From MIDWIFERY MATTERS, Issue No.110, Autumn 2006
Fiona Laird
I WANT TO SHARE my experiences and stories of working as an MSF midwife in Kalma
Camp, Darfur, Sudan. Perhaps, as midwives we share stories in much the same
spirit that explorers share maps, hoping to speed each other's journey, but
knowing the journey we make will be our own.
I have been a midwife now for 16 years, and I still love it with a passion that
I find hard to quantify. There are so many midwives you meet along the way who
shape and guide your practice, that make your journey more remarkable.
Blossom had been the first midwife I was allocated to as a student. She was
a traditionally built West Indian woman with a smile that would light up a room
and a laugh that was so infectious it just made everyone want to join in.
I was witnessing my third delivery when Blossom said, chuckling, "Fee,
you can catch this one!"
I didn't feel ready. What if something went wrong? I was really hesitant, which
just made her eyes sparkle even more.
"Jane, Fiona's going to catch your baby, with me here to help, you're doing
so well, won't be long now".
Her wisdom, calmness, and apparent complete confidence in my ability, reassured
me. I was suddenly overwhelmed; I would actually deliver this baby? Blossom
was right, of course, I caught the baby and held it in my hands just staring
at this new little life before me, and tears were streaming down my cheeks.
The parents were asking, "What is it? What is it?"
I whispered, "It's a baby!"
I have never lost that feeling.
I can imagine Blossom now, sitting drinking tea intelligently with Tao Te Ching,
on a mountaintop somewhere, nodding as he shared his thoughts
"You are a midwife, assisting at someone else's birth. Do good without
show or fuss. Facilitate what is happening rather than what you think ought
to be happening. If you must take the lead, lead so that the mother is helped,
yet still free and in charge. When the baby is born, the mother will rightly
say: "We did it ourselves".
It has always helped me to remember her total belief and faith in women's ability
to give birth, it's a gift she shared with me, and one I have relied upon a
lot recently.
The journey so far..
I left Amsterdam in the snow, and had to wait patiently on the tarmac for an
hour while the wings of the plane were defrosted. I arrived in Khartoum six
hours later, stepping off the plane into my first ever sandstorm. Great gusts
of hot red sand swirled around me as I headed for the terminal. I remember thinking
that I really had no idea what life was going to be like from this moment on.
It's amazing how you get accustomed to a completely new way of life. Every morning
I leave the house at around 7:45 am, the sun is already out, it's around 35C,
and I walk down a sandy track road to the office, passing goats and cows who
just amble by, I greet the water sellers with their donkeys and the children
who wave frantically to catch your attention. There is then a really wonderful
10 minutes spent saying hello to all the national staff, plenty of "Tamams''
(I am very well) and "inshallahs" (Allah willing). Later, we set off
in the land cruisers and make the 45-minute, cross-desert journey to Kalma Camp.
There are nearly 100,000 Internally Displaced People (IDP) still living in Kalma
today. The violent destruction of their villages, theft of their livelihood,
their land, their cattle, murder of their families, children and loved ones,
have forced them to flee. They live as refugees with little hope of ever returning
to their homes as the political jockeying continues two years on.
The clinic is a large, arching, straw structure supported by poles and sticks,
without electricity or running water. I work with 10 wonderful Sudanese midwives,
providing care 24 hours a day. We see around 400-500 women a week and deliver
20-30 high risk cases a week. There are ANC and PNC programmes, as well as reproductive
and sexual health, family planning and Sexual Gender Based Violence (rape) treatment
options and services. The job is challenging, fulfilling, demanding, testing,
frustrating, thought provoking, rewarding - ultimately it's been everything
and more.
One of the most difficult choices families have to make is who goes out of the
camp to collect firewood. Wood is scarce after two years of 100,000 IDPs collecting
it. The supplies are further and further away from the camp. The forests are
at least an hour-and-a-half away by donkey, three hours on foot. The Janjaweed
(government supported Arab militia) are there. If the men go and are caught,
they are killed. If the women go and are caught, they are raped. So, in order
for their families to eat, the IDPs have to risk their lives on a daily basis.
I can't begin to explain what it is like to bear witness to the women's stories.
Yesterday five women came to the clinic having been raped while collecting firewood
north of the camp. They had stopped to drink some water when a man in uniform
with a gun approached them and told them that they couldn't collect firewood
from there. He told them all to stand in a line. M. said she became very afraid
and started crying for her mum and dad, this infuriated the man and he fired
three shots into the air and screamed at her to stop crying or the next shot
would kill her. He then instructed them all to walk in a line with their hands
in the air. He led them down into a valley where two other armed men were waiting.
They were told to remove their clothes; they all refused. More warning shots
were fired. Each man then took it in turns to systematically beat and rape each
woman, individually, while the others were forced to watch at gunpoint. They
were all from one family; the two aunts were 29 and 26, one of whom was six
months pregnant. The three others were their nieces who were 14, 13 and 12.
