Australian Midwives

by Paula Heelan

  The health centres operate similarly to a general practice in an urban area, with consultations during office hours, but with a couple of exceptions. ‘Firstly there are no appointment times,’ Kate says. ‘It’s first in first served – although as the midwife I do see the maternity women before other patients. Secondly, there’s no other health facility or hospital on the island so we have to act as an emergency department as well, day and night. Health staff need to be sensitive to the fact that unlike in urban areas, the local people don’t have a choice of health delivery service – we are the only option. All the nurses are rostered “on call” for the after-hours and weekend calls. Up until a few months ago the island only had a locum doctor service, which left the community for weeks without a medical practitioner. We have an emergency room, but there’s rarely a doctor on hand after hours. Air evacuations are quite common for the acutely ill requiring 24-hour care or pregnant women in labour.’

  For the most part, when Kate’s on the island she’s on call every second or third night and one day on weekends. The other factor is that as the sole midwife she is on call 24/7 for maternity women. And when she’s on call she is on duty on her own most of the time. ‘You learn to cope,’ she says. ‘You just do what you can. If anything goes pear-shaped you can call a colleague.’

  In almost all communities the nurses have to drive the ambulance, which is a converted Toyota troop carrier. Having a driver’s licence to operate a manual vehicle is essential. ‘On the island we are the only permanent emergency service, with the police having to come from a nearby community, which is only possible during daylight hours,’ Kate explains. ‘Driving on the sand-hill to the houses on the island can take a little bit of getting used to.’ Kate’s experience driving a four-wheel drive on the farm has stood her in good stead many times in the wet season.

  One night in 2011, near the end of the wet season, Kate was in a Victoria River community when a CareFlight plane couldn’t land for a patient retrieval due to bad weather. In the two-bed emergency room Kate had a child on the bed with kidney problems, his mother on the floor, another unwell baby sharing the other bed with her fifteen-year-old mother, and her companion escort was on the floor. ‘Since the plane wasn’t able to land on the wet airstrip at night, we put in an all-nighter. There were no mattresses for the floor, just a blanket – but all my patients and their carers managed to sleep.’

  The women in the remote areas Kate works in are the backbone of the communities and provide strong support for each other. ‘I’ve noticed if the women say jump, the men ask how high. Generally they respect the women’s decisions and wisdom. There is, however, another side to male and female relationships in remote communities, which I believe stems largely from idleness. Many men are unemployed and so become more controlling of the girls and women. It’s very sad to see many teenage girls quite disempowered; they’re coerced into a sexual relationship, which often results in a pregnancy. Girls as young as thirteen are having babies. Their bodies haven’t matured and emotionally they’re not prepared for parenthood. The biological fathers rarely support the girls, often not admitting to paternity. With this situation there comes a whole raft of problems for the families.

  ‘If the baby is a result of non-consensual sex then there is anger and frustration on the part of the girl’s family. The grandmothers often know who the father is, but what are their choices? The kinship system is a complex organisational system that determines how people relate to each other and their roles, responsibilities and obligations in relation to one another, ceremonial business and land. The kinship system determines who marries who, ceremonial relationships, funeral roles and behaviour patterns with other kin.’

  Today there are increasing numbers of ‘wrong skin’ marriages, in which people who would traditionally be prevented from marrying become partners. ‘The whole kinship arrangement is fractured and when pregnancies occur with the wrong skin it’s a difficult situation. The girls themselves are ashamed and don’t know how to present to the clinic. Again support is often left to the grandmothers.’

  A couple of years ago a woman came to see Kate concerned that her fifteen-year-old daughter was spending her nights out with friends. She was worried about the risk of pregnancy and wanted her daughter to have a contraceptive implant. ‘We made several unsuccessful attempts to bring her to the health centre,’ Kate says. ‘The next time I saw the young girl she came to see me with her grandmother. She tested positively to a pregnancy test and an ultrasound showed the pregnancy was advanced to a stage where even if she had wanted to terminate, it wouldn’t have been safe for her. The grandmother more or less took it in her stride, and the girl, who had guessed she was pregnant, took the news calmly.’

