Prudence, one of the local staff employed by MSF here in AmTiman (in Chad), has a daughter who got married last week to an 18 year old. She's 12. Prudence didn't approve, thought it much too young, but it was the father's decision.
Two weeks ago an 18-year-old came in with a placenta praevia. This is a condition where the afterbirth is stuck onto the wall of the uterus over the cervix - meaning the baby can't get out through the vagina. If the mother goes into labour she bleeds to death. A caesarean is needed.
The mother's consent to a caesarean is insufficient in this part of the world. Her husband said no.
The mother's consent to a caesarean is insufficient in this part of the world. Her husband said no. Her father said no. She didn't oppose their views. They took her home.
She was brought back a week later, in shock, bleeding heavily, with a blood count about a quarter of what it should be. The baby was still alive.
This time, after a prolonged family discussion, the male members of her family agreed to a caesarean. However, the only surgeon capable of performing it had gone away for the weekend, to a town 12 hours' drive away, without making any arrangements for surgical cover, and his car had broken down.
We transfused her with blood donated by her family, put her into a jeep and sent her to the nearest hospital that had a surgeon, a four hours' drive away. We heard later that she got there alive. They performed a caesarean: she survived but not the baby.
The oldest rape victim I have interviewed so far has been fifteen
I watched a woman try to push a baby out through a ring of scar tissue where her vulva should have been. Along with 80 per cent of women here, her clitoris and labia had been removed in childhood. She had to have a large surgical cut made in order to allow a vaginal delivery. The next woman with a similarly scarred vulva wasn't so lucky - she delivered before the midwife arrived and instead of a controlled cut ended up with a laceration extending to her anus.
A 19-year-old in her first pregnancy had been told that real women didn't need professional help having babies. After four days' labour the baby came out dead and she was left with a breakdown of tissue between the bladder and the vagina as a result of sustained pressure from the baby's head. She now leaks urine continuously out of her vagina.
The oldest rape victim I have interviewed so far has been fifteen; my colleague saw a seven-year-old rape victim last month.
My colleague met an 18-year-old in the maternity department giving birth for the sixth time.
A woman delivered twins here a couple of weeks ago (nothing unusual - twin pregnancies are very common in African women). After the delivery she needed antibiotics & was weighed in order to calculate the correct dose. 36 kg (79 lbs). No one batted an eyelid.
A woman's worth is measured in terms of the number of babies she can produce
A woman's worth is measured in terms of the number of babies she can produce.
There's a profound reluctance to discuss sexual behaviour and its consequences. I was warned before I came that taking a basic sexual history would be impossible. One in 30 of our maternity cases tests positive for syphilis.
Our HIV clinic is well managed and run here. Ahmet, the nurse in charge, knows all the patients and they seem to like and trust him. A 36-year-old cheerful healthy HIV positive patient came in for a routine check & to pick up her regular supply of antiretrovirals. I asked Ahmet about her background. Her husband had died after a long illness, leaving her with five children. He had been Congolese and her family lived far away.
"What", I asked, after she'd left, "does she and the family live on?".
"Small business" was his evasive response.
"Is this small business anything you feel able to discuss with her?"
He looked profoundly shocked. "No, I could never do that."
So this educated, conscientious, compassionate Chadean nurse, who has been looking after the 350 or so patients in the area with HIV and/or TB for the past seven years and who has established a close professional bond with his patients, still can't, because of the local taboos on discussing sexual behaviour, quite ask the questions that could lead to a reduction in HIV spread. And if he can't then who can?
A five-year-old boy from the nomad community, who follow available grazing in the desert plains with their camels, was brought in one night. He weighed 8kg and there was a hole in his face where his nose should have been. If you are sufficiently malnourished then your resistance to the bacteria that normally live in healthy mouths disappears and you develop noma, an invasion of these bacteria which eat away your face. His mother and baby sister stayed with him in the hospital. A single parent, her older four children were being looked after by their partially sighted grandmother out in the desert.
The mortality rate from noma is 80-90 percent.
He stayed with us for a month, gradually putting on weight and starting to walk. We talked about the possibility of transferring him to the capital for reconstructive surgery. One night, the family vanished back into the desert. The mortality rate from noma is 80-90 percent. I found myself wondering what I would have done, were I his mother. Probably would have left earlier to prioritise the chances of my healthy children surviving.
An eight-year-old fell out of a tree and injured his arm. The family applied a tourniquet and left it on. For three weeks.
Noma/cancrum oris mortality rate 90%: WHO Regional Office for Africa
Female genital mutilation rate: from personal interviews with the midwives working at AmTiman hospital and from my own personal observations whilst attending deliveries and performing gynaecological examinations. This is supported by data UNICEF 2010, WHO 2011 which suggests that although the overall rate in Chad is 45% the south, while the east of the country has much higher prevalence levels
Female literacy rate 21- 26% (UNICEF & WHO data).
*I've changed the names of staff members