*Originally published in the March 2015 What Women Want issue of Al Jazeera Magazine*

Halfway down the dimly lit, main hallway

of Mogadishu’s Banadir Hospital, there is a sign above the entrance to the delivery ward, which reads: “Women are not dying of diseases we can’t treat… They are dying because societies have yet to make the decision that their lives are worth saving.”

Outside the door, family members of women being treated in the ward crouch alongside the walls in the shade, avoiding slanted columns of the harsh Somali sun that line the middle of the floor. They are waiting and sometimes praying for healthy sons, daughters, grandchildren, nieces and nephews or, at least, the lives of their wives and sisters. 

Inside the delivery ward it is also quiet and very dark, but occasional bursts of energy issue from the rooms that line the corridors running through each floor. Nurses with cooler boxes full of vaccines sprint from one room to another, orderlies rush mothers on stretchers down to the surgery theater and doctors walk briskly through, stopping in each room to make sure all is well. According to Somali custom, women giving birth should remain silent, but occasionally a loud yell reverberates up through the halls.

At the center of this is Dr. Marian Omar Salad. All around her there are midwives and nurses sprinting back and forth. There is the clatter of surgical steel; the fluttering of white coats and the muted groans of women in labor behind baby-blue curtains. In the ward, Dr. Salad wears a cerulean scarf wrapped tightly around her head and under her chin. She surveys everything with large, intensely focused, warm brown eyes that go soft at the edges.

Today, Dr. Salad is focused on a patient from the town of Afgooye more than 200 kilometers away named Howa Oofay Moalim. She came in just two hours earlier, and it is a miracle that she is still alive.

According to Dr. Salad, Howa has been in labor for nearly five days, with life threatening complications that arose almost immediately. Her baby was positioned crookedly in her uterus and his arm punctured her bladder. She has a fever and a very serious infection. The life she is trying to bring into the world now threatens to kill her.

Despite the warning signs, traditional birth attendants tried to deliver her baby. Dr. Salad says they only made things worse. The midwives in Afgooye simply grabbed hold of the child’s arm and tried to pull him from his mother out into the world. The tugs have broken his arm in multiple places. After more than a day, with Howa’s conditioning worsening, they had to bring her to Banadir. Howa walked into hospital’s front doors with her son’s arm hanging outside her body.

Dr. Salad is visibly frustrated by Howa’s condition. She says many mothers have misconceptions about the hospital that end up costing them their lives. “They think if they come to hospital that we will say caesarian section,” explains Dr. Salad. “Even if [the mother] lost three or four babies, she still prefers to go first to the traditional midwife. After she’s exhausted all her other options, she’s in a very bad situation, then she comes to the hospital in a very bad condition.”

In Somalia, women are often expected to give birth every year. Many avoid caesarian sections because a longer recovery time is needed, making such frequent deliveries impossible. But for Howa, it is now the only option.

After so many long hours, Howa is in tremendous pain. She writhes on her bed and her arms reach out wildly for the nearest attendant, hoping for any kind of contact. Her eyes dart around the room, scared and unsure. Dr. Salad is busy preparing the ultrasound, but she locks eyes with Howa, speaking words of comfort. The normally jagged syllables of Somali come out soft and steady and Howa calms down.  Dr. Salad presses the ultrasound to her skin and looks to the grainy black screen for a sign of life.

But the ultrasound only confirms her fears. She cannot find a heartbeat and it appears Howa’s son has died. “Every time it’s difficult,” says Salad.

In a country infamous for death and hardship, Somali women often have exceedingly desperate lives. They are forced to constantly navigate between civil war, clan violence, extreme poverty and poor healthcare, all with little or no say in the choices that will shape their futures.

According to UNICEF, every two hours a mother dies in Somalia due to pregnancy complications; one in 12 women will die of pregnancy related ailments. Part of the problem is that less than ten percent of births in the country are performed by a skilled birth attendant.

Even where there are efforts to address these issues, many serious obstacles stand in the way. One of them is the law. Under Somali law, a woman cannot take responsibility for her own life. For a medical procedure to be performed – even a life saving caesarian – consent must first be given by the woman’s family, often her husband and father.

