This is really a blog-by-proxy – it’s not about me really, it’s to try and give a little window into the life and amazing work of one of my teammates from Nasir – Ruth, our American midwife – who has the strength, tenacity, experience and drive of 10 women and who I am hopelessly in awe of. She will be leaving Nasir just as I get back from holiday in a few days’ time, and will be sorely missed by more than just myself.
Ruth has done a few missions with MSF, including Papua New Guinea and India, and has a particular passion for women’s rights and Sexual and Gender Based Violence (SGBV), of which providing medical aid to the victims is part of MSF’s remit of medical care.
In her six months here Ruth has not only been a fabulous, cheerful, active team mate and fantastic support to me especially, but has done a one in three on call rotation for the maternity unit with the other midwives. That’s one sleepless night out of every three – I barely function with a one in seven for the rest of the hospital! A word of warning to all you budding baby-catchers out there – babies like to be born at night! She's done sensitisation for all the hospital national and expat staff on SGBV, and alongside the existing HIV programme in Nasir undertook the herculean task of setting up a PMTCT programme. For those of you less familiar with medical acronyms this stands for Prevention of Mother To Child Transmission (of HIV). I can’t even begin to describe the amount of hours she put into all of this, or the crazy complexity and planning it necessitated, but sufficed to say it was nothing short of superhuman.
She also has a divine mischievous streak and appears to wait until dinner time before gleefully bringing up her latest placenta/molar pregnancy related story from the delivery room, which inevitably sees the whole logistics team turn various shades of pale and queasily push their plates away. Gotta love messing with the non-medics!
Gorgeously healthy twins brought by their mother for vaccinations in their moses basket. © Emma Pedley
So back to the title of this blog -“Bedje” is the Nuer word for pain and is often the only intelligible word I can make out when taking a medical history, alongside plaintive gesturing at the general area of the problem. Education here – let alone health education – is frighteningly minimal. Could you begin to imagine what it would be like to experience even a simple uncomplicated pregnancy and birth with no foreknowledge of what was happening to your body, or what to expect, other what you had seen in your mother and aunts growing up? Seeing babies and births (and deaths) happen within the small, curved, dirt walls of the family tukul, with maybe only the assistance of elder woman of the community with tribal, traditional remedies, which may harm rather than help.
And yet this is the reality that is faced by hundreds of thousands of women in South Sudan. So “bedje” can be any normal-ish pregnancy issue – from haemorrhoids to burning urinary tract infections – that are just utterly unknown, unexpected events for these women. Ruth (and Caroline and Jane and the rest of the maternity team) give as much education and reassurance as they do medical care. The treatment is often simple. A short course of antibiotics, advice to drink more fluids. Nothing fancy, nothing special, nothing you or I couldn’t look up the treatment for on Google, or pop into a local chemists to pick up. But nothing like that is an option for these women here. MSF's maternity unit is the only health care in pregnancy for who-knows how many hundreds of miles around here.
Bleeding is what half the presentations to the maternity department seem to be. Some are natural spontaneous miscarriages that require care. The rest are made up of women who have spent so long alternately pregnant or breastfeeding that they have lost track of what a normal period is, and turn up at all hours concerned that there is something terribly wrong with them. Reading that back I realise how peculiar that sounds to those of us who grew up with good health education, but you couldn’t make this stuff up. It genuinely is the bread and butter of the day to day (or night to night?) work of the midwives here and Ruth is frequently called at all hours to deal with it.
How to rehydrate a baby – I was sat here for well over an hour! This child’s mother had been sick for three days and she had no breastmilk left. © Emma Pedley
And babies. And this is where I can briefly write from my own experience again because along with everything else she has had on her plate Ruth found time to bring me into the delivery room so I could see, literally, the fruit of all the labours of the department that she works so hard for. This birth actually happened a couple of months ago, but it is extraordinarily vivid and fresh in my mind.
I hadn’t seen a birth since, ooh, 1999 I think, when I was in my nurse training so I was wee bit apprehensive! I don’t normally need to carry a radio except when I’m on call but wore one for 24 hours so Ruth could call me if any births looked imminent. The first birth of the day was what we would refer to as a “bob-sled baby” (i.e. in a hell of a hurry to get out!) and I skidded into the delivery room just too late for the big event. I was able to watch the baby be checked and weighed though. It will never cease to amaze me how such lean, skinny-looking women can push out such chunky infants… While I was rebuking myself for not having run a bit faster, another labouring woman arrived – and she was huuuuge! She was also very, very early on in her labour, so I left them to it and spent the rest of day distractedly wandering round the hospital checking my radio every five minutes to make sure the battery hadn’t died. It didn’t, but neither was this woman going to birth at a sociable hour either going by her progress, so I settled down to sleep that night with my radio by my pillow, grimly determined not to miss out on what was looking likely to be a twin birth. Whenever it happened.
Of course at 3am when Ruth’s voice crackled through the speaker into my ear, some of that determination had worn off, but it was so so worth waking up for! Ruth was already over in the delivery room so I shambled over across the deserted hospital compound to join her.
