In August 2019, I left the NHS to volunteer as a midwife in Kutupalong refugee camp in the south of Bangladesh. Approximately 909 000 Rohingya refugee are residing in 34 camps in Bangladesh's south-eastern district of Cox's Bazar, having fled systematic violence and torture in Myanmar (United Nations Office for the Coordination of Humanitarian Affairs, 2019). The move against the Rohingya people has been termed ‘genocide’ and ‘ethnic cleansing’ by international powers (Head, 2019), with an estimated 24 800 Rohingya killed by government forces since clearance operations started in August 2017 (Habib et al, 2018). Many Rohingya have witnessed atrocities committed against their families and community, with widespread rape, sexual violence, killings, disappearances, and torture of men, women and children.
I was volunteering with the HOPE Foundation for Women and Children of Bangladesh, a Bangladeshi charity created to provide healthcare for the most vulnerable women and children. Since it began, HOPE has built a women's hospital, numerous health centres in rural communities, and established a mother's club for promoting women's health and education. It is also in the process of building a new 40-bed maternity ward and obstetric fistula unit. Alongside this, HOPE established a midwifery school in 2013—the first of its kind in Bangladesh. At the start of the Rohingya crisis, HOPE attended to the health needs in the camps with a mobile clinic. Then, in December 2017, HOPE built a women and children's hospital at the edge of Kutupalong refugee camp. The facility has a delivery room, labour room, laboratory, pharmacy, two maternity wards, an operating theatre, and two paediatric wards.
‘HOPE built a women and children's hospital at the edge of Kutupalong refugee camp’
The trip from my accommodation to the camp could take between one-and-a-half to three hours, depending on traffic and rain. Roads are sadly neglected, with spine-jarring potholes ensuring that you lose a few millimetres in height with each journey. You catch sight of the largest refugee camp in the world as you come around a bend of red brick road. Rolling waves of tarpaulin and bamboo ascend and descend the hills, continuing into the distance. The shelters are tightly packed together, separated by a small path or some more tarpaulin. Privacy appears to be non-existent. Children run around or play in the small river that runs along the edge of the camp, the little boys often in various stages of nakedness.
The field hospital itself is a well-built, single-storey concrete structure. It is immaculately kept, with beautiful plants and a garden in the centre of the compound. There are western toilets, lunch is provided, and there is even WiFi and fans in the offices. The heat and humidity are oppressive, and sometimes the only thing that will cool you down is a sneaky 10 minutes in the air-conditioned operating room. I am taken to the birth centre where I am shown the labour and delivery room. It is small, with old-fashioned equipment, but has most of what you need to mitigate and deal with obstetric or neonatal emergencies. Posters line the walls explaining hand hygiene, managing a postpartum haemorrhage and how to give magnesium sulphate to a patient.
The resuscitaire is a small table with a little plastic mattress, a bag valve mask and a manual suction tool that looks like the top of a turkey baster. The labour beds seem to be designed with the comfort of the healthcare practitioner in mind. They are very tall, requiring steps for women to be able to get onto them, and have a thin plastic mattress covered in a plastic sheet. The bed offers little in terms of labour positions, with the only options being lying flat or at a 45° angle. There is a birth chair in the corner of the room, however, it seems little used.
‘The labour beds seem to be designed with the comfort of the healthcare practitioner in mind’
Midwives are in charge of the birth centre, supported by an obstetrician and anaesthetist in case a caesarean is indicated (instrumental deliveries do not take place for reasons I never discovered). The majority of staff are Bangladeshi, with a few international staff in supporting roles. I spend much of my day observing clinical care, seeing low-resource midwifery at work. I observed caesarean sections in the field hospital operating room, marvelling at the minimal equipment and reusable gowns and drapes. Nearly all equipment used in deliveries and caesareans is sterilised or washed and re-used. In a setting such as this, it is highly logical. Medical equipment is expensive, something that we are mostly sheltered from within the NHS, and there is no proper waste disposal.
