December 28

As I mentioned in my last post I’ve struggled with practicing as I’ve been taught and believe is best while also trying to respect how my Haitian counterparts were taught and what they believe is best practice.

There was a woman who came in in labor this week and when the doctor examined her he said that she would need an episiotomy (cutting the perineum to make the vaginal opening bigger) in order to give birth (this was long before the baby was even close to being at the perineum when something like that could really be evaluated). I had labored for most of the evening with this woman and thought of her as “my patient,” and was more than a bit frustrated at the prospects of her having an episiotomy. I told the nurses I was working with that I didn’t think she needed an episiotomy—and explained that in the U.S. the literature shows repairing lacerations is better than repairing episiotomies—and that if I caught her baby I wasn’t going to perform one. Needless to say, I was not allowed to catch the baby and she got an episiotomy (and actually had quite severe post-partum bleeding, I believe in part as a result of her episiotomy).

I know that the nurses where just doing what the doctor ordered them to do (as is appropriate), and that they believed that performing an episiotomy was best practice, but it was still very hard for me to watch. I however, see no easy way to reconcile our differences in practice. Although I’ve tried to talk to the nurses about why we in the U.S. don’t perform episiotomies (and various other practices), at least in this type of society behavior change needs to come from the top (i.e. the OB/GYN chief) and not the bottom (i.e. night nurses). And although I feel very strongly about the issue I’m reticent to go to the head of the OB/GYN department and try to lobby for such a change. Part of that that is me being scared and non-confrontational, but it’s also hard given that this is what is believed to be best practice and still taught in the medical/nursing schools, and I’m “just” a visiting foreign new midwife lucky enough to have been allowed to work at HIC for these 2.5 months. So, I’ve done nothing—except never perform an episiotomy and have had many moms with no lacerations (when I was told an episiotomy would be needed) or well repaired ones. I know that’s not enough and that I’m not serving my patients as best I can, but it’s all I feel comfortable with doing at this point. 

*I’m in Rwanda this week representing Hope Through Healing Hands with Dr. Paul Farmer, Partners in Health Rwanda, and Harvard Medical School. These dispatches from the road are my personal journal–recording what I’ve seen and learned on this trip. See my pre-trip thoughtsMonday’s blog, and Tuesday’s notes.

This morning we met with patients and physicians at Centre Hospitalier Universitaire de Kigali (CHUK), the urban hospital equivalent. For the past few days we have explored Paul Farmer’s vision of taking health care to the people in rural areas, so often neglected around the world.  Today we looked at health care in the city.

CHUK is the primary teaching hospital, located in the heart of Kigali. With 25 departments—17 clinical and 8 administrative—CHUK provides training, clinical research, and technical support to Rwanda’s 39 district hospitals.

Again we were able to meet patients and hospital staff. I was particularly impressed with this three-year-old little firecracker. He fractured his hip falling out of tree, but that wasn’t keeping him down! I also had the honor of meeting this dedicated woman. She’s served as a nurse in all of CHUK’s departments over the past 11 years.

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Over and over I’m impressed with how much Rwanda, with PIH and other groups, has accomplished.

For instance, Rwanda has one of the highest vaccination rates in the world—a status they have achieved through very hard work over the past eight years.

Vaccines for children here are a series of six individual vaccines that begin at birth over the first two years of life. In a country with about 11.5 million people—the majority of whom are very poor, a 94% vaccination rate has been achieved through national campaigns centered in communities. The vaccines are administered through community health centers in each of the villages. This is really, truly remarkable.

Breast and cervical cancer have been on the rise in Rwanda, so in 2010, a national campaign to vaccinate schoolgirls against HPV began that is gradually making it across the country through community health centers. The hospital at Butaro—where we were yesterday—is participating in research and the collection of data around this vaccine.

It works; it’s a great vaccine. For cervical cancer it’s very important. And Rwanda is taking a leadership role. As you can imagine, cancer is not treated well in the developing parts of the world. So it’s pretty remarkable that both a vaccine program and cancer care are coming together here.

Of course Rwanda’s remarkable progress is contrasted by the genocide that took place here 20 years ago.

