DAMASCUS - Some disagree that a minute counts during an emergency delivery. According to Dr. Abdul Salam, “a nanosecond is very important in saving the life of a woman.” As a professor of gynecology and obstetrics at University Maternity Hospital in Damascus, Syria and UNFPA (United Nations Population Fund) National Expert, she has seen enough life or death situations to know.
Last fall while at the hospital, she received an urgent call from UNHCR (United Nations High Commission for Refugees). A pregnant Somali woman in her late 20s had collapsed at the UNHCR Registration Center in Damascus. The woman, in her ninth month, had been waiting to get important protection papers, silently suffering because she was afraid of losing her appointment if she spoke up. Upon collapsing, she was rushed to the Syrian Arab Red Cross (SARC)/ UNFPA supported health clinic near the Center. The doctor on duty diagnosed her with obstructed labour and requested that she be taken to a hospital immediately.
Dr. Abdul Salam met the woman upon arrival to the hospital and confirmed the previous diagnosis. The woman was in so much pain she was unable to talk, even to tell hospital staff her name. Time was crucial – Dr. Abdul Salam knew that any delay could cost the woman and her baby their lives. “There was no time for papers,” she said, and pushed management to allow the woman to be admitted despite rules requiring IDs and advance payment. Realizing the severity of the woman’s condition, hospital management gave her permission to proceed.
One hour after the woman arrived at the hospital, she and her newborn were in good condition, recovering from an operation that was “completely safe, without complications.” Two days later, Dr. Abdul Salam saw the woman at the hospital again. The woman ran to her, hugging her, thanking her profusely for saving her life and that of her beautiful baby girl.
Dr. Abdul Salam credited the speed with which the woman received proper care as instrumental in her and her baby’s survival. “The earlier you interfere, the better the chance for success.”
Building on Past Successes
Maternal mortality rates in the Syrian Arab Republic have fallen precipitously by almost 250% from 143 deaths per 100,000 live births in 1990 to 58 in 2004. Rises in the use of family planning methods and the average age of marriage have no doubt contributed, as frequent and especially early childbearing makes women more vulnerable to complications.
But in the critical hours during and after a delivery with complications, emergency obstetric care can be the difference between life and death. Most complications during pregnancy can kill a woman within 12 hours, with postpartum haemorrhage being especially deadly, killing in as few as two hours. In Syria, haemorrhage is the cause of almost two-thirds of all maternal deaths, according to a 2006 Ministry of Health/United Nations Population Fund (UNPFA) study.
To help reach its goal of reducing maternal mortality to 32 by 2015, the Syrian Government with UNFPA support is working to strengthen emergency obstetric care, especially in the eastern region. Syria has already made significant improvements in providing obstetric care: the proportion of deliveries by skilled attendants (who are able to administer medical treatments if problems arise) rose to 93% by 2006, up from 80% in 1990, and over 70% of deliveries in 2005 were in health facilities. Yet there remain wide geographic disparities: while in Tartous 93.9% of births were in health facilities, in Deir ez-Zor and al-Hasakeh in the East only 56.4% and 58.9% were, respectively.
Deadly Delays
There are three crucial periods of delay in an emergency delivery. “It starts with diagnoses, identifying that this delivery is in trouble,” explained Dr. Wael Hatahet, UNFPA National Programme Officer for Reproductive Health, “then it’s transportation to the facility, and then it’s the availability of staff.”
Dr. Hatahet said that demand for skilled attendants and health facilities needs to be created in many areas. “If women go to a clinic once and have a bad experience, feel like no one catered to their needs, or didn’t like the quality, they’ll choose not to go back there.” Thus the focus of the Ministry of Health program is uplifting the quality of services to create demand while improving logistics such as transportation, which can also prevent people from seeking care.
Beginning this month, the Ministry of Health with the support of UNFPA is conducting situation analyses of the emergency obstetric care services in Deir ez-Zor, ar-Raqa, and al-Hasake. With this information, the Ministry of Health will be able to pinpoint weaknesses and design future efforts to meet those needs. They expect data gathering to be completed before Ramadan begins in September, and the full report by the end of the year.
Dr. Abdul Salam emphasized the need to upgrade the skills of medical attendants. In her opinion, the main delay to women receiving the proper treatment is improper diagnosis. Sometimes, “doctors and midwives don’t recognize that bleeding is hemorrhage,” or suggest the wrong treatment. She adds that “midwives can be hesitant to send [the woman] to the hospital” when there are complications.
The 2006 study on maternal deaths includes an appendix with several real-life stories that emphasize the need to act quickly. One woman in the ninth month was rushed to the hospital because of pain, vomiting, and swelling. Despite suffering from eclampsia, one of the most common causes of maternal death, the woman was given an injection and sent home. There, her condition worsened and upon returning to the private hospital she entered intensive care, suffering from eclamptic fits. She and her baby girl died soon after.
Another woman suffered from edema throughout her pregnancy, but was told by her doctor that it was normal and did not affect her pregnancy. After giving birth to a 3.7 kg daughter, she began to haemorrhage. The doctor operated upon her, declared it a success and then went home despite the woman’s continued complaints of pain. The woman was told to go home herself and left without having any tests done.
Within thirty minutes she lost consciousness and her husband returned to the hospital, but doctors did not enter her room until after an hour had passed. The woman was declared brain dead and died later that evening.
Efforts to Strengthen the Emergency Obstetric System
To strengthen skills, the Ministry of Health with UNFPA support is conducting trainings for doctors and midwives. Doctors are trained to improve their emergency care skills, and midwives to handle normal pregnancies and know when to refer cases to emergency care. Already this year, two training courses on emergency obstetric and newborn care have been conducted for midwives. Ten midwives from different governorates took part in 15-day trainings at University Maternity Hospital, which covered all shifts. More trainings are planned for this year, including a large one for doctors in the fall.
The Ministry of Health is also working to raise awareness among health practitioners and improve the entire system. A May seminar in ar-Raqqa Governorate with Deputy Minister of Health Dr. Jameel Alaweid and UNFPA Representative Lina Mousa presented recommendations and principles of emergency care. Attendees included the General Women Union and the Syrian Association for Obstetrics and Gynecology. The Ministry of Health’s Reproductive Health Technical Committee also continues to meet frequently to discuss technical issues in upgrading emergency care.
“We need to change the obstetric attitude,” said Dr. Abdul Salam. With 15% of all pregnancies resulting in complications, she said every doctor, midwife, nurse, and woman should be aware of the warning signs, which include bleeding through more than two pads a day, bloodclots, a high temperature, and shivering or sweating. “Many women are simply not aware.”
When asked if Syria can achieve the goal of reducing maternal mortality rate by 2015, as a part of the global Millennium Development Goals, Dr. Abdul Salam points to the significant changes and improvements since she first started practicing medicine: “Syria can do it.”
Annette Mullaney
