“The ambulance is here.”
Like lightning, here and then not, one moment we are seated, the next every couch is hollowed. Coffee mugs quake, hastily abandoned while magazines fly, and knitting needles are planted in woolen balls. Two minutes ago, we were suppressing yawns, all conversation topics exhausted.
It’s always like this on the Birth Unit: nothing, and then everything; nobody, and then everyone. We were expecting this chaos: it’s a full moon in September, after all. Babies don’t like to make the journey alone.
An hospital night shift is serviced by a “skeleton staff”—just enough of us to keep the place open until morning. For tonight, I am the Obstetrics and Gynecology department. Every woman in labor, every woman post-labor, every gynecological emergency, is my responsibility. It takes a village, they say; I have an intern, and a team of midwives, and together, and ours is a small one.
She wails. I won’t ever forget that sound. This isn’t the usual cry; we’re used to women in pain, to the screaming soundtrack of birth. This isn’t that. Hers is a primitive, guttural sound. It is despair.
She is wheeled around the corner, and into the department.
I watch the gurney speed past me as a disembodied voice narrates in staccato.
“She doesn’t speak English. Her husband is conversational. He is on his way. She is 22 weeks pregnant. Triplets. Been contracting strongly for a few hours. We think the water broke a few minutes ago, but we’re not sure.”
I want to reassure her, but she is going to lose all three of her babies tonight. The occasion calls for me to speak, but I have no language she can understand, and no words she will want to hear. And so, I put one hand on her striving belly, feeling for the strength of her contractions, and the other in hers. I am both a doctor and a woman in this moment. She looks at me, her eyes imploring me to help, and mine tell her what she is not ready to hear.
I don’t notice that her husband has entered the room until I hear him talking to a midwife. They are Sudanese, recently granted asylum in Australia. This is her seventh pregnancy, and they have only three living children; one baby died in early childhood in Sudan, and three others in the refugee camps. Her water actually broke a few weeks ago, he says. I sigh, I squeeze her hand, I rub her belly. She likely has an infection.
I am distracted by his narration, so I am not expecting it when her heart breaks out loud. A piercing cry penetrates the room and then, with a rush of water, their son is born. He never takes a breath. The midwives wipe their own tears as they separate him from the umbilical cord and swaddle his tiny body. They hand him to his mother, this child who is in the world, but will never be part of it. The loudest sound in the room is the absence of a newborn’s cry.
She calms, believing it to be over.
Pregnancy kills. Despite our best efforts, pregnancy still kills half a million women every year, and doesn’t do so indiscriminately. It matters that she is African, that she is Sudanese. It is a miracle that she is alive: 48 percent of maternal deaths are African women. In Sudan, the lifetime risk of dying because of pregnancy is 1 in 60. Statistically, she should have died long before that night in September.
It matters that she is a refugee. Pregnancy kills more mothers in countries in conflict than anywhere else: 99 percent of preventable maternal deaths occur in the developing world, 60 percent of those in humanitarian settings. Yet most research funding is spent to address the one percent. If money talks, our silence is deafening.
We’ve been silent far too long. For almost 40 years after World War II, all displaced people were seen as having homogenous Maslowian needs. It took a 1993 editorial in The Lancet, “Reproductive freedom for refugees,” for provision of maternal health services to women in conflict zones to became part of the humanitarian discourse. This elementary idea should not have been revolutionary, but it was. The next year, the Women’s Commission for Refugee Women and Children responded, publishing a report reiterating this call. It proved to be the fulcrum that turned the debate. The idea gained momentum, becoming mainstream in 1995: the International Conference on Population and Development established reproductive rights as a human right, sanctioned later by the Fourth World Conference in Beijing; The Inter-Agency Working Group (IAWG) on Reproductive Health in Crises was formed, as was the Reproductive Health Response in Conflict Consortium. In 1999, the first IAWG Field Manual was released, articulating concrete, reproducible strategies to implement the idea in the humanitarian setting. It took another decade for the United Nations Security Council (UNSC) to chime in: while their UNSC Resolution 1325 (2000) acknowledged the disproportionate impact of violence on women and children, it wasn’t until 2009, with Resolution 1889, that the UNSC affirmed reproductive rights and the need for women in post-conflict countries to access reproductive health care services. Thank God for the Lancet editorial board.