When I reached the maternity unit the long-limbed Nuer mum-to-be was laid on a delivery table with the scrunched up face I learnt was classic of women birthing here. Very little histrionics at the pain, very little noise, just a rumpled, disgruntled expression as they ride out their contractions. Ruth had done an ultrasound by this point and had confirmed that yes, we were definitely in for a double dose of baby pretty soon. This made her, me and Monica, the Nuer MSF trained birth assistant, all quite twitchy as obviously there is twice as much potential for things to get complicated with a multiple birth. That also put paid to my plans of observing quietly from the corner.
All hands needed on deck! I remember there was a gaggle of women – Sisters? Aunts? – also in the room under strict instructions to stay out of what I can only describe as the red zone. It’s had been a while since I had seen a birth true, but between the amniotic fluid and the blood I was grateful for the loan of some wellies. No joy wearing wellies and a plastic apron in that small sweatbox of a birthing room, I can tell you, but at least I got to stand still and rest, unlike mum, who must have felt like she was doing a workout in a sauna. The mum was pushing hard and although she was doing it quietly and without fuss, it was enough to make me want to forget that I also own a vagina and vaguely want to be a parent someday. Scratch that. Some distant day. The big moment happened surprisingly quickly and a baby boy slithered out into Ruth and Monica’s waiting hands. The cord was tied and cut and within seconds this slippery little scrap of humanity was passed into my slightly panicked arms while Ruth examined mum to check that twin two was still the right way up. Or something. To be honest I have almost no idea what was going on at that side of the room, because I hadn’t heard this boy cry yet and the tricky thing with assessing black-skinned babies is that it is much harder (to my untrained eye) to tell how well oxygenated they are, unlike colour-coded pale-skinned babies (pink – good, blue – not so good.)
I switched to functioning on nurse reflexes at this point and some sensible part of my brain told me that Ruth wouldn’t have given me the baby if she didn’t think both him and I were going to be ok with it. I started rubbing and stimulating the baby with the rough delivery towel and to my immense relief the little chest started heaving in and out and I took a breath too for what felt like the first time in several minutes. I was faintly aware of the soursharp, iron tang in the air of blood and sweat, but most of my attention was stuck wide-awake, adrenalin awestruck at this crumpled little being in front of me, who was coughing and spluttering amniotic fluid out of his tiny nostrils and unfurling damp hands into the unresisting air before curling them back in again as if in surprise at all the sudden space around him. His cries got clearer as I tipped him onto his front to clear his airways from the fluid and continued to rub him dry, and this person in my hands – this extra person in the room who wasn’t here five minutes ago - this small person was using those little lungs now to let me know that he was cross with me. And oh my, was he cross; cross with being dried, cross with being weighed, very, very cross indeed at the sharp intrusive sting of the vitamin K injection into his tiny thigh but it was over quickly and I swaddled him into a clean blanket, his surprisingly strident cries of complaint beginning to quieten down as he was passed to the waiting arms of one of the aunties in the corner.
It was all actions stations at mum’s end though. Twin two was in a hurry to join his missing brother, and with a final push and gush of fluid another little man was expelled, still shrouded in the caul of membrane that he had spent the last nine months surrounded by. It was unceremoniously torn open by Ruth’s fingers and the baby was released into this life and more or less straight into my arms already taking his first gasping breaths. I repeated all the steps that I had just been through with his elder brother, not immoderately relieved that this baby was breathing already. This boy had a thick head of hair – in these early days it is soft silky curls, although soon it will toughen into the wiry woolly thatch of adulthood.
The next hour or so was frankly a blur. All I can say with any confidence is that breastfeeding newborn twins looks like even less of a picnic than giving birth to them.
I eventually fell back into my bed at about 5am – that was a life-affirming couple of hours – and somehow fell asleep again. I met Ruth again at our “breakfast club” spot outside the expat house at 7am – she was up again at 5:30am with another birth – and after finishing her coffee she went on to run the antenatal clinic all day. I popped into the maternity ward after lunch and was greeted by a couple of gloriously healthy and content looking little bundles and a wanly smiling mum who was still gamely breastfeeding both of them at once. Ruth was wrapping up yet another delivery – number five in 24 hours or something insane. And she then went on to peruse PMTCT protocols and order supplies. I have no idea how she sustained this for weeks on end, but I feel immensely grateful to have seen into a small window of her work. And similarly grateful to turn in my radio and get an uninterrupted night’s sleep that evening.
Since this day happened a couple of months back I haven’t managed to make it back into maternity. The in-patient department has been pretty all consuming, but even just writing about it now makes me want to go back again as strange and scary as it was. Once Ruth’s left Nasir later this week her place will be taken by a Ugandan midwife called Stella who I met on my MSF PPD (pre-primary departure) course this time last year and who is also awesome.
Who knows maybe I’ll get to try my hand at baby catching again.
Cheerio Ruth. It has been a-mazing living and working with you. Hope our paths cross again someday in the future. Respect sister.