This afternoon we visited the moving Kigali Genocide Memorial, where the history of genocide worldwide is powerfully presented. It was a return visit for me, but no less humbling.

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Last time I was here, a bipartisan group of Senators laid a memorial wreath. This time, I considered what Rwanda has accomplished in those 20 years:

  • a dedicated nurse spending 11 years caring for the sick;
  • Partners in Health Rwanda’s work over the past nine years;
  • a nationwide vaccine program against polio, tuberculosis, and measles, for the past eight years; and
  • the PIH Women’s and Girls Initiative training women for the past six years.

But these are only the beginning.

Maybe the most hopeful thing I saw today was the work of Human Resources for Health (HRH). We had the privilege of meeting physicians from this innovative Rwanda-U.S. joint partnership to strengthen the Rwandan health care system.

Harvard Medical School, USAID and other US government programs are funding about 70 to 100 clinicians and administrators and planners through the Rwandan Ministry of Health to develop the clinical service infrastructure.

These are inspiring mid-career physicians from Harvard-affiliated hospitals who are changing the world. Our tour was conducted by an American orthopedic surgeon who is dedicating a period of her life to serving the hospital and the training program of young Rwandan physicians.  They are all heroes.

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The program, funded by the American Taxpayer and in its second year of an eight year commitment, is a tremendously powerful and smart investment in the future.

What is needed in Rwanda—and globally!—is a long term plan. HRH is building up infrastructure which is so badly needed to lift up the health sector here. But equally importantly, their work will make health care in Rwanda sustainable and prepared for the future.

*I’m in Rwanda this week representing Hope Through Healing Hands with Dr. Paul Farmer, Partners in Health Rwanda, and Harvard Medical School. These dispatches from the road are my personal journal–recording what I’ve seen and learned on this trip. See my pre-trip thoughts, and Monday’s blog

Who says you can’t treat patients suffering from cancer in the poorest, most rural parts of the world?

I’m writing on my iPhone on a bumpy dirt road that I am told will be paved next year. It winds for two hours through gorgeous green mountains sculpted with terraced plots of land and scattered homes stepped up and down the hillside.

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But 30 minutes ago I was on a mountain top in a cancer ward listening to the heart sounds of a 6-year-old boy with leukemia and examining the slowly disappearing lumps on the chest of a 20 year old man with non-Hodgkin’s lymphoma—both being treated with state of the art intravenous chemotherapy.

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Butaro Hospital, based in Burera District, Northern Province, is a PIH-supported facility and home to the Cancer Center of Excellence, a cancer-referral site for all of Rwanda. The cancer ward was opened up in this rural district hospital two years ago. As we toured the wards, we saw children with leukemia, women with breast cancer and men with bowel cancer.

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Paul Farmer introduced to the world the fact that HIV treatment does not have to be expensive and that it can be successfully treated in the poorest parts of the world. No one believed him at first. But he proved them all wrong.

Now he is doing the same for cancer diagnosis and treatment. If it can be pulled off in rural, mountainous, and hard-to-reach Burera, it can be done anywhere.

One third of the patients come from the local district, a third come from outside the district, and a third from around the country and even neighboring countries.

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The hospital has only the essentials: a simple plain film x-ray machine, one ultrasound machine, and basic blood chemistries but nothing like blood cultures. There are no pathologists there—photographs or iPhone pictures can be sent to partner hospitals in Boston, Brigham and Women’s and Dana Farber Cancer Center, when needed.

But the staff is Rwandan and they have been trained in concert with Partners who place a heavy emphasis on fact-based science, research, and clinical training with certification. Pride among the staff bursts forth. People are living and have hope where they were dying in despair.

It’s truly an amazing thing to see.

Kigali, Rwanda

Why are we in Rwanda? What makes it a unique place to learn about health policy, and health care delivery? What will we learn that can make us smarter as we address health issues back at home?

I thought through these questions on the flight to Rwanda, and I had plenty of time. It’s been a long series of flights—Aspen to Denver to Chicago to New York to Amsterdam to Kigali. But the real journey began today as we saw our first health facilities.