  A couple of weeks later the girl’s mother brought her back to the health centre with her two younger siblings to see Kate. ‘I had known the youngest girl since before birth. I presumed the mother had come to talk about the pregnancy, but she didn’t offer any information. So when she asked me if her daughter could have the contraceptive implant that day I was completely taken aback. My face spoke a thousand words. She looked at me and said, She’s not is she? Her daughter was only fifteen – she had to have an escort to travel and the pregnancy had to be reported to authorities. It was indeed a difficult few moments.’

  The family left the health centre and the mother returned a few days later, clearly upset. ‘She said, I’m too young to be a grandmother. She was 32. We had quite a discussion. She felt betrayed that her mother hadn’t told her of her daughter’s pregnancy. I knew enough background to quietly ask, Did you tell your mother when you were pregnant at that age? She hadn’t – she had left it to another relative.’

  When difficult situations like this arise, there is no reprieve and families understandably have trouble coping. ‘The young girl went on to have her baby and relationships were restored – but it did take some time,’ Kate says. ‘The mother’s hope was that her daughter would finish school and go away to study – unlike herself. She had fallen pregnant while away at school in Darwin and had to return home before finishing her education.’

  It might be hard to believe that a young girl could mask her pregnancy from her mother for so long, but the women wear long, gathered skirts, often with two or three layers. Two layers hang from the waistline and another over the top hangs from above the bustline with only a T-shirt underneath. So it can be quite difficult to tell if a girl is pregnant.

  With one family there was a rather surprising turn of events. Gay was expecting her fourth baby and her pregnancy was complicated by gestational diabetes. Kate found Gay quite difficult to engage with and wasn’t sure that she was very happy about being pregnant. ‘She didn’t want to know about the diabetes,’ Kate says. ‘She worked at the store, so the prospect of having to regularly travel to the tertiary hospital for monitoring didn’t suit her. There didn’t seem to be a partner for support, although she had two sisters who were very helpful, and eventually a little boy, Ken, was born.’

  Soon after Gay and Ken returned to the community Gay was back at work with Ken left in the care of Gay’s two sisters. Ken had a few minor problems and needed admission to the tertiary hospital for growth faltering. As time went by Kate began to wonder if Gay’s sister, Mandi, was wet nursing the little boy. Then one morning a local woman rushed into the clinic and said, Kate – a baby! ‘To my utter surprise, Mandi was brought to the clinic with a baby girl that she had birthed at home. There was quite an anxious period when I had to deliver the placenta with Mandi bleeding quite a lot. But mum and baby were safely transferred by aeromedical evacuation to the tertiary hospital. It was a happily-ever-after story with some wondering how on earth I could miss a woman’s pregnancy. But it can be masked well with multiple layers of skirt.’

  Travelling to and from a tertiary centre to see an obstetrician can be very difficult for women with problems during their pregnancy – and so it was for Beryl. ‘She had a son and daughter who I knew as babies. Over the l
ast couple of years she had lost a baby at eighteen weeks and then twins at 21 weeks, so when she presented to the clinic in early pregnancy we wanted to give her the best possible assistance for a happy outcome. We achieved this but it meant many trips to the tertiary centre for Beryl which was very disruptive for her family life. She endured the ordeal with grace and good humour and, at last, Sylvester was born at 34 weeks gestation and continues to grow beautifully.’

  Recently, Kate was surprised and humbled when Beryl presented her with a genuine Yolngu basket, made by her sister. ‘Beryl said the children wanted to give me a present – for me, this was a huge honour.’

  In Indigenous communities the men hold ceremonies and traditional circumcisions still occur. Boys are initiated into manhood in a cycle of ceremonies where they are taught traditional songs, dances and dreamings. ‘They’re taken out to the bush where rituals and bush craft are learned, which takes place over many weeks or months,’ Kate says. ‘The coastal people have quite different cultural beliefs and traditions from the desert people.’

