Consent

Let's say you need an emergency c-section in the United States, say for obstructed labor, or fetal distress, or preeclampsia, or any number of other reasons . If you're competent and aware, as most women in this position are, you sign a consent form. There's a consent form used in this hospital, too, except that, by law (and tradition) a woman cannot consent to the c-section herself.

Instead, her husband must consent for her. Ignoring for a moment the women's rights issues associated with this, you've still got problems. Men aren't involved in birth at all here, so somebody has to go out and find the husband and get him to sign the consent. It's then not uncommon for the husband to be working overseas somewhere (Djibouti, Ethiopia, Oman).

In this case, the woman's closest male relative now must be tracked down. Frequently there's then a dispute between the woman's father/brother/husband's brothers concerning who should sign the form.

There's also generally a fair amount of discussion about whether or not it should be signed. Is there $50 available to pay for the operation? Is it worth it--c-sections are associated with poor maternal and infant outcomes here.

All the while, you've got this poor woman hanging out, waiting for her c-section. How do you think mother and baby are doing during all this time, maybe a number of hours? Yeah, not so great. There's emergency c-sections here, but I would say there aren't really stat c-sections. By the time the woman finally gets the c-section--if the men in her life consent--it can be too late, and, no surprise, the mom and baby do poorly. No wonder people associate them with poor outcomes, but they miss the point that it's not the c-section that's the problem, it's the extended delay in receiving it.

Having c-sections available to women who need them is a remarkable achievement in developing countries, and the focus of many maternal health efforts, which I fully support. But this is a pretty vivid example of the need to look at the entire picture and understand interventions in the full context of the culture you're working in. Ignoring issues like the consent barrier means that a perfectly reasonable intervention can fall flat on its face and never benefit the intended recipients. Unfortunately, these are generally the most complicated issues to address: women's rights, the perceived value of women in a society, economies that force men to seek work away from home to name a few. It's all a bit overwhelming at times, which I think is why these issues are often skimmed over in planning: they seem to big to face. They're also just plain missed at times, especially when package interventions (as opposed to country specific) are used.

It just seems to me like if you're going to go to the trouble and expense of putting maternal health programs in place, it's worth spending a bit of extra time understanding issues in the community that might affect the programs. You'd be amazed at how rarely this is done.

It's one of the reasons why Edna's hospital is cool--she's familiar with the context because it's how she grew up. It doesn't solve all the problems--women still need consent forms signed by men. But she's aware of this need and set up systems to ensure it goes as smoothly as possible, including seeking out consent at the very first hint of trouble rather than waiting for a full-blown need. It's a start at least.