Today (Monday), the delegation piled into a Land Rover after breakfast for the 2.5 hour drive to our first stop: the Partners in Health (PIH) headquarters at Rwinkwavu. We toured the Rwinkwavu District Hospital & Health Center, which was funded in part by the Rwandan government, PIH, and Bill & Melinda Gates.

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Formally, I’m here as the Chairman of Hope Through Healing Hands, the global health nonprofit I founded. Having been both a surgeon and a public servant, I am convinced that health and medicine are the best currency for peace and healing worldwide. I started Hope Through Healing Hands to put that belief into action.

It’s a vision that is shared by Dr. Paul Farmer, PIH’s founder and director. Paul has been a friend and like-minded champion for global health for years. He has always had the vision to see things that others could not, the audacity to dream big, and the commitment, dedication, hard work to make his visions–whether a nursing school, hospital, outpatient clinic, or even an entire medical school–a reality. It’s an honor to tour Rwanda with him, and see the progress being made.

When I was last in Rwanda, in the summer of 2008, I was impressed to see how diligently international funds were used (in that case, PEPFAR funding focused on HIV, malaria, and tuberculosis care and prevention). I said then, I wish all Americans could join our delegation to see how wisely their contributions have been spent, and with accountability.

I have seen the same today in the Rwinkwavu District Hospital.

When Rwinkwavu District Hospital first opened, Paul planted several trees there on the property. Standing in their shade today, they are a visual reminder of the growth and progress that PIH—and Rwanda as a whole—has made.

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With Paul Farmer under the trees he planted.

The district hospital is in Southern Kayonza District, one of three that PIH serves. The 110-bed Rwinkwavu District Hospital and its eight health centers are in remote, rural area, and yet it is delivering care to the poor with both compassion and excellent science.

The highlight of my day was meeting the young researchers at Rwinkwavu who were learning how to conduct sophisticated clinical studies that are and will continue to be published in peer-reviewed journals. They are pushing medicine forward not only in their hospital, but globally as well!

Increasingly the hospitals in Rwanda are seeing surgical disease including cancer. For so many years, the African continent has concentrated on infectious diseases. Now that most of those are under control, the most dramatic emergence is of chronic disease of the heart and lung. In addition, there is a huge need for trauma treatment centers, which are generally nonexistent.

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After our hospital tour, we visited the PIH Women and Girl’s Initiative, a wonderful artisanal cooperative that had been started specifically for teenage girls, ages 12 to 18, an age group that has been neglected a bit in Rwandan society. The 20 young women that we met had dropped out of school for various reasons, but had banded together to start a cooperative and learn about small business. They manufacture purses, robes, aprons, gloves that are truly magnificent.

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While the medicine being done compels the surgeon in me, from a global health perspective, the most exciting thing about PIH’s work in Rwanda is that it truly is being taken up by the Rwandan people.

Initially, PIH was a health care provider in these hospitals and health centers. But increasingly, PIH has transitioned into more of an advisory role. PIH now supports the Rwandan government in providing services to more than 865,000 people at Rwinkwavu District Hospital and two other hospitals and 41 health centers, with the help of 4,500 community health workers.

At dinner I had the opportunity to sit beside Dr. Agnes Binagwaho, Rwanda’s Minister of Health. Dr. Binagwaho and I have met several times on my previous trips. She’s been championing public health in Africa since 1994. Tonight she, I, and David Vreeland, discussed the role of information technology in healthcare and the transformation it promises. Rwanda has made outstanding progress implementing health IT to support clinical decision making–a challenge we struggle with in the US as well.

This is the power of global health diplomacy—empowering a community to achieve health, healing, and peace, and seeing incredible gains for the entire global community.

Tomorrow we head North to another province, another hospital, and a cancer center of excellence. I’m excited to see what we learn there.

December 22

As the providers at HIC (i.e. the nurses) have become more comfortable with me and my abilities I’ve slowly begun to help teach the nursing students who are present during my shifts. This week I got to help a couple of the students do deliveries, which were rewarding experiences, though ones I’m not (yet) totally comfortable with. In many ways I still feel like a student myself—I graduated from nursing school in May 2012 and this is my first job practicing as a “real” (as opposed to “student”) midwife—and so it’s a bit odd for me to already be put in a teaching role. That said, I really do enjoy guiding the students and helping them grow more confident with and skilled in catching babies.

