Half way down the dimly lit main hallway of Mogadishu’s Banadir Hospital, a sign indicates the entrance to the delivery ward. It reads: “Women are not dying of diseases we can’t treat. They are dying because societies have yet to make the decision that their lives are worth saving.”
Outside, family members of the women within crouch beside the wall, avoiding the slanted columns of harsh Somali sunlight that line the floor. They are waiting, and sometimes praying, for healthy sons, daughters, grandchildren, nieces and nephews or, at least, for the lives of their wives, daughters or sisters.
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Inside the delivery ward it is dark, and mostly still but for an occasional flurry of activity as nurses armed with cooler boxes full of vaccines sprint from one room to another and orderlies push women on stretchers down to the surgical theatre. According to Somali custom, women giving birth should remain quiet, but every now and again a shout shatters the silence and reverberates through the halls.
At the centre of all of this is Dr Marian Omar Salad. Around her there are midwives and nurses, the clutter of surgical steel, the flutter of white coats and the muted groans of women in labour behind baby-blue curtains. Salad surveys it all intently with warm brown eyes that go soft at the edges.
Life and death
Today, a patient from the town of Afgooye, more than 200km away, is the particular focus of her attention. Howa Oofay Moalim arrived just two hours earlier, and the doctor considers it a miracle that she is still alive.
According to Salad, Howa has been in labour for nearly five days, with life threatening complications that arose almost immediately. Her baby was positioned crookedly in her uterus and his arm punctured her bladder. She has a fever and a serious infection. The life she is trying to bring into the world now threatens to kill her.
Despite the warning signs, traditional birth attendants tried to deliver the baby. But Salad says they only made things worse. The midwives in Afgooye simply grabbed hold of the child’s arm and tried to pull him from his mother and out into the world. The tugs have broken his arm in multiple places. As Howa’s condition worsened, they had to bring her to Banadir. She walked through the hospital’s doors with her son’s arm dangling from her body.
Salad is visibly frustrated by Howa’s plight and says many mothers have misconceptions about the hospital that can end up costing them their lives. “They think if they come to hospital that we will say caesarian section,” explains Salad. “Even if [the mother] lost three or four babies, she still prefers to go first to the traditional midwife. After she’s exhausted all her other options, she’s in a very bad situation, then she comes to the hospital in a very bad condition.”
In Somalia, women are often expected to give birth every year. Many avoid caesarian sections because a longer recovery time is needed, making such frequent deliveries impossible. But for Howa, it is now the only option.
She is in extreme pain, writhing about on the bed as her arms reach out for the nearest attendant in the hope of making any kind of contact. Her eyes dart around the room, fearful and uncertain. Salad is busy preparing the ultrasound, but she locks eyes with Howa and speaks words of comfort. The normally jagged syllables of Somali come out soft and steady, and Howa settles.
Salad presses the ultrasound to her skin and looks to the grainy black screen for a sign of life. But the ultrasound only confirms her fears. She cannot find a heartbeat and it appears Howa’s son has died. “Every time it’s difficult,” she says.
Every two hours
In a country seemingly synonymous with hardship, the women here often lead exceedingly desperate lives; forced to navigate civil war, clan violence, extreme poverty and poor healthcare with little or no say in the choices that will shape their futures.
According to UNICEF, every two hours a mother dies in Somalia due to pregnancy complications; one-in-12 women will die of pregnancy related ailments. Part of the problem is that less than 10 percent of births in the country are performed by a skilled birth attendant.
Even where there are efforts to address these issues, many serious obstacles stand in the way. One of them is the law. Under Somali law, a woman cannot take responsibility for her own life. For a medical procedure to be performed – even a life-saving caesarian – consent must first be given by the woman’s family, often her husband or father.
“Most of the time we do lose the baby for the times we wait for consent,” Salad explains. “And other times – which is much sadder – we could lose the mother for complications because of the traditions of the [family].”
