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Meinie Nicolai, President of MSF-Belgium. Photo by Bruno de Cock

Meinie Nicolai, President of MSF-Belgium. Photo by Bruno de Cock

In 2006, I was part of an MSF team that was conducting an exploratory visit in Equateur Province, an isolated, underdeveloped area in northern Democratic Republic of Congo (DRC). One day, we visited a threadbare local hospital in a dusty village along the Congo River, where we were hoping to launch a medical response to a recent outbreak of sleeping sickness.

As I entered the facility, I saw a body lying on the floor, covered by a blanket.

“Did someone die?” I asked.

“Yes,” I was told. “That is a young woman who died giving birth.”

I never learned the young woman’s name, but I’ve never forgotten her. I knew that health facilities in that area were desperately short of resources and trained health personnel. I knew that many women around the world don’t have the power to make crucial decisions, such as whether or not to spend money to hire a vehicle to get themselves to the nearest hospital, even when they desperately need to go. And I knew the statistic that tells us that some 800 women die due to pregnancy-related causes every day.i But I also knew it did not have to be that way. And seeing her lying there, like an afterthought, hit me hard.

It also made me angry. As a nurse, seeing a woman die needlessly because she could not access medical care made me want to shout from the rooftops. That was years ago, but I’m still angry about it now, because deaths like these are happening with horrifying frequency to this day—and they can be prevented.

There has been progress in the realm of women’s health. Between 1990 and 2010, there was a 45 percent drop in maternal mortality worldwide, according to the World Health Organization.ii The United Nations Millennium Development Goals adopted by the international community in 2000 further sought to reduce global pregnancy-related deaths by three quarters by 2015.

This is welcome news, to be sure. But in many countries where MSF works, a shocking number of women are still being lost. At present, 38 times as many women die in childbirth in Afghanistan as they do in the United Kingdom. Maternal mortality rates are 178 times higher in Central African Republic than in Japan, and 220 times higher in Chad than in Sweden.iii

MSF has demonstrated that it doesn’t have to be this way, that simple, inexpensive interventions carried out by trained health staff could save many of the 800 women who die every day from pregnancy-related causes. To cite just one example: In 2012, the organization started ambulance referral systems in the districts of Kabezi in Burundi and Bo in Sierra Leone. These are countries with some of the world’s highest rates of maternal mortality but very few hospitals or qualified medical workers.

Previously, complications during pregnancy were a likely death sentence for mother and baby alike. With the ambulance referral system, however, when a woman shows signs of complicated labor, the local health clinic can call for an ambulance. The ambulance arrives and takes the patient, escorted by a nurse or midwife, to a hospital where trained staff are on hand and surgical and blood transfusion services are available, for free, around the clock. The results have been dramatic: The maternal mortality rate in Kabezi dropped 74 percent; in Bo, it fell by 61 percent.iv

These are remarkably strong women and they are anything but victims.

MSF is a medical humanitarian organization that works in roughly 70 countries to treat people who have been affected by conflict, natural disasters, disease, epidemics, severe privation, and long-term neglect. At root, our mission is to provide lifesaving medical care to those who cannot otherwise access to it.

I’ve been with MSF for more than 20 years, first working as a nurse in the field, then running projects in several countries before becoming director of operations. I now serve as president of MSF’s office in Belgium. While we are not specifically a women’s health care organization, most of our patients are women and children. In project after project, I’ve seen our waiting rooms and wards full of pregnant women, women who’ve been injured or fallen ill, and women with their children. I’ve seen the lengths women will go to in order to care for their children, walking great distances in dangerous circumstances to make sure they get vaccinations and treatment, or risking everything, including rejection from their husbands, to prevent transmitting HIV to their unborn babies.

These are remarkably strong women and they are anything but victims. Many perform backbreaking labor in addition to running their households and caring for their children and other family members. During conflicts and other events that cause displacement, they often take on even more responsibility, frequently acting as the sole caretaker of their family members. Yet in spite of the huge burdens they shoulder, they rarely possess the power to decide when they themselves can get lifesaving care.

Put simply, women have distinct health risks that men do not have,
and these risks must be attended to.

On the day I saw the young woman lying dead under a blanket in DRC, I reaffirmed a decision I had made early in my career to be one of the voices within MSF that pushes the organization to pay particular attention to the specific needs women have in the contexts where we work. I am still one of those voices, and I’m glad to say I’m one of many, as you’ll see in the pages that follow.

Put simply, women have distinct health risks that men do not have, and these risks must be attended to. Let’s start with the obvious: women get pregnant and bear children. Worldwide, more than a third of all deliveries have complications, and 15 percent of all deliveries involve life-threatening complications—conditions likely to kill women if they cannot access emergency care. Globally, at least 287,000 women die during or shortly after childbirth every year.v Many could be saved by effective surgery, trained medical workers who recognize the severity of their condition, transfusion services, prompt transport to medical facilities or closer proximity to existing ones.

In far too many cases, these things are simply unavailable. My colleagues and I have lost count of the cases we know of in which women in labor could not find or afford a ride to the hospital, or a woman walked for hours or days while in labor only to learn that there was no doctor she could see until the following morning, if at all, or that she would be charged far more money than she could pull together to get the care she urgently needed.

The women and girls who manage to survive a life-threatening complication without emergency care, the so-called lucky ones, will usually lose their baby and may develop an obstetric fistula, which, while not immediately life-threatening, can have profound consequences for their health and future. Many women with fistulas not only carry the grief of a lost child; they also face rejection by their husbands, their families, and their communities.

There are solutions. Good referral systems
with ambulance services are one.
Maternity waiting houses are another.