One of the hardest things about trying to teach here is that there are some birthing practices that are standard in Haiti that aren’t viewed as best practice in the U.S./developed world (i.e. they always clamp and cut the cord immediately, in the U.S. it’s recommended to typically wait at least 2 min, they perform perineal massage while pushing, in the U.S. that’s not recommended, they perform episiotomies very frequently, most midwives in the U.S. perform them very rarely). So although I may be coaching a student through a delivery, advising her using recommendations from the U.S., often times one of the nurses will “correct” the student and tell her to do something very different than what I’ve just said. So that is sometimes frustrating for both the student and me. I’ve now started saying, “in the U.S. we do this” and trying to explain why I recommend doing something “my” way versus the “Haitian” way. And after hearing my explanations and watching me practice, some of the providers/students are slowly adopting at least the delayed cord clamping, which I’m happy about.

This week I was doing the admitting paperwork on a woman who came in in labor. I know how to ask some basic questions in Creole (How old are you? What’s your name? How many babies do you have? etc.) and so went through those with her.  For the more “complicated” question (Where were you born?) I switched to French, hoping she knew how to speak it—which she did. Her reply—Jamaica—surprised me, and prompted for me to ask her if she spoke English—which she did also. So throughout my night laboring with this woman we had conversations in a mix of Creole, French, and English, which made me smile. I know for Haitians and most people around the world speaking multiple languages is nothing exciting—and I mélange French and Creole normally with all my patients—but having that English thrown in (with her great accent to boot) was a treat.

 

I was in Aspen earlier this week working on some of the challenges facing healthcare and the health industry in the US, but it’s time to switch gears.

From my 2008 trip to Rwanda with the ONE Campaign

Sunday, I leave for Rwanda to lead a one week group trip with my friend Dr. Paul Farmer to see some of the work being done byPartners in Health (PIH) in the country. I haven’t been in countrysince 2008, and I’m anxious to see the progress PIH and other groups are making in health.

Since the spring of 2005, Paul’s PIH organization has been in Rwanda working closely with the government and the Ministry of Health to reach the rural, underserved areas of the country. PIH began by focusing on HIV/AIDS work, but has now expanded to full healthcare offerings. Today, over 800,000 people are served by PIH’s 40 health facilities.

But the health challenges in Rwanda are still vast! Next week with PIH we’ll be considering many aspects of health in Rwanda, but one in particular that I’ll be looking at while I’m there is nutrition.

I firmly believe–and have seen firsthand!–that global health diplomacy works as a real and powerful currency of peace worldwide. And a healthy start to life–a mother enjoying a safe and healthy pregnancy leading to a safe birth and healthy infancy–is crucial to building a foundation that leads to stable communities and global peace.

Food insecurity and malnutrition account for more than half of the deaths of children under 5 in developing countries, and Rwanda has had its fare share of nutrition challenges. In 2005, 18% of children in the country were underweight.

But Rwanda’s government has made real progress in child nutrition since 2009. That year, a Presidential Initiative launched to address malnutrition. The country also joined forces with the US in the Feed the Future initiative.

A 2010 health survey showed that chronic malnutrition and stunting affect 44% of children under the age of 5 in Rwanda.

In September of last year, the Right Honorable Prime Minister, Dr. Pierre Damien Habumuremyi launched a 1,000 Days Campaign, focusing on food availability and a balanced diet for pregnant women through the first two years of life of their babies.

The first 1,000 days may seem like such a small window of opportunity for global change, but the data are clear that childhood undernutrition has long-lasting consequences.

WHO models estimate that over half of adults in the prime working age group–20-29 year olds in Rwanda–have been affected by childhood stunting. Many of these adults wear the visible badges of malnutrition: shorter height or lessened muscular development. And for just as many, malnutrition has exacted a mental toll as well, diminishing the cognitive function of the working age population.

Along with the rest of what we’ll see–including a bit of gorilla trekking and possibly gorilla surgery–I’m anxious to see what progress Rwanda’s 1,000 Days Campaign has made, and the returns realized on nutrition investment.

