Name? Age (if known)? Gravidity and parity? Cause of death? I sit on a block of sandstone outside, under the trees, with the monkeys tumbling around me, and the storm clouds gathering for the evening's coming deluge, filling in the maternal death surveillance paperwork, for the seventh time this year. It's a strange and disconcertingly beautiful setting for such a sombre task. Surely, I think to myself, surely this is it. But even as I think it, I know it is unlikely to be true. Not this year, not next year, perhaps not for many years to come. Maternal deaths will continue to happen. I baulk at the final piece of the puzzle, ‘cause of death’.
I sit and stare at nothing, trying to hold back the wave of emotion that threatens to break through the fragile facade of calm I've just about managed to keep in place since she died. Cause of death. I know why her heart stopped beating and her lungs stopped breathing. I know that. I know the pathophysiology of a catastrophic haemorrhage leading to disseminated intravascular coagulation, hypovolaemic shock and extreme hypoxia. But that's not why she died. That's how she died. And for some reason, with Tigist, I can't write it. I can't reduce the devastation in her mother's eyes, living without her eldest daughter, the fear in her husband's, living without the mother of his newborn twins, the regret in my own, living with another woman in my care dying, to a few clinical sentences. I'm too tired and angry and sad—at Tigist for not pulling through, and at us for not doing it for her. Hers was a death of circumstance.
‘I can't reduce the devastation in her mother's eyes, living without her eldest daughter, the fear in her husband's, living without the mother of his newborn twins, the regret in my own, living with another woman in my care dying, to a few clinical sentences’
The phrase bandied around the non-government organisations, the United Nations, and the World Health Organization, as experts sit through round table meetings and take their notes, is ‘preventable’. It was preventable. But at what stage in Tigist's life would that prevention have to have started for her not to die? When she was 10, and withdrawn from school to help her mother sculpt and fire the black clay jebena (coffee pots) that was their livelihood, and the livelihood of many of the Funga girls? When she was 15, and married to an older man so that she'd no longer be a financial burden on her already overstretched family, where eight other sons and daughters also need clothing and feeding? Or, perhaps, when she was in her early twenties and carrying her fourth child, having suffered another miscarriage just a handful of months earlier?
Those are the causes of death: abject poverty, no formal education, early marriage, no access to family planning, limited antenatal care, inadequate understanding of health and fertility. The cause of death is that no one was there to tell her, her family, or her husband that as well as duties and responsibilities, every young woman also has choices and rights. The haemorrhage was just the final gust of wind that sent her over into the abyss, not the reason she was teetering on the edge in the first place, a symptom of a much deeper disease of global health inequalities, gender-based discrimination, child marriage, and food insecurity. Which of these, exactly, is preventable?
It's difficult to comprehend the millions of dollars poured into health programmes when, in my part of sub-Saharan Africa, almost 1 in 30 women still die in childbirth—that's one every month in my hospital (UNICEF, 2017). That's five more times this year that I'll sit on this sandstone and stare at nothing. But there's not enough space to write that, and it wouldn't feature in the report of leading causes of maternal death around the world, where the choices are really haemorrhage, infection or hypertension (WHO, 2012)—words that mean nothing, capture nothing, hold us accountable for nothing. The women whose deaths are reported are not a statistic or a diagnosis; they are women, with families, stories, hopes and dreams, successes and disappointment. They are real. Were. They were real. But then they died. So I sit on the sandstone and stare at nothing.
The years I've spent here have been full of patients triumphing over the odds, of remarkable recoveries and successful surgeries, but also full of tragedy and frustration. I reflect on it all now, sitting with the unfinished paperwork still balanced on my leg, splashed with the tears that I can no longer hold in. They aren't for Tigist alone, although her story and her death touched me more deeply than I had anticipated. They are for the hopelessness we all felt, for the fact that we really tried—we poured our own blood in to her, we operated when there was still a possibility she might live, we used every one of the meagre selection of medications at our disposal—and she died anyway. They are for the nurses who joined me at the end of the night-long vigil at Tigist's bedside, who prayed the rosary for her, helped to wrap her body, and joined her grieving relatives when it was all over. They are for her mother, who collapsed into me as I collapsed into her. They are for the hospital's medical director, who shook her head and bought the team together to tell us we did everything we could, and it was out of our hands. For the helpless, lost looks on our faces as we wondered why we couldn't do more. They are for the relatives and friends of the other patients on the ward, who helped carry Tigist's clothes and bags and four children back to village, because they wanted to help. The tears were for every patient who had died a death of circumstance, and for every clinician who couldn't stop one, and has to live with that.
While our experience of a maternal death pales into insignificance when compared to the traumatised family, there is no way to find words that capture the feeling of utter hopelessness we experience. That woman came to us because she and her family believed we would, and could, help. But when we can't, it's a feeling of desolation, of uselessness, of emptiness, that takes your breath away.
And yet, in the midst of all of that, there comes the gusty wail of a hungry newborn, the tiny, beautiful twin girls who survived their mother. As yet untouched by the tragedy of their birth, they were the small, flickering candle of hope in all the darkness. Because of the wonderful women I am proud to live with, work alongside, and love as my closest friends, these baby girls will grow up in one of the rare corners of Ethiopia where FGM is no longer practised, where women marry out of choice and not out of duty, and where there is now a chance to decide how many children they want. Because my friends went to school, and then to college, and then trained as midwives, they could take the knowledge, experience, determination and courage that their education gave them back to the villages, back to the elders and chiefs, and they could say no. And the power that word held was enough to change the world.
These wonderful, brave, women, they were the ones who fought for change. Because of my midwives, and the women that came before them and stood proudly allowing them to fly, the baby girls can have a future brighter than their mother's. They can go to school, to university, they can own land, and they can build houses. They can not only be aware of, but they can insist on, their rights and choices, as well as shouldering their duties and responsibilities. And, like my midwives, they can, and will, do it all with grace and humility and humour. Perhaps then, the circumstances will change, prevention will start, and when they are grown and ready they will have their babies, and not die.
This may only be one rural village, a thousand footsteps from anywhere, but if the women can change it here, then why can't they change it elsewhere as well? Here they stood up, spoke up, and proved change is possible. In other places, it's up to women to do the same. To take back control, to empower themselves, to fight for what is right and just and true—to fight for their very lives.
For those of us privileged enough to spend some of our lives walking with the midwives and the baby girls, it's on us too. Their successes are ours, their moments of suffering are too. Write letters, raise funds, donate to grassroots charities, read, protest, volunteer, network, research, go to conferences and lectures, lift your voices, insist on better. It takes a village to raise a child, but it takes more than that to prevent that same child dying in birth later in her life. We, the clinicians, can only do so much, as Tigist's death demonstrates. We need help. Change has to come from everywhere, from all sides, at all times. Steps have been taken, but we have some way to go, and it's a journey we have to take together. Join us. No more sitting on this sandstone staring at nothing. No more maternal deaths. BJM