A bright moon is shining into my room in Kirkuk. The street traffic is quiet tonight, but I can hear the chant of prayers from the mosque, despite the noisy air conditioning and house generator.
I reflect on my day in the maternity ward.
Four babies were born, ranging from 1.8kg-4.5kg (4lb-10lb). I think about the women we had to refer to the regional hospital, and wonder did they get there safely.
In January, I took leave of absence from my role as community midwife manager at the National Maternity Hospital and came to Iraq with Médecins Sans Frontières (MSF). This isn't my first time working with an NGO. I was a paediatric nurse in Somalia and Uganda between 1993 and 1995, but came home to train as a midwife when I saw the contribution midwifery could make to women's lives globally. Since then I have worked in Sierra Leone with Concern, Cambodia with MSF, and Afghanistan with Merlin.
I have seen women pregnant, and give birth, in the most difficult of circumstances, and I remain in awe of women's resilience in adversity. An innate maternal survival mechanism comes to the fore in famine-stricken, disease-ridden, and war-torn countries. I also see this resilience in Ireland when women receive a difficult diagnosis.
This is my first time in the Middle East, and I have been greeted with warmth and respect. I feel welcomed. It's very different to Africa or Asia, but I find that everywhere is different but the same. People are people. Just like at home, staff on our ward – all female – like to sit together and chat about our families and friends.
I have joined a project for people displaced by the war, who are returning as their villages and towns are rebuilt. MSF works to improve the healthcare system destroyed by war. In many places, centres don’t have enough medication or trained staff, or the buildings themselves have been damaged. My role is with sexual reproductive health services and there are three goals: improving maternity services within the region’s referral hospital; developing services for sexual and gender-based violence survivors; and the re-establishment of antenatal and postnatal care in a primary healthcare centre.
Baby’s heartbeat
Some areas are still unsafe, both where we work and where we live. I’m usually woken by the first call to prayer at about 5.45am and my working day starts at 8am. It’s only a few minutes’ walk to the MSF office and I certainly don’t miss the Dublin morning traffic. From there, it’s about about an hour-and-a-half drive to Hawija hospital through checkpoints manned by Iraqi security forces.
All of the Hawija midwives are qualified nurses learning about midwifery on the job. I am doing lots of on-the-job training, focusing on simple things like taking a temperature, and knowing where to find the baby’s heartbeat.
At the moment, care is exceptionally basic and I regularly have to reiterate the need to listen to the baby’s heartbeat. I am also surprised at how interventionist it is. The midwives administer drips to all women, and give drugs to speed labour, though these can add to the discomfort and pain a woman feels in labour - and there is no pain relief. There are no epidurals, even for Caesarean sections, which are performed under general anaesthetic.
As we’re in a ministry for health hospital, our role is to advise. We might suggest “why don’t you help her off the bed so she can move about?”, or “why don’t we show her how to squat?”. Invariably they tell the woman, “squat just like we do at home”, so they know how to do it. We do a lot of reflection after births to help them understand how they might have assisted a woman more. What I’d love to see is the women being empowered again to use their innate ability to give birth, and use pain-relieving strategies in labour.
As I have seen as a community midwife in Dublin, home births can be magical. Lots of women here give birth at home, but they hire private practitioners – some without any formal medical or midwifery training – and have exactly the same interventions as they would in the hospital. You can buy anything you want for labour – including diazepam and oxtyocin – in the market here without prescription.
Road curfew
Referrals into the larger Kirkuk hospital are high, because specialist care is often not available. The hospital has an ambulance service for urgent cases, but usually families find their own transport, travelling a road that has an 8pm curfew for security reasons.
Many of the mothers we see are poor and uneducated, and might be having their sixth or seventh baby. Contraception isn’t culturally acceptable. However, there is currently no routine antenatal care here – regardless of how high-risk the pregnancy.
Usually, the first time a woman attends the hospital is in labour or when her waters have broken. There will be no medical file, so a verbal history is taken from the woman herself, or from the female companion – generally her mother-in-law – who accompanies her for the birth.
When ready to push, women are transferred to the birth room, and then quickly on to the postnatal room. Families provide all the bed cloths, food and drinks and the women normally request to be discharged within two hours.
New mothers go home to their families to be cared for, traditionally remaining with them for 40 days. A lot of Irish women feel isolated after birth. These women have their families around them, doing the laundry, providing food, supporting breastfeeding. We could learn from them. They have no agenda to get out and about.
Their only job is to care for and feed their baby.
There is a huge diversity between the Iraqi women I meet in the hospital and those I work with in Kirkuk and MSF. These are exceptional, educated, empowered women. They may or may not choose to cover their heads. They all come from families who promote equal education. They tell me how the war has made Iraqi women even more resilient, how they are encouraging girls to stay in education, and how helping others has contributed to their own healing. This gives me real hope for the future of Iraq.
I know I can change very little in the short time I will be here.
However, I hope to share some of my midwifery skills and knowledge to help improve maternal care in some small way.
– In conversation with Louise Ní Chríodáin