I’ll be sure to keep you updated.

November 30

Yesterday and today I participated in a training called “Helping Babies Breathe” (HBB). The training materials are produced by the American Academy of Pediatrics, and our training was put on by a number of American doctors who do HBB trainings all over the world. I was lucky enough to be able to also participate as a trainer in the training, which was a lot of fun. There were about 40 people at our training—mostly nurses, though there were also a couple of doctors (but sadly no midwives). I had 6 women (all nurses) within my small training group.

The HBB curriculum teaches participants how to resuscitate a baby in resource-limited settings (i.e. all of Haiti). Using a Neo-Natalie blow-up baby I taught my group the basic steps of drying a baby, suctioning his/her mouth and nose, performing stimulation, and using a bag and mask to perform ventilations—all in hopes of resuscitating a baby who is born not breathing.  We practiced various scenarios including: a baby born with clear amniotic fluid, with meconium, with the baby crying right after having been suctioned, and with the baby not crying or getting a high heart beat after correctly being ventilated for a number of minutes.  Each of the participants were given training materials to use back at their specific clinics/hospitals to train additional staff, as well as a number of bags/masks and bulb suction devices to now use to resuscitate babies.

It’s amazing to think that such inexpensive/relatively low-tech products like a bulb suction device and a bag/mask can have such a dramatic difference on a baby’s outcome. It’s also very sad to think that without the proper training even in the presence of such devices, many providers here don’t make use of them.

I’ve had to resuscitate a number of babies at HIC, and each time I’ve been the only provider helping with the resuscitation. Often the nurses have told me that a baby looks dead—and why should I try to save him/her? When I have responded that the baby has a heartbeat, and is in fact not dead—which is why I’m working to get him/her to breathe again—they have laughed and thought me foolish. That mentality however, I think—I hope—is slowly changing. As the nurses I’ve consistently worked with have seen the fact that with proper resuscitation a baby can be brought “back to life”, they are at least telling me that they now see the utility in not automatically giving up on a baby, but instead trying to work to make him/her breathe. 

No one from HIC came to the HBB training—despite the hospital having received a number of invitations—which is sad, but the training has inspired me to use any downtime during my night shifts to train the nurses I work with. Hopefully with such training—and seeing my example of resuscitating every possible baby—the night shift nurses will learn the HBB techniques and will be able to pass it on to the other maternity nurses, and save lots of babies lives in the days/months/years to come.

Likewise, I hope that the providers who were trained in the past two days go back to their institutions and train others—or at least serve as an example and spark some discussion—and in doing so help babies who might otherwise not been given a chance.

 

Motherhood is a dangerous journey to take in most of the world. Nearly 300,000 women die each year from complications due to pregnancy, and 99 percent of those women are in the developing world. In Malawi, an estimated 510 out of 100,000 women will die giving birth. But Chief Kwataine, a former English teacher, has become well-known in the country for his work developing safe motherhood activities for nearly the last twenty years.

Watch this short, two-minute video to learn more about how women's (and children's) lives are being saved in Malawi. It's well worth your time.

November 22

First off, Happy Thanksgiving. I have an incredibly blessed life and am thankful for many things—but most relevant to this post is the fact that I’m thankful for the Frist Global Health Leaders Program.  Because of it, I have been given this amazing opportunity to come to Cayes and work at HIC. It has been—and I’m sure will continue to be—an incredible experience, and I am so grateful for the Program and for having been selected for it.

HIC as a hospital is trying to improve its HIV testing rates (a goal that I think is true in most hospitals in Haiti).  As such, testing rates are now closely scrutinized, and it has become clear recently that the maternity has pretty low rates of testing women while they’re here to give birth (last month was about 25%).  That low rate is in large part due to the fact that most women who come to the maternity have already been tested once during their pregnancy—sometimes multiple times—and so don’t need to be tested when they come to give birth. (The women who have had prenatal consultations typically bring their prenatal card when in labor, and that shows if/when they were tested and the results.) There is still however, a portion of the pregnant women who haven’t been tested—typically those who haven’t had any prenatal consultations—who do need to be screened when they arrive to give birth.

