After more than 25 years of outstanding practice in the Cook Islands, Dr May Aung will retire in June. As RANZCOG marks International Women’s Day, we spoke to Dr Aung about her career in healthcare and about practising O&G in a remote and challenging Pacific location.

Dr May Aung moved to the Cook Islands in 1989, joining her husband Zaw Aung, who had been working there as a UN volunteer. They were initially based in Mangaia, the southernmost island. A general practitioner in Myanmar since 1975, May soon found herself working with patients there, despite not holding any official appointment. In 1993, she took a position on Aitutaki, the second-largest island, working there until 2001, when she was asked to move to the largest island Rarotonga, to work more closely with the Ministry of Health. May has been in Rarotonga since then, serving as head of her department from 2005, and eventually becoming Director of Hospital Health Services in 2017.

Obstetrics & gynaecology had always been an area of interest for May, ever since she was attached to an O&G department after completing her internship. However, in the Cook Islands it became increasingly central to her work, particularly as for much of her time there she was the only female doctor in the country.

“I wanted to do O&G all the time,” May recalls. “But when I got to the Cook Islands, it pushed me more because I felt responsible as the only woman doctor in the country. And the women felt very comfortable with me looking after them.”

In 2004, May became the first non-Cook Islander to be awarded a scholarship through the New Zealand Scholarship Scheme, completing a Diploma in Gynaecology & Obstetrics at Fiji National University. There was the option for further study, but May was facing too many demands back in the Cook Islands.

“I was qualified to continue my Masters, and FNU waited for me five years,” says May. “But sadly the Cook Islands wouldn’t let me go back because there was no-one to carry on the services in the country. They wouldn’t let me leave to continue my studies because there was no-one to work.”

And there has indeed been a lot of work. In Aitutaki, May oversaw around 50 deliveries each year; after moving to Rarotonga, her team was dealing with 250 to 300 births annually. May has been on call 24/7, attending every delivery, and she speaks with pride about the fact the Cook Islands has maintained a zero maternal mortality rate since 1995.

Alongside countless successful births, there have been other achievements along the way. May cites a mammogram screening program that she is currently overseeing, which follows on from a highly successful overhaul of the Islands’ cervical screening set-up.

“When I started, we were using conventional smears on glass slides,” she explains. “But now we’re doing HPV screening, which one only has to do every five years, and this improves our screening uptake. How did I get to that? I went to do a presentation in March 2019 in Auckland, and I met the New South Wales Australian team, and they supported me to progress to cervical cancer screening by HPV.”

These achievements have taken place amid the considerable challenges of operating in the Cook Islands. The country consists of 15 islands spread across 2,200,000 square kilometres of ocean, with transport links extremely limited, especially among the more remote northern islands. Staffing is another issue, with a shortage of midwives on many of the islands.

May describes one case of a woman with a ruptured ectopic pregnancy in Rakahanga, an island with no airstrip, necessitating a three-hour boat trip before she could receive treatment. In another case, May had to fly to Pukapuka to perform an emergency Caesarean taking with her a limited team as well as two drums of aviation fuel because there was none on the island for the return flight.

Challenges such as these are a constant for May: “Currently I have four pregnant mothers who are due this week. I’ve been trying to transfer them, but there is no fuel for the flight to go up, and one flight is down because of a brake problem. And my heart is very heavy because one is a gravida nine mother in Pukapuka.”

These challenges inevitably place an intense emotional burden on May: “It is very lonely because you are the only person practising O&G in the country. You are 24/7 on call, and I never failed to attend one delivery in my career. And sometimes, you are so tired, but you still have to continue your clinics.”

Nonetheless, May draws great satisfaction from her work: “Because you have saved many lives, and the appreciation and gratitude from the families, I think it’s worth all the stress and the hard work. The children I delivered in Aitutaki and in Rarotonga, they’re now having babies, and I have delivered them. And when I go on the road, they are calling me ‘Dr May, Dr May’, and they say ‘Oh, my mother told us you delivered me.’ It really makes me happy.”

For women O&G specialists considering working in the Pacific region, May advises: “It is a very hard and challenging career, but it is worth it because you are saving lives and looking after not only one patient, but the whole family. I’ve made lots of friends, and I was able to help people to improve their health and change their family status through doing O&G.”

Dr Aung was instrumental in the Cook Islands’ hugely successful COVID-19 vaccination program.

Recently May has been heavily involved in a project quite removed from her usual O&G practice. Since late 2020 she has been instrumental in the rollout of the COVID-19 vaccine in the Cook Islands, and as she recounts it, her participation was somewhat unexpected.

“I just got pulled into this thing,” she explains. “Over Christmas 2020, the then-Secretary of Health decided to leave suddenly. I was told on the 24th, and the new secretary was a nonmedical person. So I was dragged along to cabinet meetings with this new secretary, and the prime minister asked us ‘Have you finished your deployment and COVID vaccination plan?’ And I had no knowledge. This is not my area, this is a public health area.”