  One night Kate was woken by the sound of clapping sticks and corroboree chanting. ‘A final ceremony was taking place before the boys would be taken out bush. My phone rang at 4.30 am. Someone had been burnt. I suggested they apply cold water. But the caller said, No, Yapa [nurse or teacher] really bad burn. I said, Okay, I’ll come down.’ As part of the ceremony the men had been burning leaves while other men were jumping over them. In the process three men’s legs were accidentally burnt. ‘When they came in to the health centre I sat two on the floor on towels wet with cold water and put the worst burns victim on the bed. I kept applying cold water and then one after the other, I bandaged them. In mainstream hospitals you don’t tend to treat people on the floor. In remote nursing you make the best possible decision for the patient and one of the principles of burns first aid is to apply cold water over a lengthy period as soon as possible – so you get quite inventive.’

  Doctors and nurses, locally trained or not, abide by the cultural rules and health-centre protocols. ‘With limited resources at the clinics, the Aboriginal health workers are an invaluable resource and provide vital assistance,’ Kate says. A program she has been involved with called Strong Women, Strong Baby, Strong Culture has made a difference in communities. Kate works with a community strong woman (a senior woman) in Milingimbi, Judy Lirririnyin, and together they provide the best outcomes for the local women. Judy says she and Kate learn from each other. ‘I help Kate with language translation, patient history and cultural ways and she teaches me about Western medication and care. We have a lot fun as we work – and together we work out the best way to care for the patients and expectant mothers.

  ‘The idea is to support the health and wellbeing of pregnant women and children up to three years of age,’ she says. ‘There’s a lot being done now to strengthen family units and cultural practices and to prevent and promote early intervention of lifestyle illness and disease before, during and following pregnancy.’ The program recognises the traditional cultural approaches to parenting and lifestyle, supporting pregnant Aboriginal women and their babies through better diet, education and antenatal care. The aim is to increase the birth weight of babies and improve early childhood development.

  The program relies on and supports senior women in participating communities in providing direct support to pregnant women and their families. ‘The senior women encourage attendance at the health centre for regular antenatal care and provide advice on nutrition,’ Kate says. ‘The program has a long-term outlook with lasting benefits rather than only treating immediate health problems.’

  Kate works in communities steeped in tradition. ‘I was consulting with a young pregnant woman who had quite a complex medical condition recently. As we were talking she said, You know sea turtle? I said, Yes I know the sea turtle.

  ‘Yes, sea turtle, that my dreaming, she said. There didn’t seem to be a connection between her medical condition and the sea turtle and I worried I may have missed something in the translation. It was clear though, that it was important to her that I knew her dreaming.’

  The significance of dreaming came up again for Kate at a later time when a woman she had looked after throughout her pregnancy came to the clinic to see her shortly after she arrived home from hospital with her new baby. ‘The baby had a parrot feather entwined into the fringe of her hair. It must have been held with resin of some sort because the feather was well and truly stuck to the hair. I asked if that was her dreaming. No, she said, my dreaming is crow. I must have looked a little surprised because I hadn’t heard of the crow for dreaming. Then to clarify her point she stood up and performed the perfect rendition of a crow mildly flapping its wings and jigging from one leg to the other. We both fell about laughing. Then we discussed the meaning of the feather and she told me it draws the wisdom of ancestors while the baby sleeps. The parrot, she said, was her husband’s father’s dreaming. Whenever I am taken into cultural confidence like this I think, What a great thrill and privilege.’

  Family relationships are complex in Aboriginal culture. The social structuring and relationships between people is known as the kinship system. It allows each person to be named in relation to one another. When Aboriginal people accept an outsider into their group they name that person in relation to themselves in order for the person to fit into their society. They like to know in their own minds what the kinship relation of that person is to them and that person must have a defined social position.

