Each day, around 800 women across the globe die because of complications during pregnancy or childbirth. Doctors Without Borders, the international medical organization that sends physicians to impoverished areas, recently launched a multimedia project to illuminate the reality of these unnecessary deaths. Because Tomorrow Needs Her has stories, pictures and videos detailing the organization’s work with women in regions that lack basic medical care, including the journal of an OB/GYN who was stationed in Bo, Sierra Leone, in 2012.
When I came across it, I was haunted immediately. Dr. Betty R. Raney’s journal is as horrifying as it is beautiful. It containing excerpts from the actual diary she kept while working at the Gondama Referral Center, a high-risk, 24-hour pediatric and obstetrics hospital. She writes of the helplessness she felt as mothers and babies continually died before her eyes, as well as the hope and joy in seeing an eight-year-old sexual assault victim start to smile, laugh and run around again after treatment. There are images and details I can’t get out of my mind; some that even kept me up at night.
Dr. Raney graciously agreed to speak with me about her experience over the phone on Thursday morning. The interview has been lightly edited for clarity and length.
One of the most horrifying things I read in your journal was the number of maternal deaths you saw at your facility. You had never had one woman die during labor on your watch in your entire 25-year career in America, but after you arrived in Bo, you had upwards of seven maternal deaths a month. Why is it so dangerous for women to give birth in Sierra Leone?
There are several reasons for that. One of the biggest ones is: there is no prenatal care. The government really encourages these women to get at least three prenatal visits during the course of their pregnancy, but the problem is they all live out in villages in the countryside. None of them have transportation, and there are no clinics near them. So it just doesn’t happen.
Their nutrition is poor, additionally; in the country there is a lot of high blood pressure among women. That causes a lot of difficulties. There’s a lot of preeclampsia and eclampsia that goes on during the pregnancies, and that can kill women, and it certainly causes babies to die.
So there’s no prenatal care, there’s a lot of malaria, there’s a lot of chronic disease. If women do develop a problem during the end of their pregnancy, it may take them two to three days to get to us and, by that time, the problem is so severe that we just can’t help them. We do everything we can but the baby may already be dead, or the women may have already bled out by the time they get to us.
It’s really just crazy. When a woman would get sick during labor or the baby wouldn’t come out, a man would take a long stick and they would tie a cloth to it to make a sling. Sometimes they would walk through the countryside or the hills for 12 hours, 18 hours. They would walk to us and when they finally got to the town, if they had money, they would hire a motorcycle to get the woman the rest of the way. By then she would be unconscious, and they would prop her between themselves and driver of the motorcycle to get to our hospital.
Before you headed to Africa, you spent most of your career practicing in the fairly affluent cities of Indianapolis and then Charleston. What pushed you to start working with Doctors Without Borders?
I always wanted to do some type of mission work. I grew up as a missionary kid in a little village in northwestern Thailand. My dad was a doctor; he was a medical missionary. My mom was a teacher. We lived there until I was 17. Of all the organizations I investigated, Doctors Without Borders was the most impressive because, with all the money donated to them, such a huge proportion of every dollar went straight to the field and straight to the patient.
And why Sierra Leone? What was Doctors Without Borders trying to accomplish there?
They were trying to reduce maternal mortality, primarily. It’s one of the poorest nations in the world. When I went there, one in eight women would die either during the course of their pregnancy or during labor. The program they set up there, the little hospital I worked at, reduced maternal mortality by about 61 percent just by setting up this hospital and by creating an ambulance system. Ambulances were stationed in outlying areas, and by getting patients to us quicker, before the point of no return, they were able to reduce maternal mortality.
The cost of reducing maternal mortality by that percentage rate is really what amazed me. It was so low. Something like €1.5 euros per person living in that area.
Going from working in the U.S. at facilities where you had easy access to all the necessary medicine, supplies and support staff to working at a remote high-risk obstetric clinic with only one other Western doctor must have been a shock. How did you prepare while you were still stateside?
They emailed me reams of material about the project there. I, of course, read all of that. But the best preparation was my 25 years of experience in obstetrics. I ended up seeing things there and did things there that I had never experienced. It was scary. It was fascinating. It was challenging. I loved every minute of it. But I was really grateful I had all of that experience under my belt because I think for younger physicians going there who don’t have a lot of experience—maybe they’re right out of residency—it would be a scary thing and quite difficult. On top of that, it helped that I had grown up in Thailand.
What were your first impressions of both Bo and your obstetric facility?