Despite this, May agreed to help. She started to ask questions and gather information, reaching out to bodies such as UNICEF, the World Health Organization (WHO) and the New Zealand Ministry of Health for support. By Easter 2021, May and her team had put together a plan.

“We started vaccinations on 17 May on Rarotonga,” she continues. “And we’ve been going to the outer islands to give the first dose, second dose and the booster. We went around each village talking to the people before we gave the immunisation. So the uptake was very good. We’ve covered 98% of the 12-plus population in Cook Islands. With the five to 11 age group, we are around about 82%.”

It’s an astonishing success that comfortably surpasses the efforts of many far wealthier nations – Australia and New Zealand included. But May is characteristically humble.

“This was not only the Ministry of Health effort, it was a community effort,” she says. “We were supported by all other agencies and ministries, and the traditional leaders, the church leaders, the youth, the NGOs like the Red Cross. So I think it is a united achievement by all the people of the Cook Islands.”

May’s remarkable work in the vaccine rollout serves to enhance an already extraordinary legacy during her time in the Cook Islands – one that her colleagues keenly endorse. Dr Martin Sowter, an obstetrician and gynaecologist based in Auckland and a member of RANZCOG’s Global Health Committee, has regularly visited the Cook Islands for nearly 20 years to mentor colleagues and build O&G capacity there, has worked closely with May over that time.

“Every doctor encounters a couple of colleagues over the course of a career that they regard as personal ‘superheroes’ – an embodiment of everything that makes a great doctor,” says Martin. “For me, May has been one of those people. Her quiet, determined, meticulous and completely caring approach to her work and her patients has kept the women of the Cook Islands safe from the start of their pregnancies through to old age. In her role as the nation’s only O&G specialist she’s had a workload and range of responsibilities that most Australian and New Zealand colleagues would find crushing”.

“More recently, as the director of hospital services she has been a master at making politicians believe that a good idea was their idea and then ‘getting stuff done’. I still fondly remember meeting her in Auckland a few weeks before their COVID vaccine rollout when the New Zealand program was still bogged down by committees and dithering. New Zealand experts were worried about cold chains, vaccine supplies and wondering if the Cook Islands could really run the vaccination program.”

“May and her team just threw everything at the project and rolled the program out across the nation’s 13 inhabited islands in weeks, with possibly the highest and fastest vaccine uptake in the world. May is far too modest to take any credit for this but she was absolutely crucial to the success of their COVID vaccination campaign.”

Dr Amanda Noovao-Hill grew up in the Cook Islands. Now based in Queensland, she is currently Head of Secretariat for the Pacific Society for Reproductive Health (PSRH), of which May is a member. Last year May and Amanda secured funding for two midwifery leaders and a medical officer to represent the Cook Islands at last year’s PSRH conference in Samoa – though unfortunately due to travel logistics and COVID, the three clinicians were unable to attend.

In her capacity as Clinical Associate Professor in O&G at the FNU’s College of Medicine, Nursing and Health Sciences, and as a former RANZCOG Global Health Committee member, Amanda frequently provided support for May in efforts to strengthen O&G service and training in the Cook Islands. Strategies implemented by May and Amanda included: audio and video conferencing with the Rarotonga O&G Unit and the outer islands clinical teams providing advice and support; enabling on-site training of a local junior doctor and a postgraduate trainee; assisting with recruitment of regional O&G support; and facilitating training opportunities for other health-related specialties.

“Thank you May for your love, sacrifice and service to the Cook Islands, and your professional collegiality to the regional academic institutions and our professional societies,” says Amanda. “Kia manuia I toou akangaroianga. Te Atua te aroa.”

Now, May is finally on the verge of stepping away from O&G. She first broached the idea of retirement three years ago, but the Ministry kept persuading her to stay on. Now however, she is adamant she will not extend any further. It’s time for a well-earned rest.

“I don’t think I will do anything,” she laughs. “I will not be doing anything in regard to medicine. I will just enjoy life. I really don’t know what to do yet; maybe some planting flowers, or fabric painting, which I enjoy very much.”

And as for the Cook Islands?

“I will stay for a while, but we will definitely have to go back to Myanmar at some stage. I have family there. I have my house. So I will have to leave the Cook Islands, which will be sad. But I have been trying to prepare myself.”

As a child, John Keogh always thought he would be a farmer when he grew up.

“My father was always going to come and sit under a tree on my farm and watch me work,” John recalls. “That was the plan.”

Well, plans changed for John and a career in medicine beckoned.

“I was originally planning to go into general practice and thought I would be a rural general practitioner in a country town. As I started training in general practice, I realised that was a different and special skill set – you need a very broad knowledge over a wide range of things,” John says.

“I knew as a rural GP I’d need to be able to deliver a baby, so I did a Diploma of O&G. lt was eye-opening – I absolutely loved it.”