The doctor explains that sometimes it is even the family matriarchs who, unused to modern medicine, block women from receiving the procedures needed to save their lives.
Salad cares deeply about Somalia’s mothers and wants to change the minds of those who are sceptical about her and her work. But that change often comes only as women are on the brink of death.
Neither living nor dying
For the past week, Salad has seen one patient in her ward every day. Isha Adan Abdullah would not be alive now if it were not for Salad. She is gaunt and has yet to recover fully from her ordeal, but she tells her story with doleful, incredulous eyes as Salad adjusts the dress hanging from her shoulders and softly pats down her sleeve in an almost sisterly manner.
She was at home with her children in Murale – around 250km outside Mogadishu – when she went into labour. It was raining heavily and the midwives in the area couldn’t reach her, so she had only her family by her side. She knew almost immediately that there was a problem. After two days of labour, she still had not given birth, and began to bleed.
“From her history we think that she had a uterine rupture at that time,” Salad interjects.
Isha continued to bleed out while begging her family to take her to the hospital. She waited another 10 days, fading in and out of consciousness. “They told me it was God’s will and that they would pray for me and God will help me,” she says. “They refused to take me. A few days later I told my family I want either to die or to live.”
Finally, after two weeks in labour, Isha could barely breathe and was unable to tolerate the pain any longer. She asked her family: “What do you want to do? Do you want to cook my meat after this?”
“This is like a [Somali] saying,” explains the doctor, looking compassionately at Isha, “do something about this or I will die.”
Isha’s family agreed to bring her to Mogadishu for treatment.
Five days after the operation, Isha is happy to be alive but is still in pain and has difficulty moving. She shifts stiffly on her bed every few minutes. Salad says her strength will return, but she will never have another child. “Her uterus was in very bad shape and we had to do a hysterectomy.”
“Sometimes there is something so simple and you can do something about it,” she says. “[Then] it becomes complicated and you can’t do anything at that time. It’s very frustrating.”
Seeing women like Isha suffer is the hardest part of Salad’s job.
“I did see one, they brought her … [on a] cart. I had to go over to the cart just to listen. Between the time I arrived and the time she died was, like, a few minutes. A situation like that is very hard to take,” she recalls.
Salad says stories like that are common. But in a country where women face such significant hardships, Banadir’s maternity ward also highlights one area where women play a leading role – the hospital. Many of the staff here, from the surgeons to the orderlies, are female.
“Mostly, Somali women, especially in obstetrics and gynecology, they like females to work because they say we are Muslims, we like for the midwives to be females; it is traditional,” explains Dr Nafiso Abdulrahman, another female surgeon at the hospital.
She has just come from a successful surgery – saving the life of a mother and her child after convincing a sceptical family of the need for the operation. “It’s a normal thing: this one is every day,” she says.
Surgeons at the hospital can perform anywhere between one and six surgeries a day. With nearly 800 beds, Banadir is one of the largest and most advanced public hospitals in Somalia, but it is consistently underfunded, understaffed and operating over capacity.
“[In] the entire city of Mogadishu, with a population of 2.3 million, we have only one free maternity hospital, which is Banadir Hospital,” says Dr Abdullahi Mohamed. Mohamed works for the humanitarian organisation Swisso Kalmo, which helps administer the maternity ward. “Banadir Hospital is the only national referral hospital in all of Somalia,” he adds, pounding his fist onto his desk with each word for emphasis.
The hospital was opened by Mohamed Siad Barre in 1977 as part of a huge infrastructure development project with the Chinese government. When the dictator’s regime collapsed in 1991, the hospital struggled. For the past 20 years, there has been spotty support from humanitarian organisations. “An [organisation] would come, will stay for a couple of minutes, couple of months, and no agency ever thinks about what we call sustainability for a hospital,” explains Mohamed.
