Pakistan: "I fought for my patients"

From February to August 2011, midwife Rose-Louise Cadot worked with the MSF team in Hangu, Pakistan. The purpose of her mission was to support the team in the maternity unit -- which remains under the direction of the hospital and the Ministry of Health -- to improve the quality of care.  It was a difficult, but inspiring, task.  Rose-Louise accepted the challenge.  

This article is based on an interview conducted by Nour Guerrodj-Richard for the October 2011 issue of the "Professions sage-femme" publication.

Rose-Louise has been a midwife since 2006. She joined her first MSF mission in 2010 and spent six months in Congo (Brazzaville) In February 2011, she joined MSF's programme in Hangu, Pakistan, near the Afghan border.

MSF provides free medical care and emergency surgery at the city hospital 24 hours/day, seven days/week. "I support the local teams," the midwife explains. "I help them improve labor and delivery conditions for women."

The first barrier she faced was a common one – language.  Most members of the team speak only Pashto or Urdu, and rarely English. That obstacle was removed in April 2011, when an interpreter arrived. Rose-Louise also had to adapt to a very mixed team, including "Dais," traditional Pakistani midwives with several months of clinical training; "lady health visitors," who have had two years' training, including one in obstetrics; and resident nurses, who have completed three years of study.

The most significant factor is that the patients in the Hangu maternity unit include many women who have received little or no prenatal care and often have no medical file. "The Ministry of Health units offer prenatal visits, but it is very difficult to assess the quality of that monitoring," the midwife explains. "If you're lucky, the mothers arrive with an ultrasound or a medical prescription issued during the pregnancy.  But that's still quite rare."

Rose-Louise did not challenge the practices of her Pakistani colleagues. She adapted. "I wasn't used to some of the recommended treatments here," she says. "For example, it's common to administer Valium to Pakistani women during labor to ease pain. As a result, the newborn may not be breathing at birth. Since I couldn't prevent that, I took charge of reviving the baby."

However, Rose-Louise did want to make several improvements at the Hangu maternity unit - in hygiene, monitoring of work and detection of warning signals. To do that, she organized a permanent team assigned to the labor and delivery room. Until then, hospital staff had rotated among all the departments.  Rose-Louise remains optimistic. "It takes a long time to change habits and we still have a long list of projects. But the team is much more involved and they've made great progress."

As a result, by the end of her four-month mission, Rose-Louise's colleagues consult her more regularly, which gives her an opportunity to train them in clinical diagnosis. "One day, a patient arrived with a hand prolapse (a sign that the fetus is in a transverse lie and cannot be born vaginally).  I took the mother to the operating room for an emergency C-section. She delivered twins – both in great shape! This could have been a serious case but by calling me, the team made the right move. Until MSF arrived, the Hangu hospital did not even have an OB-GYN operating room and patients who needed surgery were referred to neighboring towns. It takes time for the teams to absorb these changes."

Rose-Louise also works regularly with the MSF team in Peshawar. In May 2011, the team opened a hospital dedicated to women's health and to gynecological and obstetric diseases.

There's still a lot of work to do. For example, women who need emergency care often arrive at the hospital late – sometimes too late. "We had a patient who arrived in a coma following eclampsia (a serious complication of pregnancy that can be fatal for the mother and/or the fetus, characterized by convulsions). Despite the emergency caesarian, treatment and the care we provided, she died several hours later. She had not received the prenatal care that could have prevented this and she arrived too late. Nothing more could be done for her. These kinds of examples are more common than I ever would have imagined." Similarly, young Pakistani women who give birth typically do not nurse in the maternity ward, but at home. "MSF is not well-established enough yet to propose a change. As a result, patients leave the unit too soon – sometimes just one hour after delivery. Postpartum monitoring is not as careful as in France, for example."

In spite of everything, the programmeme is moving forward. MSF has been providing the maternity unit with necessary medicines since July. Previously, the unit ran out of supplies frequently In addition, families were responsible for buying medicine, at a cost of up to 10% of the average Pakistani's salary. "Our work might be a drop in the ocean of needs," Rose-Louise acknowledges, "but I fought for the patients of Hangu."