For years, 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 city were absolutely beautiful. My housing was very nice, much more than I expected. As for the hospital, Rabia Balkhi is a tertiary-care 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 they are extremely willing to learn. They are like sponges, absorbing all the information they could.

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 whole lot.

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 spent 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 instruction,” says 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. During O’Sullivan’s 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 physicians 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 our 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 eyes.”

My stay is nearing an end, and I am seeing progress. One of the attendings is doing a research project collecting data 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 and follow 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. The residents really want to come to lectures now and seem much more receptive to one-on-one teaching.

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 come in time.”

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.