10 minute read
MIDWIFERY ON THE MARGINS
RIght: Tertia van der Walt with children in Kurdistan.
Tauranga midwife Tertia van der Walt has volunteered as a midwife in several countries, an interest that began when she worked with her husband, a dentist, when he was volunteering in Kosovo. “This ignited my passion for serving marginalised people,” she says. “When I became a midwife I wanted to use my skills towards this purpose.”
Tertia was a secondary school teacher before becoming a midwife and particularly enjoys the teaching elements of voluntary work. She described two of her assignments for a midwifery standards review and this is an edited version of her reflections.
KURDISTAN, IRAQ
I arrived in Kurdistan on 17 July 2019 to work in a refugee camp on a placement with Frontier Alliance International, a Christian aid organisation. In my last conversation with the team at Frontier Alliance before I left home, they stressed that the health system in the refugee camps was “unstable, dysfunctional and uncontrolled” as a result of the ISIS attacks as well as regular air strikes from hostile neighbouring countries. Prejudice among ethnic groups led to ill treatment and sometimes there was no care available for the sick and for pregnant women
My “job” was mainly to educate and train staff members and pregnant women regarding antenatal, labour and birth and postnatal care. I was to pay special attention to a healthy lifestyle, natural birthing, breastfeeding and identifying post natal depression (PND). I was told that as there was a lack of postnatal care, breastfeeding rates were low. The mortality rate was high because of poor birth practices, inadequate referrals, emergency obstetric care and a high incidence of anaemia.
I was overwhelmed by the receptiveness of the women who turned up for the education and training sessions. Working with a translator was new to me and sometimes I was so carried away with what I shared with the women that I had to stop to give the interpreter the opportunity to explain.
I focused on being open, present and aware of my body language and mannerisms so that I could communicate clearly and acknowledge each woman with respect. The women were eager to know more and I often wished that I could spend more time answering all their questions. They would, without being offended, interrupt me if I suggested something that was not culturally appropriate for them. For example, when I recommended that they should go out for short periods of time postnatally to get Vitamin D from the sun and to socialise, they stated that they have to stay in the house for six weeks after their babies are born. I also learned that words like bra, vagina and breast were to be used very discreetly.
I met with a local obstetrician to gain more information regarding birthing practices. She explained that all women made use of obstetric care antenatally and for the labour and birth although one in five really needed obstetric care. She said that the C-section rate was about 35% because women were free to choose a C-section and with the lack of information available to them, they considered it the easiest option. She mentioned that she had done a C-section on a woman the previous day who had already had eight babies by C-section and that everything went well. That of course was an exception as placenta previa, lesions, accreta and hysterectomy rates were high.
Contraception was not widely accepted as wealth was often measured in the number of children. The availability of beds in hospitals for women in labour was limited and the staff often had little to no training. It was standard practice to do an artificial rupture of membranes at four centimetres and commence syntocinon augmentation, but as infusion pumps were limited, most were running free, controlled by only the drip rate. Women were asked to bend their arms if the contractions were getting too severe to cut off the flow of syntocinon. Active third stage was standard practice, again because of the lack of trained people to handle a possible haemorrhage. Research has shown that postpartum haemorrhage is the leading cause of maternal mortality in the developing world and while a 500ml blood loss may have little impact in wellnourished women, women who are poorly nourished and anaemic may not survive.
Women usually stayed a maximum of one night after a birth (C-section included). Tolerance of disabilities is low. Mental health assistance is taboo with a high incidence of PND as a result.
We regularly visited a family with nine children to help with supplies. There were initially five children but when the woman fell pregnant again she gave birth to quads. They were not receiving any government support and lived in a three roomed house. The mother was always friendly and welcomed us when we visited; I did not hear her complain once. It was very interesting to see the way babies sleep in Kurdish culture. They are strapped to “sideless” cots which limit their movements and eyes are often covered in order to sleep better in the shared areas. I am sure this would not go well in our culture.
Culture of course also plays a big role in the way that new ideas and research are utilised. Women in Kurdistan, as in many countries, are suppressed and remain uneducated as a result. But I saw hunger for better outcomes and education which filled me with hope that nothing is stagnant and change is possible. Gandhi once said: “It is good to swim in the waters of tradition, but to sink in them is suicide.”
I have reflected a great deal on all the information I received and things I noticed when interacting with the women in Kurdistan. These women, just as any others, want to be appreciated, cared for, nurtured, supported and loved. As mothers, they have the right to a health care system which will protect them and their babies. However, life for them is mostly about survival, because as displaced as many of them are, they struggle to enjoy being pregnant or being a mother. A recent study by the International Institute of Health found that PND is up to four times higher amongst refugees and displaced families than in host community families. No holistic postnatal follow up service is available to families. My thoughts wandered to the privileged women in New Zealand and the care they often take for granted.