It was a little hard to get used to living there. The town was very small. There really weren’t any stores as we know them; there was an open market where the local people bought their food. It was this crowded little place, where you had to walk through mud and filth to get to the market. You would get to the place where you wanted to buy some meat and nothing was refrigerated, and the chicken was sitting out in the open with the flies and the bugs crawling all over it, so you’d pretty much decide you didn’t actually want the meat after all.
Bo was a pretty decent town in terms of cleanliness, but most of the people had no electricity. Most of the people had no running water. Just a very, very poor community. The hospital itself was pretty interesting. It was just a series of buildings. We had electricity at the hospital because Doctors Without Borders had generators that ran 24 hours a day. We did not have air conditioning; we had one operating room where we did our cesarean sections, and that was the only room in the whole hospital that was air-conditioned. But the nationals never liked to turn the air conditioning on because for them, it was too cold.
The hospital was pretty basic. We had a ward with 20-30 beds in it; we could expand it as needed. There was a bed with a little thin mattress on it, and sometimes we had a sheet for them, but most of the time we didn’t even have that. They just lay on this vinyl mattress. But we didn’t have pillows for them; we didn’t have blankets. All of the money we had really went to the serious things we needed for them like antibiotics, surgical equipment, and surgical sutures. It was just bare necessities. They were just so thankful for anything we had for them, and for the fact that they had anything to lie on.
You know, the bathrooms were outside the surgical ward. They would have just had surgery and they would have to go outside the building to go to the bathroom. Each of them had to have a family member who slept on the concrete floor underneath the beds, and that person was their caretaker. And that person helped them to the bathroom. If they needed a blood transfusion, that person had to give their blood or get another family member in from the village to give blood so we could give it to the patient. The one thing we were always short of was blood.
I read about the politics behind trying to get blood to your patients for transfusions, and it sounded absolutely insane. You were basically having to bribe people working at the hospital in order to save your patients’ lives with blood. Why was it such a struggle to get blood?
Well, to have a blood bank, you have to have donors. In the United States, people donate for free or you can get paid to donate your serum or your platelets, but there’s no such facility over there. A lot of the blood we would have donated we couldn’t use because it was positive for HIV or it was positive for hepatitis. Something like 57 percent of it was positive for malaria. So we would take that blood, because we could treat the patients for malaria. But a lot of the blood we couldn’t use.
It was a fight every single day. Some days I would bargain with them and I would say, “If you give me that unit of blood you have, I will give you a unit of my own blood,” but Doctors Without Borders didn’t let me donate my own blood, so that didn’t really work. It was one of my biggest struggles there.
From your journal, it sounds like your first few days at the facility were especially tough. How were the patients and the problems you were seeing different from what you were used to in the U.S.?
They were problems that just didn’t exist here. One of the reasons is, in this country, we have legalized pregnancy termination. In Sierra Leone, abortion is illegal. There is no outlet. There’s a very, very high rate of women trying to get illegal abortions there, and it is one of the top five causes of maternal mortality in that country. It’s right up there with postpartum hemorrhage, complications with delivery and hypertension disorders.
Across the world, it kills millions of women every year. A lot of these would be 14- and 15 year-old-girls that came in, and somebody had tried to put an instrument up them, and the instrument would perforate their uterus into their abdominal cavity. They would end up with an abdominal cavity full of pus, with a pregnancy that extruded into the abdominal cavity. That was something I saw every week and I had to operate on every week.
These were young, young women. Some of them died; a lot of them were left infertile at the age of 14, 18, 19. The pregnant women who had no prenatal care would present with crazy things. They would present with just an arm hanging out of the vagina.
They would go into labor and the baby would be in the wrong position, and the water would break. So the baby would be laying crosswise in the abdomen. You cannot deliver that way. They would come in and you’d lift the sheet up—and there’s a little hand hanging out of the vagina. If the baby was alive, this little hand hanging out of the vagina would grasp and squeeze your finger, but most of the time it wouldn’t do anything because the baby was dead.
When women in the United States are pregnant, at the end we know if the baby is transverse and we do a cesarean section before they go into labor. But these women would go in labor and it would take them 18 hours to get to our hospital, and by that time, the baby’s dead. These are things that would never happen in America with women who have access to prenatal care before they deliver. It was so sad because I would have days on Labor and Delivery where every single baby in utero that walked in the door, every single one was dead.
You also wrote in your journal about finding out that pediatricians in Sierra Leone allow HIV-positive mothers to nurse their newborn children. Why is that?