“Most of the time we do lose the baby for the times we wait for consent,” says Dr. Salad. “And other times – which is much sadder – we could lose the mother for complications because of the traditions of the [family].”

Dr. Salad says sometimes even elder women of the family – unused to modern medicine – sometimes block life saving procedures.

Dr. Salad cares very deeply about Somalia’s mothers. She wants to change the minds of those family members who are skeptical of her and her work but the change often comes only as women are brought to the brink of death and back.

LOST GENERATIONS

For the past week she has seen one patient in her ward every day. Her name is Isha Adan Abdullah and she wouldn’t be alive if Dr. Salad hadn’t saved her. Isha is gaunt – she has yet to fully recover from ordeal – and often looks down at her knees with doleful, incredulous eyes. Dr. Salad adjusts the dress hanging slightly from Isha’s shoulder and lightly pats down her sleeve, almost like a sister, as Isha tells her story.

She was at home with her children in Murale – around 250 kilometers outside Mogadishu – when she went into labor. It was raining heavily then and midwives in the area couldn’t reach her, so she went into labor with only her family by her side. She knew almost immediately there was a problem. After two days of labor, she had still not given birth, and she began to bleed.

“From her history we think that she had a uterine rupture at that time,” adds Dr. Salad.

Isha continued to bleed out while begging her family to take her to the hospital. She waited another 10 days, fading in and out of consciousness. “They told me it was God’s will and that they would pray for me and God will help me,” she says. “They refused to take me. A few days later I told my family I want either to die or to live.”

Finally, after two weeks in labor, Isha couldn’t breath and she couldn’t stand the pain any longer. She asked her family “What do you want to do? Do you want to cook my meat after this?”

“This is like a [Somali] saying,” explains the doctor, looking softly at Isha, “do something about this or I will die.”

Isha’s family agreed to bring her to Mogadishu for treatment.

Now in her fifth day since the operation, Isha is happy to be alive but she is still in pain and has trouble moving. She shifts stiffly on her bed every few minutes. Dr. Salad says her strength will return, but she will never have another child. “Her uterus was in very bad shape and we had to do a hysterectomy.”

“Sometimes there is something so simple and you can do something about it,” she says. “[Then] it becomes complicated and you can’t do anything at that time. It’s very frustrating.”

Seeing women suffer like Isha is the hardest part of Dr. Salad’s job.

“I did see one, they brought her with the cart. I had to go over to the cart just to listen. Between the time I arrived and the time she died was, like, a few minutes. A situation like that is very hard to take.”

Dr. Salad says stories like that are common. But in a country where women face such significant hardships, Banadir’s maternity ward highlights one area where women are allowed to play a leading role – the hospital. Many of the staff here – from the surgeons down to the orderlies – are women.

“Mostly, Somali women, especially in obstetrics and gynecology, they like females to work because they say we are Muslims, we like for the midwives to be females; it is traditional,” says Dr. Nafiso Abdulrahman, another female surgeon at the hospital.

She has just come from a successful surgery – saving the life of mother and her child after convincing a skeptical family of the need for the operation. “It’s a normal thing: this one is every day.”

Every day is different at the maternity ward in Banadir. Surgeons can perform anywhere between one and six surgeries per day. With nearly 800 beds, Banadir is one of the largest and most advanced public hospitals in Somalia, but it is consistently underfunded, under staffed and operating over capacity.

“The entire city of Mogadishu, with a population of 2.3 million, we have only one free maternity hospital, which is Banadir Hospital,” says Dr. Abdullahi Mohamed. Dr. Mohamed works for humanitarian organization Swisso Kalmo, which helps administer the maternity ward. “Banadir hospital is the only national referral hospital in all of Somalia,” he adds, pounding his fist onto his desk with each word for emphasis.

The hospital was opened by dictator Mohamed Siad Barre in 1977 as as part of a huge infrastructure development project with the Chinese government. When the Barre’s regime collapsed in 1991, the hospital struggled. For the past 20 years, there has been spotty support from humanitarian organizations. “An [organization] would come, will stay for a couple of minutes, couple of months, and no agency ever thinks about what we call sustainability for a hospital,” says Dr. Abdullahi.