In 2012, organisations including UNICEF, the United Nations Population Fund and the World Health Organization stepped in to support Somali government efforts to improve maternal and child health. That support has allowed the maternity ward to serve more women, and Mohamed says the hospital now delivers more than 21 babies a day and up to 750 a month. From mid-June to November 2014, doctors at Banadir performed more than 560 emergency caesarians, he explains.
“Without having a hospital like this or a [maternal health programme] what [are] you going to expect? It would be a total disaster in terms of human life,” he says.
But despite the progress the hospital has made, funding, infrastructure and staffing remains insufficient. “We lost three generations,” explains Mohamed, reflecting on the past two decades of conflict.
Salad is a small reason for hope – one of the few in a new generation of doctors in Mogadishu. She has been working at the hospital for the past two years as a surgical resident and helping to teach a new crop of students from the University of Mogadishu.
Life as a surgical resident isn’t easy in any hospital. But, in Mogadisdu, Salad must sometimes weigh the lives of others with her own responsibilities to her family and her physical safety. Sometimes she works double or even triple shifts and must then walk home alone through Mogadishu’s crumbling streets in the middle of the night. She says her mother often criticises her for working beyond her assigned hours.
“The problem my mother has is that it’s not safe for you to go [out] late. [Security] is not stable but I do take the risk to save the lives of the mothers,” she says as a grin creeps across her face.
In the delivery ward, Salad is still waiting for Howa’s family to return. In the next bed, another woman enters the final stages of labour. Salad interrupts her consultation with Howa to help deliver the baby, and just minutes later the screams of a healthy baby boy fill the ward. His mother had walked in off the street just hours before.
After watching the nurses weigh the baby and check on the mother, Salad heads upstairs to scrub in for surgery. Howa’s family has come and Salad now has permission to save her life.
The scrub-in is a kind of transformation for Salad. Her smile drops and her eyes lose focus on her hands. She looks through the window into the theatre and begins to visualise the procedure. Her surgical nurses help her pull on her gloves and scrubs as she talks through the operation with her two assisting surgeons. She carefully surveys her tools and then approaches Howa, whose face has been covered by a green curtain. A heart rate monitor jolts every second or so, as another nurse looks on.
The doctors take their time under the bright lights, taking a collective breath before Salad makes her first incision. Once the procedure begins, speed and efficiency are critical. Salad’s hands do not falter as she moves closer to Howa’s uterus. Her motions are compact and practiced; no movement is wasted.
In under five minutes the surgeons get their first glimpse of the child and they draw a collective gasp. Salad’s face breaks for a moment and her eyes widen. “He’s alive.” She has Howa’s son in her hands. “Alive.” She starts massaging the child’s chest to encourage his new heart. She gives him a gentle shake to try and wake him, but he won’t respond.
Salad hands the child to one of her nurses as she again turns her attention to Howa. “Oh my god,” she says one final time before her eyes refocus on the woman in front of her.
As Salad and her team quickly repair the damage to Howa’s uterus, two nurses continue to massage the newborn baby’s chest in the corner of the room. He doesn’t cry so with light but firm fingers they give sharp compressions, then step back and wait. There is no movement and no sound. After a few seconds they give more compressions and wait. Then, suddenly, the child gives a quiet cough, kicks his legs and draws in a single breath.
In just over 30 minutes the procedure has been completed. Salad has saved Howa and her son, who survived half-born for nearly five days. Her face has softened again, and she is standing over the newborn boy, looking on with concern. He will have a long recovery. His arm is broken in multiple places and the lack of oxygen over the past few days may cause developmental issues later in his life. But for now, Dr Marian Omar Salad sees a small victory.
“Sometimes it’s hard. Sometimes it’s very, very ..,” she stops to think. “Some of the situations you cannot do [anything]. Your hand is tied and it’s very frustrating. And sometimes it’s very rewarding. You could save a mother who couldn’t deliver at home and you do a caesarian section and you see her baby alive – it’s very rewarding.”