The physical injuries from the beatings and rapes are really hard to see and
treat, but the women's resilience is humbling. As I listen to their many stories,
I feel so angry at the injustice of it all, and only hope that through MSF advocacy,
change will be driven.
In complete juxtaposition there are the births, and the last four months have
been the most affirming and reflective times I have spent as a midwife in my
career so far.
I truly put all the theory into practice. My midwifery tutor, Miss Dunford,
had a healthy disregard for the technocratic society in which she found herself.
She was particularly disquieted by the increasing reliance of midwives on machines
to monitor the progress and process of childbirth. As students we were not allowed
to use sonic aids before palpating and confirming the position of the baby,
and then auscultation the foetal heart with a Pinnard's stethoscope. I can still
hear her saying that a good midwife relies on her hands, her eyes and her ears.
At the time it all seemed so old fashioned. I hope that maybe our paths will
cross again and I will be able to thank her for sharing with me another great
truth.
I have delivered six sets of twins. This is considered very lucky, so for a
while I was almost revered. There is a belief among the midwives and women that
I was somehow responsible for this happy outcome. There really was no dissuading
them, and for a while, I was greeted as "Teeman diya inshallah!" -
twin midwife Allah willing.
One of the sets of twins were to be my greatest challenge, as both presented
as footling breech. There I was, standing in a straw roofed hut with no running
water or electricity, chanting the mantra, "Hands off the breech",
my trusty wooden Pinard's in hand (which has proved to be one of the most useful
things I brought with me!) thinking if I were at home, and confronted by this
big foot hanging out of a primigravida, I'd be pulling the emergency bell and
running off to theatre. My heart was beating out of my chest, there was just
me, myself and I. The first twin delivered weighing 3.6 kg, I passed her to
mum and breathed a small sigh of relief. I then turned back to be confronted
by a determinedly wriggling foot! The second twin weighed in at 3.2 kg. She
required some basic resuscitation. Obviously there was no resuscitaire to hand,
just 40 C heat, a towel, and a reliable Ambubag. I am happy to report that both
mother and babies are doing well.
Birth is a truly amazing sight to behold when the mechanisms you have read about
in books happen right before your eyes, without complications.
I have also had the joy of looking after Medina, who will always be known as
the miracle baby. Her mother Hawa presented to the clinic in labour at term.
She had had an antenatal visit three weeks previously where twins had been confirmed,
along with polyhydramnious. Medina was the first twin born weighing 900g; she
came out screaming and went straight to the breast and sucked well. Her sister,
the second twin, was stillborn weighing 3.6kg with hydrops fetalis evident.
There must have been a twin-to-twin transfusion.
Medina was really so small, that I really believed she would only live for a
few hours. She surprised us all. On day seven she weighed 750g. I gave Hawa
metoclopramide 10mg tds, as her milk supply had diminished, and it worked! Twelve
days later Medina was 1kg, breast-feeding well and looking like she might just
make it. Sadly, when she was thirty-six days old she got a chest infection and
died within a few hours. It's the stark reality of being born in a place without
neonatal support.
The artistry of midwifery has been passed through generations and is an inherent
part of practice in Sudan. I have witnessed midwives using the same tried and
tested methods for bringing on contractions; nipple and fundal stimulation,
walking, changing position, using acupressure points in the hands and feet.
They also mix 500g of sugar with about 500ml of hot water, to make a thick syrup
and give it to the woman to drink - it really seems to work. Sugar is to Sudan
as tea is to England, it cures all ills. One of the more unusual methods, which
I sadly don't think I will be able to bring home, involves the grandmother,
mother and any other women attending, all spitting on the labouring woman's
abdomen followed by rubbing it really hard.
When I get back home and friends and colleagues ask me, "What was it like?"
My answer will be so hard to put it into words. Professionally, there is no
fear of litigation, and so no defensive practice occurs. There are no laboratory
tests to rely on, no ultrasound to confirm your palpation. Your clinical judgement
is all you have, sometimes to solve problems and complications you have never
seen before. It's empowering. There is a genuine belief that you will do your
best without question. You are only seen as an instrument through which God
plays his tune. Inshallah.
The women of Kalma all labour and give birth silently. They have no access to
any pain relief, they deliver in a straw huts or tukals, without any electricity
or running water, through often long, difficult and arduous labours. Where does
the ability to cope with that come from? Khaltouma one of my very wise midwives
told me,
"We have a secret in our culture, it's not that birth is painful, it's
that women are strong "
I feel privileged and fortunate that my journey has taken me to Kalma. Midwife
means "with woman" - the truth over centuries; I've learned to value
how important that is here in Sudan.
Updated January 17, 2007 LW