  A woman with whom Kate had become friendly came to see her at the clinic one day. ‘She wrote me a little note asking to adopt me as her sister,’ Kate says, smiling. ‘My first thoughts were, I wonder what the culturally appropriate way to respond is? In another community I had been given an endearing name but not invited into someone’s family so profoundly. I thanked her and tried to explain how honoured I felt. The cultural aspect still concerned me so I asked my strong woman friend and teacher (my Yapa) what I should have done. She patiently and kindly explained, Nothing, you just have to be like a sister and friend. My Yapa has taught me a great deal about Yolngu culture and she tries valiantly to teach me the language of Yolngu Matha. When I am in the community and hearing the language all around me, I can pick up quite a few words.’

  Subsequently, the children and young people of her friend’s family and extended family call her Marnyi Bonba (Grandmother Butterfly). ‘The name is apt because I do fly in and fly out on a regular basis. The older women of her family call me Bonba. There is quite a complex set of rules for the names people are called inside and outside the family or clan.’

  Once on a quiet Sunday morning there was a sudden, torrential downpour in the community Kate was in. ‘It was pretty impressive and the gushing water afterwards, likewise. After lunch, I took a walk out the back of my donga [a small transportable building] towards the river with another couple, a nurse and a teacher. We came across a bunch of small boys excitedly catching loads of fish. The fish ranged from three to ten centimetres long and were jumping all over the grass and the road. I raced back to get my camera. When I asked the boys where the fish came from, they chorused, The sky! I really thought they were pulling my leg. A man came along with his son and they began to put the fish into an old milk bottle as fast as they could catch them. I asked them the same question – Where did the fish come from? The man said, From the sky after the big rain! I took his word for it. He told me he had a large dish that he grew fish in then he put them in the river for catching later.’

  There is in fact a meteorological explanation for the phenomenon. Scientists say it happens when a waterspout (or tornado) sucks water into a cloud which retains the water until the cloud passes over a warmer ground temperature and it rains. In 2010 it was reported that hundreds of live spangled perch rained down upon the town on two successive days. A tornado was believed to have sucked up the fish, which were then frozen at high altitudes and thawed as they fell – which might have been hundreds of kilometres f
rom the origin. ‘Whatever the phenomenon, it was an amazing sight with water rushing and fish flicking over parched ground,’ Kate says.

  Kate likes to ride a pushbike from her house to the health centre or the shop. At she peddles by, the young women and children call out, Hey, Marnyi Bonba. ‘Recently Judy, the strong woman with whom I work closely, asked me when I was going on leave and how soon I’d be back. I told her and for me, her response was the ultimate compliment – Yes, you have to come back and help me with antenates and postnates, you understand Yolngu.’

  CHAPTER

  3

  Chloe Coker

  It was 2 am and Chloe Coker was lying on a mattress in the hallway of a house trying to zone out. She had been sheltering here in the tiny settlement on Milingimbi Island for the past twelve hours. Tropical Cyclone Lam, a massive category-four system, was crossing over and the destructive core was battering the island. Things were getting rough. With roaring wind gusts of up to 260 kilometres per hour, more than 1000 residents were bunkered down in houses. Residents who lived close to the water were in a cyclone shelter – the expected tidal surge was a big concern.

  Chloe, in town for a three-month contract as women’s health nurse and midwife, was on duty. A born leader, the 30-year-old had done all she could to help the community prepare. She had helped let the locals know what was to happen and suggested they move from their houses if they lived near the water to the cyclone shelter out near the airport. All the houses were cyclone rated, but it was the storm surge that was causing the greatest concern. Cyclone kits and boxes containing basic medical essentials including Panadol, bandages, bandaids, water and heat blankets were prepared for dispatch. ‘We made sure our outreach emergency bags were ready in case we didn’t have a clinic to return to after the cyclone. We also ensured the house we were bunkering down in was ready – we taped the windows, collected bedding and linen from other houses along with a few other essentials like filling buckets, sinks, washing tubs and baths with water. We knew we would be without water and electricity during and post the cyclone.’