Janet Coleman is a Midwife and has worked in South Sudan and Chad
Janet Coleman refuses to accept the lead-up to retirement should involve a gradual winding down of pace. Instead, the 58-year-old midwife has reignited a passion she held as a youth for volunteering and is making a difference to the lives of thousands in developig countries, working with Médecins Sans Frontières. "I knew from an early age I would end up in nursing, as I wanted skills that would enable me to travel. I began my training in New Zealand but quit after being involved in an accident. When I turned 20 in 1971 I took a boat to South Africa. Arriving wtih only $300 in my pocket, I went to the large general hospital in Johannesburg to see about any nurse aid jobs. They suggested I do my nursing training and arranged a work permit."
In 1980, a year after completing her midwifery training, Coleman was travelling around Asia when she learned of a need for people with obstetric skills. "I'd heard from other travellers of a need in the refugee camps on the Thai/Cambodian border. Médecins Sans Frontières was responsible for obstetrics in the Khao-I-Dang refugee camp and I was tasked with establishing antenatal clinics throughout the camp, which at its peak held 120,000 Khmer refugees, and working in a busy delivery suite," she says. Following a break from this kind of work to raise a family, rather than preparing for retirement, Coleman felt it was time to put her skills to use in a different setting again.
"In 2005, I signed up with Médecins Sans Frontières again and was sent to Akuem in southern Sudan for six months. I was the midwifery supervisor, serving a catchment community of 300,000 people. I remember landing in this remote African village and being swept with an overwhelming feeling of isolation, wondering what on earth I had done leaving my family for six months. There was no internet access or cell phone coverage. I compared it to being on the moon but hot. The care was opportunistic - 'meet, greet and treat' scenarios. The hardest times were when women were in obstructed labour and we had no way of transferring them out. There never seemed to be a plane when needed. It was a most challenging but rewarding experience, due to the remoteness and the lack of surgical facilities." The Médecins Sans Frontières team saw many challenging obstructed labours because women did not seek help from the bush hospital soon enough.
" I remember landing in this remote African village and being swept with an overwhelming feeling of isolation, wondering what on earth I had done leaving my family for six months"
No surgical facilities
"There was an absence of surgical facilities, and often women had been in labour for three to six days, by which time the baby had died. To ensure the health of the woman and prevent haemorrhage and infection, we performed a destructive procedure. Unfortunately a number of these were necessary and became part of my scope of practice." In two cases symphysiotomies were performed when the baby was alive with a woman in obstructed labour. "This involved an incision to divide the ligaments of the symphysis pubis to increase the pelvic diameter to help assist in the safe delivery of a live baby in an obstructed labour where there is no facility to do a caesarean. Thankfully, there were good outcomes in both cases." Coleman recalls with sadness the number of relaives who brought babies whose mothers had died giving birth, to the hospital, in the hope the babies would be fed. But with no spare milk, this was a death sentence. "Sometimes we could persuade a relative who was breastfeeding to breastfeed another. There was a lot of education and translation to achieve this."
In 2008 Coleman was sent to Am Timan in south east Chad for four months, where Médecins Sans Frontières was working in partnership with the Ministry of Health. "Here I was responsible for three antenatal clinics in the surrounding countryside and for supporting the delivery suite and maternity ward in the hospital, for a catchment of well over 50,000 people. The most rewarding of these roles was visiting the most distant clinic. It was a two-hour drive along an almost invisible dirt track, and the village was cut off from health services for six months during the wet season. "The villages en route knew when the Médecins Sans Frontières truck would be passing and the journey was always interrupted by villagers running out to stop us for medical attention. However, there were always more women to be seen than time would allow and there was always someone who needed urgent treatment, like a child with malaria or someone who had not delivered the placenta following a birth."
Last year Coleman returned to southern Sudan to Aweil, a town now about 40 minutes drive from Akuem, thanks to new bridges over three rivers. She was there for six months as maternity manager on a maternal and child health programme reaching an estimated target population of 800,000. A visiting obstetrician calculated the team was seeing only about 30 per cent of complications, because women simply could not make it to the hospital because of the distances they had to travel. No other facility or organisation was providing obstetric care and many complications were occurring at village level. "We saw many obstructed labours and there was a high mortality rate of women with Hepatitis E who were either pregnant or had recently given birth. This was because there was no sewerage system and a contaminated water supply. Approximately one in 100 women died in hospital from pregnancy-related causes or accidents. If women arrived at the hospital in time, there were better clinical outcomes than if they waited. I remember an obstetrician, completing a maternal death report, wrote for the cause of death: 'She turned up to the hospital too late.'
"One particularly sad case I recall was a woman who was five months pregnant. She had been returning home through a field when the wind changed and she became caught in a farmers' burn off. Her family bought her in covered in dirt and with 70 per cent burns to her body. The only part not affected was her abdomen that she had been trying to protect with her arms. She lost her baby the next day. Her care was so time-intensive we showed the family how to care for her. When our bandages ran out we had to buy sheets from the marketplace and rip them up. She never complained and was fully conscious. Her family stayed with her until she died on the 10th day, and then the family invited us to celebrate her life with them. She had three surviving young children." Despite the vastly different locations Coleman has worked in, she has found many of the challenges to be similar. "When working in developing countries or politically unstable areas, human resources can become a real issue. For example, in Akuem, many staff members were inadequately trained or had received on-the-job training. The first midwifery school in southern Sudan opened in May 2010. The training is paid for by overseas donors but there is little funding for living expenses. Most people are very poor, so it is a real struggle to just live, let along gain some education."
"Thankfully, these challenges are often overshadowed by the rewarding aspects of this work - achieving good outcomes under adverse conditions. People are also very grateful to receive care, which they know they probably wouldn't get if we weren't there."
Job descriptions can be very broad when working in the field. "You deal with people who have diseases and ailments you've never seen. Before working in Akuem, I never knew how to care for a baby with neonatal tetanus or a pregnant woman with a scorpion or snake bite," she says. "I have also found that basic clinical skills may be needed far more frequently than they would at home, such as resuscitation of a woman or newborn. You may be providing emergency care around the clock. The work you do on a field placement in many ways can't be compared to normal nursing at home. They are completely different roles. There are many opposites: you have to expect dirt, dust and usually heat, coupled with unpleasant smells, rather than a sterile environment. You may be working with poorly trained or untrained staff, but they are extremely dedicated and hard working. There are no real set hours of work. There is never just one 'worst case scenario' and security is usually a problem to some degree."
Innovative and creative
Finding solutions to problems is a big part of the role. "How to you protect the overflow of patients waiting in a corridor when it rains? Where do you put patients who may be contagious, or where in the ward to you place a patient who you know will die? You have to be innovative and creative." For many field staff, the hardest part of the job is being separated from family and friends, but psychologists warn returning home can be more difficult than going, especially if you have been working in a conflict zone or extreme poverty. "While in the field, work is the prime focus. Returning home, work may seem less stimulating and this is part of a culture shock that lessens over time. You also have to quickly adjust to a highly regulated and structured medical hierarchy, which can be difficult when you've had so much responsibility," Coleman explains. "Thankfully, these challenges are often overshadowed by the rewarding aspects of this work - achieving good outcomes under adverse conditions. People are also very grateful to receive care, which they know they probably wouldn't get if we weren't there."