Working with Doctors Without Borders in a war-torn country, OB-GYN Rasha Khoury tries to save a pregnant woman in critical condition.
Dr. Rasha Khoury is a Palestinian woman who works as an emergency obstetrician with Doctors Without Borders (Medecins Sans Frontieres -MSF) and is a fellow in Maternal Fetal Medicine at Montefiore Medical Center in the Bronx, NY. Dr. Khoury’s clinical work and research centers around reducing maternal morbidity and mortality by improving access to high quality, dignified and safe abortion and contraceptive care, antepartum, delivery, and postpartum care among vulnerable populations (including women of color, women living in poverty, and women enduring displacement and war). Her work as a humanitarian medical aid worker has taken her to Afghanistan, Iraq, Lebanon, Cote d’Ivoire, and Sierra Leone.
This story originally aired on August 28, 2018 in an episode titled “Abortion: Stories from doctors and patients - Part 1.”
Story Transcript
I’m riding in a white pickup truck and I’m crammed in there with three other people, a pile of flak jackets which are very heavy, helmets and chemical weapon survival kits, which I'd never seen before. When I saw them I wanted to go home instantly. And we’re riding from our very sleepy village where we sleep and we smoke too many cigarettes and we eat too much rice and driving to the destroyed town where we work every day.
It’s about a four-hour drive everyday to work for about ten hours in the hospital with our local staff and the route from the village to the destroyed town always made me feel homesick. Because we would ride in this convoy of white pickup trucks, past these rolling green hills with herds of sheep and shepherds and small village houses, and then the terrain would change into these flat fields with UN refugee camps which are basically white and blue tents, hundreds and hundreds of tents, and then these requisite soccer fields with little kids playing.
Then we’d get to the part that was probably buildings before and now is just pile of rocks that were kind of collapsed down. Then we drive a little bit more and come across burnt car skeletons. This was our cue, the women’s cue to put on our head scarves for the rest of the day.
Then we’d drive past building after building that was destroyed and bombed in ways that I could never really decipher how exactly it happened. We’d always wondered did the people get out in time?
Then we’d get to the checkpoints and there was about four of them before we got to our hospital. In each checkpoint we’d sort of roll up, slow down, turn off the sappy music that was playing on the radio, take off our sunglasses. Everybody would kind of tensely smile at the armed guards as they checked our papers and waved us through.
Eventually we’d make it to our buffer zones around our hospital which were filled with very smiley, unarmed guards who were MSF workers or Doctors Without Borders workers and they would smile and wave us through.
Then we’d get to this ER in the hospital where we worked every day for about ten hours with a lot of local staff, so people who lived in the community, and we treat everything from the totally extreme to the totally mundane.
I am an obstetrician-gynecologist. I’m sort of a nerdy activist and I work for Doctors Without Borders which is a humanitarian medical aid organization. I’m Arab and I’m from an Arab town very much similar to what I’m describing. I can’t tell you the exact location for security reasons but you can imagine any place at war then that’s the place that we’re in.
So on this day, I arrive and the ER is crammed with people crying from shrapnel wounds, screaming from burns, people having heart attacks, people that sliced their finger cutting bread, really everything, and my staff run over and they say there's a woman in the maternity ward that I need to go see. She's having trouble breathing.
So having trouble breathing is an alarm sign in medicine and I run over to make sure this person is okay, much like somebody having an allergy. I see she's hunched over. She's really struggling to breathe. She looks exhausted and her mother is standing by her side. The patient tells me that she's pregnant but she's not sure how far along the pregnancy is. She whispers to me in Arabic, which is my first language, and she says, “I really need this pregnancy to end.”
I carry her over with my staff to a bed just so she's more comfortable and I send somebody to grab the ultrasound machine from the ER so we can scan her and figure out what’s going on. My younger staff are so excited because I've been training them how to use the ultrasound and they love every opportunity to practice.
They're putting the probe on her belly and they're kind of sliming over too much gel and they're trying to see what they see. Instantly, I can see that there's way too much water inside her uterus. It’s a problem that’s probably causing her to have a hard time breathing.
And they're looking and looking and I see one fetus. I see the heart beating and then I realize we haven't quite seen all the fetal parts. So I ask if I can help move their hand on her belly to check what’s going on.
And I realize that the fetus doesn’t have brain structures. This is a problem called anencephaly which just means the absence of brain structures and these fetuses actually can’t survive. It’s a really rare problem. You almost never see it in the U.S. In my ten years here working, I've seen it a handful of times. And that week, in this project we’d seen it five times in five different women. It’s linked to things like not having access to food, fortified food to early pregnancy care to family planning, to healthcare in general.