Between the hours of 9am to around 4pm those women who haven’t been tested can easily get tested, as there’s a woman who tests pregnant women—typically it’s those women who are at the hospital for their prenatal consultations, but she happily tests ones here to give birth too (and I’ve sat in and watched her counsel women and she does a great job). The problem however, is that when this woman isn’t at the hospital the pregnant women who haven’t been tested, can’t get tested. So for most of the afternoon, and all of the night shift, we aren’t able to test women who haven’t been tested during their pregnancy. This is particularly difficult given the short amount of time that the women stay in the hospital after they give birth (an average of 6 hours). I had a woman on Tuesday come in, give birth around midnight, and then want to leave at 7am. I tried to convince her to stay until 9am to get tested—she sadly stayed until around 8am (I checked on her before I had a delivery and she was there, but when I finished with the delivery and went to see her again she was gone).

We’re trying to work on ways to address this problem—but as far as I can tell it comes down to the lack of money to pay someone to offer testing during “off hours” and the lack of motivation on the part of the nurses/doctors/midwives. Until a real solution is found I’m just going to try to beg women to stay until they can get tested in the morning (which I was successfully able to do on Wednesday). 

 

November 15

Most days (or I should say nights rather)—I forget I’m working in Haiti. We have normal, beautiful deliveries with happy, healthy moms and babies. I got to catch twins the other day (!!), and the first was breech—which was quite exciting/stressful for me, as breech babies typically are sectioned in the U.S. and so the breech delivery skill-set is a dying art. Sure we have the occasional loss of power, or we run out of gloves, but overall things at the maternity run in a manner pretty similar to how they would back in the U.S.

And then there are nights where I am harshly reminded that I’m in a developing country, in a hospital with limited resources, where standards of patient care are—at times—very different, and where things happen that wouldn’t occur in the developed world. Below is a sad, frustrating, and a bit graphic example of such a case.

Last night a woman was carried into the delivery room with an IV already in place and fluid dripping. She had been brought from another hospital that was about 45 min away from Cayes. She had had an obstructed labor for the past three days. As a result, when she arrived her baby’s head (the baby had died—how long ago no one knows) was right at her perineum, but wouldn’t come out. Her vulva was terribly swollen and she looked incredibly worn out (which was more than understandable given what she’d been through). She was still having contractions—probably due to the fact that she was getting pitocin through her IV—but they weren’t doing anything but causing pain.

We called the doctor on call to see what he wanted to do about this woman. It was clear to me—and the nurses—that no amount of pitocin was going to make that baby come out (unless the baby decomposed enough to be able to be pushed out with the pitocin induced contractions). I was concerned about her increasing risk for infection and for fistula formation—among other problems—and so was hoping the doctor would come in to perform a c-section (given that we had no vacuum or any other way I could think of to try to extract the baby vaginally). The doctor however, got mad at the intern for calling him, and said that the woman just needed pitocin and that was that. After the call, the nurses all lamented the doctor’s decision, but said that this was just how it was in Haiti—that women suffered. They were much more laissez-faire about it than I was—in large part I think because this is normal/expected to them, and (obviously) not for me.  I think also because I knew what materials we didn’t have, and how they could have changed the situation—and the nurses probably didn’t as well—that it made it that much more frustrating for me.

I struggled with trying to think of something we could do for her—but I couldn’t think of anything. (Being a new/inexperienced midwife is hard at times because I wanted to help this woman so very much, but have never been taught about how to address obstructed labor—I’ve only read about it and its consequences—and don’t have any experience with it (until now), or anyone to offer me advice as to the best treatment plan.)

In the end we—tragically—monitored the woman all night. She made no progress and didn’t get any rest because of her contractions. I happened to be at the hospital this afternoon (around 3pm) and saw her finally heading back for a c-section. I can only hope that she has no long-term consequences of this birth—though I’m not too optimistic about that.

I realize this is not an uplifting post, but it is a reality that any healthcare worker who has the privilege to work—or wants to work—in the developing world will have to continually confront. My hope is that with time the norms will change, and appropriate resources/trainings will be provided to decrease the frequency of such cases, and ensure that women don’t have to just suffer.

 

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