I really admired these women for the “simplicity” of their lives, with few material possessions, their humbleness, generosity and resilience. It was easy to fall in love with the people of Kurdistan. They are the largest group of people who do not have a homeland of their own, a people waiting to be born into the family of free nations. I enjoyed sharing knowledge with these women. I would like to return to give more support towards these women, especially those in the refugee camps who are forcibly robbed of so much that makes life tolerable and meaningful.
BETHLEHEM, PALESTINE During a visit to Palestine in the Middle East in September 2017, I had the opportunity to shadow health care professionals in their work with pregnant women in Bethlehem. I was warmly welcomed and invited to visit and share in the work of the dedicated midwives.
The Holy Family Hospital in Bethlehem specialises in gynaecology and obstetrics and offers the only place for women of the region to give birth in a setting which provides obstetric care. The hospital, a beautiful stone building, is immaculately clean with all the necessary facilities. The cost of treatment and birth are determined by the woman’s socio-economic situation. For those unable to pay, charges are reduced or waived. The hospital’s operating costs are sustained by the French Association of the Order of Malta which runs the hospital. It was a privilege to witness the high quality maternity care given to all women, regardless of race, religion, culture or social standing.
The director of the hospital shared its vision and expectations and how proud it was of the service provided to pregnant women. She inquired about the PROMPT (Practical Obstetric Multi-Professional Training) workshops for emergency obstetric are that we have in New Zealand and hoped to introduce something similar to the midwives there to enhance their skills. While following the head midwife in the antenatal and postnatal wards, she pointed out that
they have a high daily turnover of women coming and going and as many as 26 postnatal discharges can take place on any given day. The fertility rates in Palestine are amongst the highest in the world. An average of 450 babies are born in the hospital each month. Women are allowed to stay for only 24 hours after birth. I was introduced to a woman who was induced at 38 weeks because of retina displacement, two women with PPROM, (preterm premature rupture of membranes) three women with gestational diabetes and many more. While walking through the wards, I once again realised that women are women no matter where we live; we have the same needs, desires and necessity for quality care.
Not all women are lucky enough to reach the hospital in time to give birth as the more than 500 checkpoints across Palestine can extend a journey that should take minutes into hours. As many as 10% of pregnant Palestinian women may be forced to endure labour or childbirth at a checkpoint. I shadowed three midwifery students in the labour ward and was touched by their dedication, professionalism and their pride in every task performed. A four year midwifery degree equipped the students to qualify as midwives and to work an average of four shifts per week in the hospital with payment of about 4000 Israeli shekels (NZ$1600) per month. All midwives were committed to continuing education as a means of ensuring quality patient care.
It is standard procedure for each baby to be examined/ checked by a paediatrician after birth. A vitamin K injection, Hep. B vaccination and eye ointment are routinely administered to every newborn. Premature birth is a common phenomenon and is often the result of women’s lifestyles that may include poor nutrition, smoking, hard physical work in fields and walking long distances with cattle for grazing. Advanced technology in the hospital’s neonatal intensive care unit makes it possible for the medical team to adequately care for these premature babies. There is no policy or strategy in place to stop smoking during pregnancy as it is such an embedded part of the culture and commonly accepted in most public places.
Breastfeeding is a familiar practice in Palestine at a rate of about 97%. Therefore, pethidine as pain relief
Tertia admired the women of Kurdistan for their generosity and resilience.
during labour is a big no-no because of the effect it can have on breastfeeding after the birth. I was told that Tramadol IV was used successfully for pain relief instead as it has less marked maternal sedative effects and less neonatal depression for the baby (and there is the belief that it shortens labour). Epidural analgesia is also available to women at a very low cost.
I also accompanied an obstetrician, paediatrician and midwife in a mobile clinic to distant Bedouin villages where they do antenatal visits and baby checks on a regular basis in an equipped minivan. Every woman’s blood pressure is taken while the obstetrician does a scan of the baby on a mobile scanner. The obstetrician informed me that the women regard the scan as a very important part of each antenatal visit. He also shared that, although not evidence based, he believes that giving an enema to a woman once she is in labour, shortens labour by at least an hour.
I admired the commitment of the health professionals to their patients in the midst of political turmoil and poverty. It was a huge privilege to have a little peep into such a proud midwifery setting and to see the similarities with what we experience here.
Postscript: Tertia was hoping to volunteer at a new health centre in Gaza, Palestine during July and August but her travel plans were disrupted by the Covid-19 pandemic. “Hopefully flights may become available soon,” she says. square
