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Prenatal Care in Rural Nigeria

Before coming to GW, obstetrician Amr Madkour, M.D., volunteered in West Africa with Doctors Without Borders.

It was a scene that Amr Madkour, M.D., witnessed all too often during the final months of 2012. A  man rushing his wife into a rural hospital’s labor and delivery triage area, only to be turned away because nothing could be done — she had died en route.

“People were coming in a just a little too late all the time,” recalls Madkour of his time in northern Nigeria. Following his gynecology and obstetrics residency, Madkour practiced emergency obstetrics for three and a half months in West Africa with the humanitarian organization Doctors Without Borders. “There isn’t much in the way of pre-natal care in rural Nigeria,” explains Madkour, “so most women deliver at home either by themselves or with traditional birth attendants. It isn’t until things go very wrong that they seek out a hospital.”

Sadly, oftentimes nothing can be done for patients whose arrival at the hospital is so delayed, exacerbating an inherent distrust of physicians and hospitals that Madkour witnessed during his time abroad. “We relied on our reputation for doing good work in the hospital to try to change the existing stereotypes,” he said. The approach was effective; the hospital’s volume has nearly tripled since Doctors Without Borders arrived in 2006.

Madkour, who joined the faculty of the Department of Obstetrics and Gynecology at GW’s School of Medicine and Health Sciences (SMHS) in January 2013, was raised on a military hospital complex in Saudi Arabia in the 1980s, where his parents — both physicians — instilled in him an interest in medicine and a drive to help others. “My father was very much a humanitarian; his work didn’t stop at the hospital,” Madkour recalls. “I knew that a big part of what I wanted to do revolved around providing health care for women who don’t have access to care.”

When Madkour began medical school at Texas Tech University, however, OBGYN held little appeal for him. It wasn’t until his final rotation that Christopher Powers, M.D., an obstetrics and gynecological physician, took an interest in him. “We developed a strong relationship; he became my mentor and I was hooked immediately,” Madkour recalls. “He had me doing C-sections with him during my rotation, and I quickly became interested in getting into the surgical side of gynecology.”

In 2011, during the third year of his general OBGYN residency at Johns Hopkins University Hospital, Madkour traveled to Vietnam for a monthlong rotation at an urban teaching hospital in Hue with the nonprofit organization Jhpiego. “Seeing the practice of medicine in a different context was a very valuable experience for me,” he said. “Childbirth is full of mystery. It’s fascinating to see how much we’ve evolved for our bodies to be able to go through this type of process, and how complicated it can become when it goes wrong.” Following his residency, Madkour traveled to Indonesia, again with Jhpiego, to work on a project designed to reduce maternal and newborn mortality by improving standards at district and community hospitals.

Those experiences inspired Madkour to join Doctors Without Borders in September 2012, which took him to a small hospital in the town of Jahun in northern Nigeria for his first experience with rural fieldwork. During his months of practice in Nigeria, Madkour witnessed a steady flow of cases that would have been extraordinarily rare in the United States. “I saw an average of two to three cases of eclampsia a day in Nigeria — active cases where a woman was seizing in front of me. I think I saw one case during my entire residency.”

It was the rainy season when Madkour arrived in Juhun, which meant that “there wasn’t an hour where you wouldn’t see a new case of malaria,” he says. Women who have malaria during pregnancy are at an increased risk of miscarriage, stillbirth, and delivering low-weight newborns. “I saw degrees of anemia in these women that I didn’t even know could exist,” Madkour says.

The lack of resources at the rural hospital forced Madkour to extrapolate innovative solutions from his training without the aid of the usual equipment. “You operate based on certain principles, whether they’re surgical principles or principles by which you evaluate and treat a patient. And you just have to make judgment calls,” he said.

While his experience in Nigeria was trying — a lack of beds meant women often labored and delivered on the floor, and Madkour saw up to nine deaths per week — he believes the clinical skills he honed while practicing in a low-resource setting make him a better physician for his patients here at home. “There are very few surgical complications that I haven’t encountered or feel uncomfortable dealing with, such as complicated obstetrical maneuvers,” he says. “I also now have a greater appreciation for the privilege of working in one of the best health care systems in the world. We still have plenty of issues like the rising cost of health care, but we have almost every resource imaginable at our disposal.”

Madkour credits his decision to join the SMHS faculty as an assistant professor of obstetrics and gynecology to his desire to “be somewhere that has a strong reputation for excellence in international medicine.” SMHS’ location in Washington, D.C. was another factor—“I wanted to be somewhere that I can continue to develop networks in global health and promote resident engagement with global health.”

Nancy Gaba, Director of the Obstetrics and Gynecology residency program at SMHS, says Madkour is an exciting addition to the faculty. “Thanks to his international experiences, he brings a unique skill set which greatly benefits our patients and educational program,” she says. “Dr. Madkour has been tasked to work with our residents to improve their understanding of global health and create meaningful international educational opportunities for them. This will be a great addition to our residency program and will benefit women who most need their care.”

As for his ongoing dedication to the practice of OBGYN, Madkour says he treasures the relationships that he is able to build. “As a male obstetrician, my gender poses an additional challenge in gaining a woman’s trust. But the relationships I develop with my patients end up being very long-term, meaningful ones.”