Maura Daly is a Doctors Without Borders/Médecins Sans Frontières (MSF) midwife recently returned from working in Khamer, a town in northern Yemen’s Amran Governorate. Here she describes what pregnant women in this part of Yemen face in terms of access to care, and her experiences working to meet their needs.
Describe the project where were you working.
MSF’s Amran project opened in 2010 to respond to the needs of internally displaced people who were coming from the North of the country to escape violence, and also to support the population that was already there and in need of medical care. Right now our objectives in Amran are to provide for the health needs of the population of Khamer, including malnutrition and obstetric care, and to respond to any emergencies.
Khamer is the town we are working in. The population in that area is about 90,000, but we’re reaching a population of about 100,000 because people are also coming to us from a number of surrounding valleys.
MSF is running the Al-Salam Hospital, a Ministry of Health facility, including the emergency room, the inpatient department, the operating room, the intensive care unit, physiotherapy activities, maternal care, and the nursery. We also support another health center 45 minutes north of the hospital, where we’re doing emergency, inpatient, and obstetric care.
Describe the situation your patients were facing.
Yemen’s maternal health indicators are among the worst in the Arab world. Women marry young. Usually, their first period comes and they get married right afterwards. Or sometimes they will marry before their first period and be saved for their husbands until that day. They tend to have many pregnancies. I would routinely see women with 16, 17, 18 pregnancies, usually it was above 10.
It is estimated by the United Nations Population Fund that six women die in Yemen every day due to pregnancy-related causes, and the maternal mortality rate is high at 270 deaths per every 100,000 live births. At Al-Salam hospital in Khamer, we had about 200 deliveries per month and our complication rate was really high, between 30 and 50 percent. Often women would come very late and by the time they arrived, their situation was quite complicated.
Why is the mortality rate so high?
There’s little or no health knowledge, and a lot of distrust of doctors. We’ve had problems in the past at the project where people actually fought with the health providers because of the lack of trust there.
In Yemen, most births are not attended by a skilled attendant. Instead, births take place at home with family. So when something dangerous happens, there is no one there to manage it.
There are also inadequate services in remote areas. Most people live in rural, sparsely populated regions with no doctors at all. They can’t reach a hospital or a skilled attendant because there are no cars or ambulances to take them. So most of the women who comprise the high maternal mortality numbers, they’re suffering and dying at home.
There is also the issue of women being unable to advocate for themselves. So if a women is at home, and she’s pregnant and can’t feel her baby move, or if she starts to bleed, or if she’s just feeling ill, she can’t go to the hospital. She has to wait for her husband or another male family member to take her. Additionally, once they get to the hospital–I can’t tell you how many times I had a woman who was sick and her husband wasn’t there to give permission for her to get the emergency medical care she needed.
What is most challenging about working there?
The tribal context in Yemen makes things volatile and difficult to understand for outsiders. From the local town all the way up to the top of government, tribes are really important in terms of making decisions. In Amran Governorate alone, there are several tribes. It is really important when you’re negotiating with people to know who is in what tribe; “He can’t talk to him and he can’t talk to the other one…” The tribal aspect informed a lot of how we took care of people and those issues have become even more complicated because of the presence of the Houthi.
For me, it was difficult being both a woman and an authority figure because women are not usually seen as authorities there. So in the beginning I was challenged a lot: “Oh, you don’t know what you’re talking about,” and that type of thing. Over time, I feel like I gained respect. But in the beginning, especially speaking with fathers, and husbands and trying to get them to understand what I was saying, they’d be looking over my shoulder as though they were looking for the male doctor.
Plenty of times when I couldn’t get my point across, I’d call the male doctor and have him come and talk. At a certain point, I was willing to compromise. But that was a challenge for me.
 World Bank: http://data.worldbank.org/indicator/SH.STA.MMRT