In 2012, organizations including UNICEF, the United Nations Population Fund and the World Health Organization stepped in to support Somali government efforts to improve maternal and child health. The support has allowed the maternity ward to serve more women.

Dr. Abdullahi says the hospital now delivers more than 21 babies per day and up to 750 per month. He says from mid-June to November 2014, doctors at Banadir performed more than 560 emergency caesarians.

“Without having a hospital like this or a [maternal health program] what you going to expect? It would be a total disaster in terms of human life.”

But despite the progress the hospital has made, there is still not enough funding, not enough infrastructure and not enough doctors, nurses and midwives. “We lost three generations,” says Dr. Abdullahi reflecting on the past two decades of conflict.

Dr. Salad is a small reason for hope – one of the few in a new generation of doctors in Mogadishu. She has been working at the hospital for the past two years as a surgical resident and helping to teach a new crop of students from the University of Mogadishu.

Life as a surgical resident is not easy in any hospital. In Mogadishu, Dr. Salad has to weigh life and death with her own responsibilities to her family and her physical safety. Sometimes she works double and triple shifts and must then walk home through Mogadishu’s crumbling streets in the middle of the night. She says her mother often criticizes her for working beyond her assigned hours.

“The problem my mother has is that it’s not safe for you to go late. [Security] is not stable but I do take the risk to save the lives of the mothers,” a big grin spreads across her face and she crosses her arms.

SMALL VICTORIES

In the delivery ward, Dr. Salad is still waiting for Howa’s family to return. In the next bed, there is a commotion as another woman enters the final stages of labor. Marian stops her consultation with Howa and moves over to help deliver the baby. Just minutes later come the screams of a health baby boy. His mother walked in off the street just hours before.

After she watches the nurses weigh the baby and check on the mother, Marian heads upstairs to scrub in for surgery. Howa’s family has come and Marian has permission to save her life.

As soon as she starts to scrub-in Dr. Salad transforms. Her smile drops and her eyes lose focus on her hands. She looks through the window into the surgery theater and begins to visualize the procedure. Her surgical nurses help her pull on her gloves and O.R. scrubs as she talks through the operation with her two assisting surgeons. She carefully surveys her tools and they approach Howa, whose face has been covered by a green curtain. A heart-rate monitor jolts every second or so, as another nurse looks on.

The doctors take their time under the bright lights, surveying Howa one more time and taking a collective breath before Dr. Salad makes her first incision. Once the procedure begins, speed and efficiency are critical. Dr. Salad’s hands do not stop as she moves closer and closer to Howa’s uterus. Her motions are compact and practiced, without any wasted movement. The closer she comes, the faster she moves.

In less than five minutes the team of surgeons get their first glimpse of the child and they draw in a collective gasp.

Dr. Salad’s face breaks for a moment and her eyes go wide. “He’s alive!” She has Howa’s son in her hands. “Alive!” She starts massaging the child’s chest to encourage his new heart. She gives him a gentle shake to try and wake him, but he won’t respond.

Dr. Salad hands the child to one of her nurses as her hands move even faster, turning her attention now to Howa. “Oh my god,” she says one final time before her eyes refocus on the woman in front of her.

As Dr. Salad and her team quickly repair the damage to Howa’s uterus, two nurses in the corner continue to massage the newborn baby’s chest. He is not crying like a normal newborn child so with light but firm fingers they give sharp compressions, then step back and wait. There is no movement and no sound. After a few seconds they give more compressions and wait. Suddenly, the child gives a quiet cough, kicks his legs and draws in a single breath. The nurses start chattering in relieved voices.

In just over thirty minutes the procedure is done. Dr. Salad has saved Howa and – miraculously – her son, who survived half-born for nearly five days. Her face has softened again, and she is standing over the newborn boy, looking on with concern. He will have a long recovery. His arm is broken in multiple places and the lack of oxygen over the past few days may cause developmental issues later in his life. But for now, Dr. Marian Omar Salad sees a small victory.

“Sometimes it’s hard. Sometimes it’s very, very-” she stops to think. “Some of the situations you cannot do [anything]. Your hand is tied and it’s very frustrating. And sometimes it’s very rewarding. You could save a mother who couldn’t deliver at home and you do a C-Section and you see her baby alive - it’s very rewarding.”