DR Rasha

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Dr. Rasha Khoury is an obstetrician-gynecologist based in New York City. Dr Khoury worked in a Doctors Without Borders/Médecins Sans Frontières (MSF) trauma facility in April and May 2017.

Disclaimer: The location of the project has been withheld to protect MSF patients and staff. Although abortion for medical reasons is legal in the country where the project operates, it is still a very sensitive issue.

My handheld radio crackled under my long dress. “Cars are leaving in 10 minutes.” I cursed under my breath. I needed to stabilize this patient before we left. I radioed back, “Can we hold the departure time?” The field coordinator finally texted, Ok, but keep me posted. Delaying the Doctors Without Borders/Médecins Sans Frontières (MSF) medical convoy inside the city was always a risk. Ongoing fighting meant that we had to leave the hospital by late afternoon each day. Our local colleagues remained overnight to keep medical activities functioning 24 hours a day.

I was waiting for the patient to deliver. She was anemic and bleeding heavily. We were transfusing her as fast as possible with blood from our blood bank but I anticipated further hemorrhage after she delivered. I sent our ambulance to local hospitals—which were still only partially operational because of the conflict—to look for fresh frozen plasma (FFP). I took a breath and noticed the patient’s mother pacing. The patient was crying in pain and squeezing the midwife’s hand; my colleague was calm and soothing. I refocused to place a second IV cannula and provide more fluid for resuscitation. Someone ran over from the operating theater with a medication that helps to control bleeding. Time was moving in slow motion, but every second was critical. My clothes were drenched in sweat.

Out of the corner of my eye I saw the field coordinator in the hallway, then heard the radio, “Convoy on hold for medical emergency.” I felt relief. Minutes later the patient delivered. It took an hour to stabilize her with all the medications we had available to make the uterus contract back to its usual size, four units of blood, two units of FFP, many liters of normal saline, a urine catheter, and continuous uterine massage. The midwife smiled proudly as the patient’s mother kissed her hand. We were able to save her life and avoid performing a hysterectomy—two outcomes that are rare for patients in her condition.

The patient had risked her life to reach MSF’s trauma center. She was pregnant but unsure how far along the pregnancy was. When we examined her, she complained of shortness of breath and her belly was unusually ballooned. She had not felt fetal movement for several days. We performed an ultrasound and determined that she was around seven months along. We also saw that the amniotic fluid level inside her uterus was too high—a medical condition often associated fetal abnormalities. The dangerously high level of fluid was likely worsening her shortness of breath.

The fetus had heart activity but lacked brain structures. This condition is called anencephaly—a fatal fetal abnormality that causes death in utero or almost immediately after delivery. The condition is directly linked to folic acid deficiency. Conflict makes this anomaly—a rare deficiency in countries like the United States (US)—considerably more common when people cannot access folic acid fortified foods and supplementation, family planning, early pregnancy diagnosis and treatment, and affordable health care services. During my time in the trauma unit, I saw pregnancies affected by anencephaly multiple times a week but in my 10 years of training and practicing obstetrics in the US, I have only seen this condition a handful of times.

It is dangerous for women carrying a fetus with anencephaly to go into labor while at home, especially in times of instability and conflict. anencephaly puts the mother at high risk of hemorrhage both before and after delivery—a preventable complication, but one of top five causes of maternal mortality each year. Our patient had travelled several days to reach our facility. If I had sent her home without inducing her labor, it is unlikely she would have made it to a functioning health facility in time to receive the care she needed to survive.

Explaining the diagnosis to the patient was not easy; the accumulation of suffering was visible everywhere on her face. Her husband and three of her five children were killed in the fighting. But knowing the risk she faced if we sent her home, and knowing her fetus would not survive, we offered to induce her labor to end the pregnancy safely in our facility. Here I could attend her delivery and she would have access to an operating room and blood bank should she need those services. This care would be free of charge; in keeping with our principles, MSF provides free care to everyone regardless of race, religion, or political status.

Safe abortion care plays a vital role in reducing maternal morbidity and mortality. MSF is committed to offering safe abortion care services if needed. How we provide these services depends on the specific context and is tailored to keep patients and staff safe.

Unsafe abortion is one of the five main causes of maternal mortality worldwide, together with hemorrhage, eclampsia, sepsis, and obstructed labor. Unsafe abortion accounts for 13 percent of maternal deaths around the world, according to the World Health Organization. MSF’s priority is preventing the consequences of unwanted pregnancy and unsafe abortions.

Wherever MSF works, we must navigate different value and belief systems, taking social norms and laws into account without allowing them to inflict further suffering on vulnerable groups. MSF stands behind safe abortion care as a medical necessity and argues for it from a humanitarian and evidence based perspective.

Had we not been able to provide this care to the patient, it is quite possible she would have died from the obstetric hemorrhage at home, or in another medical facility that may not have had all the resources she needed. She remained hospitalized overnight for observation; most women insist on going home within hours of delivery. The following day I found her waiting for our MSF convoy to arrive so she could say her goodbyes. We talked with her about what she had just been through and provided her with contraception, iron, and a high dose folic acid supplementation to prevent this happening again if she were to unexpectedly become pregnant in the future.

When we think of insecure environments and conflict, we often think of direct injury and death, food and shelter shortages, or perhaps we think of the spread of diseases. The countless people with indirect injuries leading to death or near-death experiences, like this patient, remain mostly invisible.

  #tomorrowneedsher #womenshealth Because Tomorrow Needs Her focuses on some of the impediments to women’s health, exposing injustices that disproportionately affect women and girls around the world.