A child has a greater chance of survival if the HIV-positive mother nurses that baby, because if they don’t nurse, they go home to their village and the babies are sometimes given cow’s milk or they’re given water or they’re given coconut milk, and those things kill newborn babies. The other thing is there is a very high death rate in malaria in newborn children. Everyone over there has had malaria. The mother has antibodies to malaria, and she passes it over to the newborn through her milk.
That baby, with the mother being HIV-positive, is much more likely to grow up into a young person than a baby whose mother did not breastfeed. They just die from infection, from malaria, from so many diseases when they don’t have the antibodies from their mother.
Is female genital mutilation still prevalent in Sierra Leone? Did you see many patients who had been victims of that practice?
Yes. About 95 percent of the patients I saw had undergone that. The main reason they do that is to remove the women’s pleasure so they do not stray from their husbands, because women are viewed as being the property of their husbands. Even the nurses and the nurse midwifes I worked with, who were part of the national staff there, they all had undergone this procedure. It’s almost like a secret society that the young girls are inducted into.
As they grow up, the older women teach them that this is a wonderful thing and this is truly the only way to become a woman and it’s just an exciting thing that you join the adult world of women when you have it done. The men aren’t the ones that are really trying to propagate this practice. It’s the older women who do this.
Yes. The older women are the ones who lure the young girls into accepting this genital mutilation. It’s almost ritualistic for them.
Can you tell me a bit more about the locals you worked with? You mentioned nurses and midwives. Were there doctors as well? What sort of training and education did these locals undergo?
There weren’t any national physicians at our hospital. All the doctors are in the capital, Freetown, because there they can make money, so we had a real lack of physicians in our town. We did have nurses and midwives in our hospital that were national staff, who would go to nursing and midwifery programs. Sometimes the government would send them out of the country for this training, but there was training in Sierra Leone, though it was quite far below the standards we’re used to in the United States.
Don’t get me wrong: the midwives had delivered hundreds and thousands of babies and they were really good at that. But the nurses in the hospital out on the floor were simply not up to standards of taking care of pediatric patients. They see death so much that they become relatively inattentive. Sometimes they just didn’t tend to things because they thought death was inevitable in a patient. I would walk into a ward and there would be a patient having a seizure and sometimes the nurse would say, “I’m going to get to it,” and then do something else.
Of course, there were some excellent nurses, especially the ones I worked with in the OB area.
Was it part of your job to train the local nurses and midwives to be able to take over your practice when your assignment was up?
Yes, it was. We would have regular training meetings, asking, for example: What do you do if you encounter a shoulder dystocia? It’s like if you’re trying to deliver the baby’s head and the shoulder gets stuck, what are the maneuvers you would have to do to make sure the baby gets out safely? We would have training meetings on hygiene, proper washing of hands, how to prep a surgical patient. We had training meetings all the time.
I found out when I got there that, if a woman delivered and had a tear on her perineum, most of them didn’t sew that up. I taught them how to look at that laceration, and taught them if the tear goes through to the rectum and you don’t sew that up, those women are going to walk through the rest of their lives incontinent of stool. They were very good at getting babies out but we had to teach them how to recognize these lacerations that needed to be sutured.
There were didactic meetings, where we did lectures, and there was a lot of hands-on training. They have something called a chief health officer, who would be something like a PA in this country. We had a PA who we taught to do cesarean sections, and he is out working in Sierra Leone now, taking care of pregnant women. He did not go through a residency and surgical training like we did, but we taught him how to do C-sections and D and Cs. He was one of the only ones working in the country when the Ebola crisis hit, because nobody else would be out in the countryside taking care of women. They were too afraid. But he hung in there.
From your journal, it’s clear you saw a lot of horrifying things during your time in Sierra Leone, including an infant who had been sexually assaulted by a family member. What sort of an effect did seeing this have on your mental health?
In the first part of my six-month tour there, it would just knock me down a bit. It would just devastate me; I couldn’t get it out of my brain. But after seeing it over and over, it kind of energized me to take care of these patients because they needed help so badly. It made me realize how much more help is needed in the country. If everybody in America went over there and spent one week watching what went on, the problem might be gone, because everybody would want to help and everybody would want to jump in, and we could get this mess straightened up.
What has Doctors Without Borders been doing in the region since you’ve left?
Unfortunately, when the Ebola crisis hit, the hospital had to close down. A lot of the staff died from Ebola and it was too hard to keep the hospital open. Doctors Without Borders had been there since 2007, but they had trouble getting workers into the hospital to take care of the patients. It was a challenge that was overwhelming.
Lisa Ryan is a writer in Brooklyn. She likes Tim Hortons and aspires to brunch with Amal Clooney. Follow her on twitter: @lisarya.
Images via Lynsey Addario/ VII