My first experience of providing labour care to a Rohingya woman was not long after I had started at the camps. She was a 20-year-old primip, with a wonderful tie-dye headscarf, who had managed to get to 7 cm before her cervix had pumped the brakes and not dilated any further in over four hours. She was being supported by her sister, and although neither of us understood what the other was saying, we managed to communicate remarkably well in encouraging her sister to try a variety of positions in an attempt to get dilation started again. She was silent with each contraction, leaning on her sister for support and would slowly walk around the room, swaying her hips.
I would mimic different movements and positions for her to try, much to the amusement of the traditional birth attendants. The woman would look at me and say something in Rohingya to her sister, who would laugh but then turn stern, talking quickly to her sister and moving her into the positions I've suggested. I think I had a supporter. The labouring woman and I go about like this for the next couple of hours, me suggesting positions and movements, her reluctantly trying them out with the positive encouragement of her sister. She would mostly be silent, except when she got a cramp. She would call me to her and point to her leg, motioning for me to rub (I received a swift chastising if I was not quick enough).
Hours passed with still no progress. Obstructed labour is a common obstetric complication within poorer communities, where early marriage, childbirth and malnutrition are common traits (Neilson et al, 2003). For this, the only real course of action is a caesarean. For a young primip, this is not a decision taken lightly. I was informed by one of the doctors at the camp that once a woman has a caesarean, all her subsequent deliveries will also be caesareans. For Rohingya women who may go on to have six or more children, it is a complex issue. However, the decision was made, and she was moved to the operating room where she delivered a healthy baby girl. I will forever be in awe of this young woman with the tie-dye headscarf, who laboured silently and without complaint, getting on with what she had to do, supported by the women around her.
Amongst happy deliveries, there were also terribly sad moments. I came into the birth centre one morning to find a woman being examined by ultrasound. The midwife had been unable to detect a fetal heart rate, and the woman had just been told that her baby had died. Upon reading her notes, I saw that this was to be her fifth stillbirth out of eight pregnancies. With a lack of medical intervention or antenatal care, this woman had continued to become pregnant and lose her babies due to a potentially very solvable problem. The complexity of the situation increased, as when it was suggested to her that she could use contraception, she replied that she could not without her husband's consent. Use of contraception in Rohingya society is a subject that must be broached with great tact and sensitivity. Religious leaders and elders of the community hold much sway in this area, and have been reported to state that attempting to limit the number of children born is a ’sin’, with sentiments such as ‘women are born to bear children’ being commonly expressed (United Nations Population Fund ([UNFPA], 2018).
‘I will forever be in awe of this young woman with the tie-dye headscarf, who laboured silently and without complaint’
Regardless of this, women appear to have little choice in the matter, with husbands and mothers-in-law found to be the most important decision-makers regarding contraceptive use and reproductive health-seeking behaviour (UNFPA, 2018).
Different standards of care is a complex issue to explore. In the UK, the training of healthcare professionals is enhanced by the high-quality equipment, medicine and facilities that are provided by the NHS. In countries such as Bangladesh, healthcare professionals have to work with what they have, rather than what they need.
Cultural powers also play a role in the general working of a hospital or clinic. All midwives in Bangladesh are women, purely due to the nature of the job and prevailing conservative attitudes within communities. During my time at the camp, I was informed that the male doctors are not allowed to touch Rohingya women outside of surgery, or even ask them intimate questions, which means that they use purely observation and a middle woman who whispers the more personal questions to the woman in labour, waits for the reply and then whispers the response to the doctor.
‘Cultural powers also play a role in the general working of a hospital or clinic’
Upon speaking to the midwives, I learnt that some of them had had a hard time in persuading their parents that becoming a midwife is an acceptable occupation. Whereas women in the UK have long been part of the workforce – and are a valued and acknowledged force of nature in various aspects of the industry – women in Bangladesh have had a harder time getting their voices heard. This, in my opinion, leads to a well-defined hierarchy between doctors and midwives, exacerbated by a tiered hospital structure similar to UK maternity care in the 1960s, leaving midwives with nowhere to turn if they disagree with a plan of care.