When a woman does manage to deliver her baby successfully, the lack of sufficient newborn care in many places jeopardizes her child’s ability to survive the first few weeks of life. A newborn’s chances of survival are even slimmer if the birth was prolonged and complicated. In 2013, 2.8 million babies died before they were a month old, mostly due to asphyxia, infection, and pre-term or low birth weight Again, access to properly trained medical workers and relatively basic care could have saved many of these children.

There are solutions. Good referral systems with ambulance services are one. Maternity waiting houses are another. In places where a woman lives far from the nearest hospital, she can spend the last weeks of her pregnancy in a house near a working hospital, alongside other pregnant women who can then count on getting the care they and their babies need when they give birth. That’s exactly what MSF offers in Masisi, DRC, at a 70-bed maternity waiting house that is almost always filled to capacity. This is another simple intervention with profound consequences.

The challenges women contend with go beyond childbirth, of course. For a host of reasons, women are more vulnerable to contracting HIV and they struggle to get treatment if they do. They also bear the terrible burden of possibly passing the virus to their child.

Just growing up female can lead to health risks: In many countries, the custom of female genital mutilation (FGM) persists, affecting up to two million girls each year. FGM has no health benefits and is extremely painful and debilitating, with both immediate and lifelong health consequences.

In wartime, access to health care often declines, affecting everyone. For women, though, conflict results in even fewer options in maternal or pediatric care, or vaccinations for their children. Conflict also creates environments of rampant exploitation of women and girls and of rape used as a weapon. Displacement in general, whether due to economic necessity or man-made or natural disasters, leaves women and girls more vulnerable to sexual violence and trafficking.

In many of the places where MSF works, women have no access to birth control and little control over their sexual lives. If a woman or girl has an unwanted pregnancy, there are very few options. If she carries the pregnancy to term, she could bear harsh social consequences. If she decides to seek an unsafe abortion, as millions of women with no access to safe abortion do every year, she risks severe injury, even death.

These issues and the suffering they bring about are not new or unknown, yet they still have not been adequately addressed. MSF tries to help as many people as we can; more often than we’d like, we are the only medical organization in the places where we work. In 2013, for instance, we assisted with more than 182,000 births, provided medical care for more than 11,000 survivors of sexual violence, and offered prevention of mother-to-child transmission care to nearly 16,000 mothers living with HIV and their babies.

This book is part of the call
to all involved and to all who care that more should be done
to address the specific medical needs of women and girls around the world.

We’re the first to say, however, that many women are beyond our reach, that there are many services that we do not offer at present (such as treating breast cancer), and that there are policy and human rights debates we don’t get involved in beyond the framework of our medical activities, such as the fight for women’s rights.

At the same time, though, we do advocate for the people we treat. We call on the international and humanitarian communities—along with national governments and parties to conflict—to act when lives are at stake.

This book is part of that effort, part of the call to all involved and to all who care that more should be done to address the specific medical needs of women and girls around the world. It is a collection of first-hand accounts from MSF aid workers—midwives, OBGYNs, physicians, nurses, and counselors—who have treated women and girls in a host of different countries and contexts over the past two decades. Their stories illustrate how limited access to health care can have devastating consequences for women the world over. They also show the tremendous impact that care can have on an individual’s life.

This is not an academic book, or a policy book, or an “aid” book. It’s an attempt to bring together the views and experiences of people who’ve been in the field and who can articulate both the depth and scope of the needs that exist—along with the opportunities to provide meaningful assistance. It includes the voices of women describing their stories and obstacles in trying to get the care they need. And it’s capped off by journal entries from an MSF OBGYN who encountered seemingly insurmountable challenges nearly every day of the six months she spent providing care for women in Sierra Leone. Despite the struggles, she saw clearly the impact her work had on the lives of her patients.

In early 2014, I visited an MSF project in Bangui, Central African Republic. The country was and still is, as of January 2015, in the midst of a conflict that has killed tens of thousands and driven around one million people—20 percent of the population—from their homes.

At the Bangui airport, MSF has a makeshift field hospital next to a refugee camp where huge throngs are seeking sanctuary. We provide health services and emergency first aid, as we’ve done in many places over the years. But we also have a delivery room and a space to treat survivors of sexual violence. These, too, are an integral part of MSF’s response. Bullets are often fired over the clinic and our staff members have to lie down until the shooting stops. But we have no plans to stop providing a space for women’s health.

These women will not be afterthoughts. They cannot be, because, as the title of this book says, tomorrow needs them.

This is true in Afghanistan, Pakistan, Sierra Leone, Burundi, Colombia, South Sudan, DRC, and in every other country where MSF works—in every other country, period. As an organization, we look forward to the day when women the world over have access to the kind of medical care many of us in the developed world take for granted; to a future where no girl or woman has to die because she could not reach a hospital in time; and to the day when I can be confident of entering a remote rural hospital without seeing the body, shrouded on the floor, of a woman lost in childbirth.

I hope this small project goes some way to furthering this dream. And I thank you for your interest in the global crisis of access to medical care for women and girls.

Meinie Nicolai
President, MSF Belgium

i World Health Organization. Maternal Mortality Fact Sheet, No. 348. May 2014.
ii Ibid.
iii WHO, UNICEF, UNFPA, The World Bank, and the United Nations Population Division. Trends in Maternal Mortality: 1990 to 2013, p. 31-35. 2014.
iv MSF, Safe Delivery: Reducing Maternal Mortality in Sierra Leone and Burundi, November 2012.
v WHO, UNICEF, UNFPA, The World Bank, Trends in Maternal Mortality: 1990-2010, p. 1, 2012.
vi UNICEF. Child Survival: Neonatal Mortality Rates Are Declining in All Regions, But More Slowly in Sub-Saharan Africa, updated November 2014.

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