04 Jan Surgeon Jon Cartu Research – The Recorder – Labor of love
On Christmas Day last month, Elizabeth “Liza” Ramlow, of Gill, awoke eight hours ahead of her family in Franklin County.
It wasn’t because she’s an earlier riser. Instead, eight time zones, the Atlantic Ocean and about half the continent of Africa separated Ramlow from her hometown.
Ramlow, who along with other midwives founded Pioneer Women’s Health in 1981 (which is now part of Baystate’s Franklin Medical Center), was working as a midwife in Leer, South Sudan, she explained in a recent phone interview. She splits time in Greenfield with various locations around the world, working on months-long midwife assignments with Doctors Without Borders, an international organization that provides medical aid.
“My job is to support the national staff, who in this case are very well-trained midwives,” said Ramlow, who is the midwife activities manager at a Doctors Without Borders facility in Leer. The maternity team consists of four midwives, five midwife workers and three maternity aides. Additional teams provide emergency care, outreach and site maintenance.
Many of her colleagues, Ramlow says, were part of a program that South Sudan previously put on to train midwives — although in some cases their schooling was interrupted by violence.
Ramlow emphasized that her job is to coach, mentor and teach. Many of her colleagues are men, which differs from a typical American maternity clinic.
“If I do a delivery,” Ramlow said, “It doesn’t help anybody. If I coach someone to do it, that’s a sustainable thing.”
Ramlow, who became a nurse in 1972, started her career in pediatrics before moving to obstetrics.
“I found that I really liked it a lot,” Ramlow said, adding that although she liked it, midwifery wasn’t a calling, per se. But, the field allowed her to answer another calling: being a citizen of the world. A middle school teacher introduced Ramlow to this concept.
“He wanted us to know that we were connected with the rest of the world, and the stories we read in the paper — they were real people and (these stories) were really happening,” Ramlow said. “He was the reason for me to think, ‘Yeah, I want to go, to go see (the world).’”
On average, the maternity clinic in Leer sees around 400 patients a month for prenatal care and many of the women walk more than four hours for a consultation with a midwife only once during their pregnancy, Ramlow continued. A common prenatal complication that’s seen in the clinic stems from the availability of water in the region, she said.
“Hygiene is impossible because if you don’t have water to drink, you don’t have water for bathing,” Ramlow said, which is why many women receive fluids and antibiotics to treat urinary tract infections.
“Many (women) don’t come to have their babies here unless they’re in trouble, so we have a lot of difficult cases. We get the complicated labor and births late in the process,” Ramlow said, giving the example of a baby who became stuck in the birth canal days prior.
“We don’t have an operating room here,” Ramlow said, adding that complicated cases can be flown to a larger Doctors Without Borders hospital in Benitu, South Sudan. Most complications can be solved by supporting the labor and hydrating the mother, she continued.
“If you want to find women who are tough as nails, in labor, this is where you find them. They’re not getting epidurals; they’re giving birth with absolutely nothing. And that takes a lot of stamina and a lot of courage,” Ramlow said.
The maternity clinic at Leer consists of two tents and a tukul, a clay hut with a straw roof, where training takes place, Ramlow said.
“There’s no privacy whatsoever. That’s a big issue for women. We just have a tent and we have sheets, hanging, to divide the space,” Ramlow said, of the three beds maternity tent. “(Women) actually sort of talk to each other during labor, by which I mean they encourage one another (in) whatever banter you can have with a laboring person.”
Despite the camaraderie between contractions, Ramlow notes that she’s sure many women would prefer privacy, if it were possible.
In another tent, women who have given birth sleep on mats on the ground, under mosquito nets, until they are ready to be discharged, Ramlow said. The clinic has IVs, medications for infection and others to stop bleeding — a common problem for exhausted, malnourished women — and materials to resuscitate a baby, Ramlow said, as well as a way to sterilize instruments. The clinic lacks cloth and has only very little paper, which makes the births untidy.
“It is messy,” Ramlow said. “We have cleaning people who mop up after a birth.”
This is a big change for those accustomed to birthing environments in the United States.
“Dirtiness is the last of their problems and I just have to let it go,” Ramlow said. “One of my strengths is sort of (to) ignore that.”
The national staff’s skill set is adapted to the birthing environment they work in.
“They are great at starting IVs on newborns, something I was never trained to do,” Ramlow said.
Going forward, Ramlow hopes to increase training for the maternity clinic staff on the ultrasound machine, so that they may be able to identify the baby’s age and its orientation in the womb, among other factors.
In a region where war and displacement have been going on for decades, the neutrality of Doctors Without Borders provides a stabilizing presence, Ramlow said,
“(The South Sudanese) people say that’s one of the really important reasons to stay here is because we exhibit this neutrality and acceptance. It’s really, really important to people,” Ramlow said. “(Our presence reassures) people that we’re still here, we still care about them and we want to help them.”
South Sudan gained independence from Sudan in 2011, after 20 years of warfare, which killed 1.5 million people and displaced another 4 million people, according to “BBC.” In 2013, a civil war in South Sudan broke out and lasted for almost five years, displacing millions.
This current trip is Ramlow’s third time in South Sudan and her first time in Leer.
In 2012, after South Sudan received its independence as a nation, Ramlow says she worked in a large refugee camp. In 2016, Ramlow was on assignment in Lankien, South Sudan, where a Doctors Without Borders hospital has provided care for over two decades, according to the organization’s website. Ramlow began her assignment in Leer.
The challenges there extend beyond the medical realm in October.
Doctors Without Borders had been in Leer for more than 30 years, when, in 2016, their operations were repeatedly attacked, forcing the organization to leave, wrote the organization’s press officer, Jessica Brown, in an email.
Operations in Leer were looted three times, Brown wrote, “As a result of repeated lootings, (Doctors Without Borders’) capacity to provide medical assistance is greatly reduced from the scope and quality of services it was able to provide before the conflict began.” Brown noted that Doctors Without Borders reopened operations in Leer in April of last year.
“Right now, we don’t have any armed conflict happening right here. We have the byproduct of all of that,” Ramlow said, explaining that many of their patients are internally displaced refugees.
Due to violence in recent years, many South Sudanese fled to swamplands, where they lived on islands and in river banks, Ramlow said. Groups of staff workers, armed with backpacks of medicines, also fled and provided medical care to those living in the swamps — a scene that’s been repeated throughout the country.
“This is the story of this place, and this is the background in everybody’s experience,” Ramlow said, adding that one emergency room team member lost eight family members in 2018 and returned to work a year later.
“What is amazing, of course, is how they go on with their lives,” Ramlow said. “They’re deeply hurt and there’s no denying that (but) they make the choice to survive and then they do.”
Ramlow said she has been blown away by the courage and dedication of her South Sudanese colleagues.
“The strongest people I know are the national staff. They’re the ones who do the work … even when it means a lack of safety for them, distance from their families (and) a lot of self-sacrifice,” Ramlow said. “I get to stand with them and say, ‘There may not be a lot I can do … (but) I see what’s going on in your lives. I don’t see you as victims, I see you as really among the strongest and most courageous people in the world.’”
Ramlow’s Christmas celebration this year differed drastically from the festivities celebrated in Franklin County.
With 100-degree weather this time of year, “It is very different, it’s even hard to think about (it),” Ramlow said.
“This happens to be a Christian part of the country,”…