This defined hierarchy, in my opinion, led to an intensely difficult event that I am sure will remain with me for a long time. I arrived at the birth centre and was told by one of the midwives that a woman had been admitted with a face presentation. I had expected the face presentation to have been diagnosed with a vaginal examination with still some cervical dilation to go. However, upon observing this woman at the height of the contraction, vaginal gaping was obvious, with a very squashed mouth and chin appearing with each involuntary push.
Now, at this moment in time, I knew very little about face presentations. It is only afterwards that I did some research surrounding management. However, evaluating the situation before me, I thought a caesarean would almost certainly be indicated. The midwife looking after the woman had repeatedly appealed to the doctor to operate but was dismissed, being told that most face presentations can deliver vaginally and that the baby will die if they operate. The proceeding two hours consisted of my witnessing care that involved what I can only describe as aggressive fundal pressure, repeated unnecessary vaginal exams with zero sterility, and the fetal heart rate ascending to hover around 190 bpm.
Meanwhile, this little face was becoming more and more swollen. Finally, the doctor agreed to do the caesarean after it was clear that no progress was being made. It then took another hour to track down the anaesthetist. This baby was finally born, alive, trying his very best to breathe.
His face was purple, skin peeling from his cheeks from the prolonged swelling and a huge lump on his brow where his head been compacted against the anterior bones of the pelvis. He was rushed to the paediatric ward where the plan was made to transfer him to the neonatal intensive care unit in another field hospital an hour away.
He was put into the arms of his grandmother who would be making the journey with him. Shock, sadness, confusion and resignation lined her face. She looked to be no stranger to hardship; however, this was a different kind of suffering. I tried to reassure her as she got into the minibus for the hour-long journey. Language was no barrier here, looking into her eyes with one hand over my heart and one on her shoulder hopefully expressed what I could not put into words.
I went back to the operating room to see how the mother was doing. The doctor was sitting on a bench and asked casually how the baby was doing. I wanted to rant and rage about her delay in deciding to operate, to tell her that this situation could have been avoided. I paused and then replied that the baby was breathing and had been transferred out, and then left the operating room. I was informed two days later that the baby had died.
Being involved in aid work in another country requires a good deal of tact and sensitivity on your part. I was acutely aware that I didn't understand local norms, customs and culture, and thought that it is wiser to take a step back and imitate a sponge whenever faced with a new experience.
To look at things through privileged eyes, knowing that I can leave this desperate place and go back to the (for the most part) well-funded, efficient NHS with high standards of care means that I am not in a position to judge anyone as to how or why they act as they do in aid scenarios.
I saw care that I was shocked by, but context must be taken into account. Is the care this woman is receiving still better than her not receiving any care at all? My previous story leaves this open to debate. In Bangladesh, 62% of deliveries are at home and without a skilled birth attendant (Sarker et al, 2016; Perkins et al, 2018). Bangladesh has a maternal mortality rate of 173 in 100 000 and a neonatal mortality rate of 17.1 in 1 000 (World Bank, 2019a; 2019b). Within the Rohingya community, where conditions are even more fragile, it would be realistic to assume rates are worse.
I value the time I spent in Bangladesh immensely. It may have not always been enjoyable, but I learnt a vast amount. I experienced a different, complex and chaotic country and witnessed the incomprehendingly difficult situation that the Rohingya have been forced into. I enjoyed the giddy highs and worked my way through the crushing lows that come with being a midwife.
Most importantly, I met some truly wonderful people. I cannot describe the strength of the women I met, and I feel so privileged that they let me, however briefly, into their lives. Our unbelievable luck at belonging to a country that has a working healthcare system, that is entirely free, is a resource that we should never take for granted. We must value and protect our NHS and understand the privilege of our situation. For the Rohingya and much of the rest of the world, such care is entirely out of reach.