Reproductive health care is particularly important for vulnerable women. More than 120 million of the displaced are women and girls. The average length of displacement for refugees is 17 years, over half of a woman’s reproductive lifetime. After almost 25 years of recognizing the problem, these women still represent 60 percent of all preventable maternal deaths; more than one refugee woman in five is sexually assaulted and in refugee camps, the average age of marriage is fifteen—where girls aged between fifteen and nineteen are twice as likely to die from childbirth as women in their twenties, while girls under fifteen are five times more at risk of death. Preventing unwanted pregnancy could, and should, be the answer, and access to emergency and maintenance contraception is strongly desired, but often is inaccessible or stigmatized. Consequently, sexually transmitted infection rates are high in refugee camps.
We know all of this and our response? Only four percent of UN inter-agency funding is allocated to programs addressing these concerns, and less than one half of one percent of all funding to fragile states goes to women-focused groups. After almost 25 years of recognizing the unique dangers faced by women and girls in humanitarian crises, the international community is failing.
I think of that night, and that mother, often. I think about how it is shameful, but unsurprising, that having survived the years spent in the purgatory of displacement, she lived to see the death of three children. Her heartbreak isn’t unique. One in seven women experience pregnancy complications, and a complicated pregnancy is implicated in neonatal morbidity. In fact, the most significant cause of neonatal death is premature delivery. Pregnancy kills newborns. The most dangerous day in a child’s life is the first—of the four million newborns who die in the first month of life, three million die in the first week, and of those, more than two million on that first day.
Over the last two decades of trying, the international community has kept more women alive during, and after, pregnancy. We have improved global infant and child health statistics, yet preventing newborn death in crises eludes us. Most of this heartbreak is preventable, if prioritized. We haven’t yet: mothers in low- and middle-income countries experience 99 percent of neonatal deaths, yet this is not reflected in funding for prevention programs. Our neglect is consequential: 450 newborn children die needlessly every hour from causes we know how to treat. Every day, almost eleven thousand mothers live the unimaginable, in refugee camps, or away from home, their grief barely acknowledged.
This year, like last, four million other children will be born into the world, and never experience life, stillborn. I remember that night, and that woman often. I remember her face as she held her unmoving child, his silence pitiless. Worldwide, fewer mothers will ever know this pain, albeit with a caveat: access to modern healthcare. For the lucky minority, improved care has led to improved statistics.
They call stillbirth “the silent killer,” and in its wake, families mourn on mute. Statistics are abstractions built with concrete realities: planned lives are deconstructed, hopes packed away, dreams are buried and the child unmentioned, but never forgotten. They call stillbirth “the epidemic of grief.” When asked, many of these women–almost all–speak of hopelessness, speak of shame, of wanting to erase their pain by trying again. It never works. Scientific victories must seem hollow to a mother who has lost seven children while navigating three medical systems across the developmental divide: in Sudan, in refugee camps, in Australia.
I think of that night often. It wasn’t over.
I reclaim my hand, and am reaching for the ultrasound, to check on her daughters, still clinging to life within her, when she is overwhelmed by a contraction so powerful she folds herself in half. She grips my fingers, whispering a prayer, “no. No. No. No.” She crosses her legs in denial, willing her body to submit to her heart. It takes another twenty minutes, and both her daughters are born, stillborn. The room is oppressed by grief.
It matters then, that she is resettled. Eight months later, I deliver their son, eleven weeks premature, by emergency caesarean section. Her pregnancy was complicated by severe pre-eclampsia that threatened her life, and his. He would spend twelve weeks in the neonatal intensive care unit before going home.
I am struck by the unquestionable fact that had she not made it to Australia, had she remained internally displaced in Sudan, or waiting, still, in a refugee camp, this pregnancy would be the one that killed her.
Pregnancy kills, and it doesn’t do so indiscriminately. Mothers live, and die, according to which side of the “right” border they find themselves on.
“But then Claire got pregnant again, and that made her desperate to try to return to home, to see if our parents were still alive… But by the time we arrived — three years after we left, Claire by this point five months pregnant — the war had destroyed Congo. It was toppled and covered in ash, like a child had kicked over and burned a building-block town. Rob’s family huddled in their house, starving, living on sweet potato leaves… Claire did go to the hospital to give birth to Frederick, but even that building was bombed a few hours after he was born, so Claire wrapped him in a blanket and ran back to Rob’s uncle’s house, where she joined us under the bed. With no food Claire’s milk dried up within a week.”