Mary Jo O’Sullivan, M.D., professor emeritus
of obstetrics and gynecology at the Miller School of Medicine,
dreamed of one day giving back to the underprivileged. As a
young physician, she spent two years providing medical care
with a non-profit organization in Jamaica, an experience she
never forgot. But life kind of got in the way of her dreams.
Instead of practicing medicine outside of the country, O’Sullivan
spent 30 years caring for expectant mothers and delivering
their babies at the University of Miami/ Jackson Memorial Medical
Center. She also headed up the department’s Maternal
Fetal Medicine Division and worked toward dramatically reducing
the transmission of HIV from mother to child during pregnancy.
“I was so profoundly impacted by my experience in Jamaica
that this burning need to go somewhere in the world and help
again never left me,” O’Sullivan recalls. So after
stepping down from her full-time duties at the medical center,
her dream came true in January: O’Sullivan went on a
three-month medical mission at the Rabia Balkhi Hospital for
Women in Kabul, Afghanistan. She was there with International
Medical Corps, a global humanitarianorganization under contract
with the U.S. Department of Health and Human Services to improve
the quality of care and training at the hospital in an effort
to reduce maternal and infant mortality.
During her stay, O’Sullivan kept
a journal, portions of which follow:
The day I arrived in Kabul it was bitter cold, there had
been snow over the weekend, and the mountains surrounding the
were absolutely beautiful. My housing was very nice, much
more than I expected. As for the hospital, Rabia Balkhi is
facility by Afghan standards, which bears no resemblance
to U.S. standards.
There are about 10,000 deliveries a year.
There are only six labor beds and often ten to 12 women in
labor, and only
five delivery beds. Both the maternal and
infant mortality rates in Afghanistan are among the highest in the world. Even
in Kabul, the capital, only about 10 percent of women get any prenatal care.
Staffing at the hospital is unique. There are no nurses here—there are “midwives”—women
with a ninth-grade education, up from sixth grade in recent years, who receive
18 months of didactic training, then do three months of practical training
without pay, and then are hired. They have no nursing skills, but I will say
extremely willing to learn. They are like sponges, absorbing all the information
We do not have sterile gloves for deliveries, and there are
no delivery trays. When mom delivers, she is lying on a black
garbage bag so that when the placenta
delivers it goes in there, and often the baby is put on this same bag. There
is so much to be done, and three months seems a short time to accomplish a
International Medical Corps is involved
with nearly every aspect of the development of Rabia Balkhi.
O’Sullivan’s primary role during this mission was
to train attending physicians, residents, and midwives. The work week was Sunday
through Thursday, from 8 in the morning until only 4 in the afternoon because
it wasn’t safe to be out after dark.
During a typical day, residents would
present cases of importance or cases in which there were
complications, similar to what
is done during morning report
in the U.S. O’Sullivan and others would then accompany the residents
and faculty on morning rounds in labor and delivery. Afternoons were usually
giving lectures and rounding again, usually with just one resident and a midwife.
“This was a much better time for teaching because it was more one-on-one
O’Sullivan. “Part of the problem was it was hard to determine where
exactly the residents were in their training. Several years ago, there apparently
was a system of rotation from one year to the next, but that’s not the
case any longer.”
Being able to restore order out of chaos
could have life-and-death implications for the mothers and
their babies, something O’Sullivan and those conducting
the training saw firsthand.
Several of the babies who died had fetal distress, but trying
to get the doctors and midwives to check fetal hearts during
labor is difficult. I get the feeling
that with us pushing them all the time they just think we are making a whole
lot of noise about nothing.
There are no ventilators for premature
babies, so those weighing under 1,500 grams, or just over
three pounds, are not even
expected to survive. I am hopeful
that the extensive training on neonatal resuscitation for the pediatricians
and midwives now getting under way, something that is crucial
in this setting, will
hopefully make a difference. And I’m told the hospital is due to get
ventilators very soon.
Another big challenge was maternal mortality.
three-month stay, seven mothers died. “Death was always there, and it was
very hard to watch young women die; it was one of the most difficult things to
handle emotionally,” O’Sullivan recalled after her return to Miami. “In
this country we are used to multiple sources for help when women are critically
ill; in Afghanistan those facilities don’t exist. It was truly like stepping
back in time.”
I have to remind myself this is a country
that has been at war for 30 years, and anything related to
health care for women
and children was totally neglected,
especially during the Taliban rule. And maybe the staff just can’t connect
to being caring, gentle, and to speak kindly to help women in labor, or even
get upset about death because they have seen so much.
A third of the women who die in childbirth
hemorrhage either during delivery or shortly thereafter.
Others die from such
complications as obstructed labor,
septic shock, and eclampsia, and are already critically ill when arriving at
the hospital, often because they’ve been in labor or sick at home for
too long before being brought in.
In the beginning, O’Sullivan remembers, there were times she wasn’t
sure she was making any progress at all. “Some of the residents were
most appreciative and receptive, but many were not. And some of the attending
felt threatened by us and angry that we were trying to change things. But what
was great was that gradually over the weeks, they did turn around and began
to put more effort into things. I would like to think they were just following
example. They too began to demand more from the residents and themselves, and
then in turn asked more from us. You really do have to prove yourself in their
My stay is nearing an end, and I am seeing
progress. One of the attendings is doing a research project
to determine if over time the perinatal
mortality would improve. The residents are saying to me, “Show me how you’d
do it—how would you deliver a breech?” which was encouraging. There
has also been a definite improvement in getting women to the OR for a diagnosis
of fetal distress, down to 30 minutes from almost two hours. There is more
of an effort to understand why they need to monitor labors more frequently
the WHO guidelines for doing partographs, which is how we chart progress in
labor. When there are sick women, I get called more and more often for advice.
really want to come to lectures now and seem much more receptive to one-on-one
While she can point to improvements, O’Sullivan believes the goal to establish
an American-like residency program at Rabia Balkhi any time soon could be too
ambitious. But she believes it can happen over time if the government remains
stable, if there are no new wars, and if the economy continues to improve. “In
the meantime, every effort must be made to improve what can be fixed now in
terms of patient care and education of medical professionals; the rest will
O’Sullivan had been back from Afghanistan for just a few months when she
received an e-mail that reported a definite downward trend in the perinatal mortality
rate at Rabia Balkhi. It gives her hope for their future. “I do not regret
for one minute that I went. I did not expect it to be easy, yet somehow I guess
I thought I could make a bigger difference. Did I make a difference? I think
so, but really only time will tell.