I start to tell her what’s going on and I’m explaining what I see and she starts to sob. Her mother, who is standing by her side, explains to me that just a few weeks ago she had lost three of her five kids in a mortar attack then it collapsed her home, and a couple weeks later her husband had been killed while trying to escape the siege of where they were with his elderly father.
So I take a deep breath because I’m also delivering some pretty terrible news and start to figure out how we’re going to move forward. Then in the background of where we’re standing I start to hear the word ‘haram’. ‘Haram’ is a word in Arabic that means forbidden in Islamic jurisprudence. It’s also a word that’s sometimes thrown out for socially unacceptable behaviors in the Arab world.
People are saying haram, haram, haram, haram. All these different people. People are weighing in from other wards. The cleaners are weighing in. All my maternity staff is weighing in. To me it was very clear what needed to be done. What needed to be done was for us to help her end this pregnancy so that she would be okay.
Outside of our facility, which was a Doctors Without Borders facility, was a completely wrecked town with no other healthcare facility. So I’m starting to think what is going to happen to her if we don’t do this here? What if she goes home and feels worse? What if her shortness of breath gets worse? What if she goes into labor at home and starts to bleed and it’s unattended? She could basically lose her life.
So I’m discussing with my team and I’m trying to bring them on board and people are really hesitant. Eventually they say if I as a non-local staff take responsibility for this abortion, they're okay with it.
I internally get really mad because we’re a humanitarian organization. We offer impartial, neutral medical aid. We treat armed groups that perpetrate violence and the people who are victims of violence. For some reason when it comes to women and abortion, we get all wrapped up in the morality and the risk of the medical aid we’re providing.
But I keep all this anger to myself and I sort of reflect on it many months later when I’m not in that situation. In the moment I say, “Okay, no problem. I’m a non-local staff. I'll take the responsibility. I'll do this abortion.”
We are stressed because I soon have to leave because at sunset everyday our medical convoy has to leave this destroyed town because of risks of mortar attacks and kidnapping and such things, so I feel like I’m racing the clock.
We start to give her the medications that induce her labor. It’s something called an induction termination, which is just another word for abortion and she actually starts to go into labor. She starts to contract, she breaks her water and then she starts to bleed, which is a very common problem when you have too much water in your uterus. Now I’m getting really nervous because I really don’t want anything to go wrong with this abortion and nothing bad to happen to this woman.
I’m working with my midwife and she's amazing. She's supporting this woman. The mother is praying for her, and we’re grabbing bags of saline and blood and the different medications that we need. In the midst of all this, my radio, which is how we stay safe in the field in such projects, starts to go off and it’s saying, “Medical convoy is leaving in ten minutes.”
I start to curse under my breath and I radio back, “I can’t leave. We have to hold it for a medical emergency.”
And holding the convoy in a destroyed town for a medical emergency is not a small thing because you're putting all your team members at risk.
I continue to work and then out of the corner of my eye I see my field coordinator peeking and look at what’s happening and then I hear on the radio, “Everything on hold until the medical emergency is finished.” And I think I need to give this guy a hug later because that’s amazing.
I keep working with my midwife and the patient. I’m like, okay, she's got to deliver soon, she's got to deliver soon. And in a little bit of time she does deliver then she starts to have a hemorrhage which is a very severe type of bleeding.
And we’re running and all the different team members are running to get more blood from the blood bank, to get medicines from the operating room. We have a very fancy thing called the uterine balloon that helps keep the uterus from bleeding too much and helps it contract. And we’re doing all this massage and the mother is praying. After about an hour of a lot of stress and a lot of sweat, the patient is okay. Her blood pressure is okay and she smiles a little bit.
Her mom is kissing the midwife’s hand and the midwife just looks so incredibly proud. Then I realize I’m really late for this stupid white truck convoy and I say goodbye and I run to the convoy and I get into the truck. This German nurse turns around, looks at me and she says, “You're late.” In the moment I was like I wanted to say some curse word expletive but I’m just so proud I just can’t say anything. I’m like we were the best, we did the best thing that day.
So on the ride home I’m thinking and talking with the people in the truck with me. I think when you think of war you think of really serious injuries and death from shrapnel and bombs and gunshots and you don’t really think of all the people that suffer from lack of access to medical care and lack of access to abortion. And a thousand women everyday die from pregnancy or from complications of pregnancy and that’s a really big and serious thing.
I’m so proud to be an abortion provider and to be a humanitarian aid worker who helps take care of women so that they can actually survive these events and thrive in their communities.