause of maternal mortality in the 20th Century). Women die from hemorrhage (usually after delivery because the uterus does not contract properly to stop the bleeding), from infections, from pre-eclampsia and eclampsia (disorders of high blood pressure unique to pregnancy), from obstructed labor (also the cause of obstetric fistula), and from complications of unsafe abortion.
Each of these causes of maternal death requires prompt emergency attention. Almost none of these problems can be predicted with any accuracy (80% of maternal deaths occur suddenly and unexpectedly from these complications and 15% of otherwise normal pregnancies will develop one of these complications)–complications that can become life-threatening in short order if prompt emergency intervention does not occur.
Maternal death dropped in Europe and the United States because we developed the ability to give intravenous fluids, to transfuse blood, and developed cheap drugs that could reliably make a flaccid uterus contact to stop the bleeding. We developed antibiotics in the first half of the 20th Century to combat infections. We developed good drugs to lower blood pressure and to prevent eclamptic seizures, and we developed drugs that could facilitate the induction of labor to speed delivery (The cure for pre-eclampsia and eclampsia is delivery of the baby). We also developed safe techniques for cesarean delivery and better anesthetics. And because deaths from unsafe abortion are largely due to hemorrhage, infection, and uterine injuries, these techniques reduced abortion deaths dramatically even before abortion was decriminalized and made safe by better techniques of pregnancy termination.
This was all hastened by the development of transportation and communication infrastructure in Europe and North America. And it was speeded and coordinated by the development of medical professionals dedicated to the care of women: Obstetricians and gynecologists. This, too, was a product of the 20th Century. The professional organization of OB-Gyns in the United States, The American College of Obstetricians and Gynecologists, is actually relatively new. It was founded only in 1950 (the year before my father graduated from medical school and started his OB-Gyn residency training).
Meaningful improvements in women’s health in Africa must be led by a strong cohort of obstetrician-gynecologists who need to provide services, train others (medwives, general practitioners, emergency surgical technicians in rural areas, etc). There are not nearly enough obstetricians in Africa. At present many African countries have NO in-country residency training programs to produce obstetrician-gynecologists and all countries are incredibly short-staffed. For example, there is only ONE practicing obstetrician-gynecologist in the entire country of Sierra Leone as I write this.
This meeting brought African OB-Gyns together with their American counterparts to discuss innovations in OB-Gyn residency training and to report on the increasing (and encouraging) number of American universities that are partnering with African institutions to improve OB-Gyn training throughout the continent. There were teams at this meeting from Cameroun, Ghana, Liberia, Senegal, The Gambia, Uganda, Kenya, Rwanda, Tanzania, Zambia, Malawi, Botswana, Sierra Leone, the Democratic Republic of the Congo, and Ethiopia.
I came to the meeting with Dr. Samson Mulugeta, Head of the Department of Obstetrics and Gynecology at the Mekelle College of Health Sciences, where we are in the process of developing a mulit-institutional collaborative program to improve the residency training program there (funded by a very generous grant from The Worldwide Fistula Fund). The meeting went a long way towards lining up the goals we need to achieve.
While I was busy at the meeting, Helen enjoyed the hotel and found the large market in Accra, where she busied herself with buying African fabrics (now safely transported back to Mekelle, where they will be transformed into exquisitely fashioned garments).
After the meeting was over, we stayed on in Accra for a couple of extra days as houseguest of two additional old, dear friends, Dr. Demi Lassey (anesthesiology) and her husband, Dr. Anyetei Lassey (obsterics & gynecology).