John then moved to the UK to work as an obstetric registrar for a year. “By the time I was a third of the way through that year I knew that I wanted to specialise and that a career in O&G was for me.”

Since then, he has worked in Perth and Sydney and internationally in England, Ireland, and for a short time in Tanzania.

He is now based in Northern Sydney, where he has been for the last 25 years.

“I feel it is a great privilege for me to be involved in a time that is so completely real and so deeply personal to women and their families as the birth of their child,” John says about why he loves his job. “And now 36 years later it still makes my heart race!”

My Sister’s Baby

Grateful for being able to work in a system with resources, and with a team of dedicated and highly skilled midwifery and medical colleagues, John is also aware of the very different reality facing many women in lower- and middle-income countries – no midwife, no doctor, no pain relief or epidural, no Caesarean, no help if something goes wrong.

“It’s a tragedy that more than 300,000 women, and many, many more babies, die every year in childbirth, mostly because they birth without trained support. That’s like every pregnant Australian woman dying every year, year after year.”

That is how ‘My Sister’s Baby’ came about. “I wanted to somehow make a difference to the lived experience of women round childbirth in resource-poor settings. But I didn’t want to reinvent the wheel. The aim is to help raise funds to support groups who are already doing this work on the ground, but whose capacity is limited by resources. Groups like the Barbara May Foundation, run by Australian Obstetrician and fistula specialist Dr Andrew Browning.”

“The idea is to invite women and families who are having a baby here to reach out to another woman somewhere else in the world, who is going through the same journey as they are but under very different circumstances, and say to them ‘My sister, I am going to make your journey a safe one’.

“I’m hoping that other obstetricians and midwives working in Australia might join with me and ask women in their practices to join in making safe birthing a real option, and in so doing, make a real difference to families just like theirs.”

����TV has joined with other medical colleges in calling for clean energy by 2030 to protect health.

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A RANZCOG Foundation Global Health grant funded Dr Hamura’s important research into the timing of antenatal care in Papua New Guinea, informing education and improving outcomes for local women.

In 2017, Dr Nancy Hamura from Papua New Guinea – then a trainee – was awarded a RANZCOG Foundation Global Health research grant to support her Master of Medicine research project, an integral part of her O&G training.

Dr Hamura’s research explored the factors associated with the timing of initiation of antenatal care at Port Moresby General Hospital. Her research findings have informed development of education for women about the importance of booking early for antenatal care.

Now a Pacific Associate member of RANZCOG, we look forward to the continuing role Dr Hamura plays in furthering women’s health research and education in Papua New Guinea, and improving equity of access to quality health care.

Dr Galabadage Jayasinghe’s recent placement in Papua New Guinea was a valuable learning experience.

The Advanced Trainee, who is based at Westmead Hospital in Sydney, was the recipient of the RANZCOG Women’s Health Foundation’s NSW Regional Committee Travelling Scholarship. The scholarship supported her travel to Port Moresby General Hospital, to undertake a 6-month clinical fellowship.

“The experience taught me a great deal of respect for the challenges that registrars and consultants have to deal with in developing countries,” Dr Jayasinghe says.

 

“As a registrar in Australia I am so protected from resource issues; in PNG the registrars are constantly having to work out where the next batch of gloves are going to come from, or whether there is going to be enough IV fluid to get them through the day. You are constantly having to rationalise these issues while doing your day-to-day job.”

And as a result of the lack of skilled personnel at the hospital, Dr Jayasinghe gained valuable experience in paediatric resuscitation, and in caring for unwell mothers. “The O&G registrars and consultants become extremely skilled and have really huge breadth of knowledge and clinical experience because they do everything.”

One of the areas Dr Jayasinghe was exposed to in her time at the hospital was vaginal triplet deliveries. “They are very, very uncommon and unheard of in Australia,” she says. “So, gaining the opportunity to do vaginal triplet deliveries was amazing.”

A love for global health

Dr Jayasinghe, who has also worked in Tanzania and the Solomon Islands as a medical student, credits her father for her love for global health. “My father worked for the UN for more than 20 years and would often be overseas in places like Afghanistan and South Sudan, and he would say one of the greatest things he would see was the impact of medical NGOs were making in these areas,” she says.

“My original inspiration came from him. And having been born in Tanzania and having Sri Lankan heritage, I know that health care is an issue in those countries, and so it was something that I endeavoured, once I was fully qualified, wanting to give back.”

And her advice to colleagues considering volunteering overseas?

“Do a lot of research before going ahead with it. For me, I found it really beneficial to speak to people who had already done a placement in PNG and I had a lot of conversations with Professor Glen Mola [her supervisor] about what my role was going to be”.

“Make sure you think about it from all possible angles and ask the people on the ground in the countries what they need and what is beneficial for them.”

����TV’s vision in global health is to improve the health of women and their families, particularly in our geographical region.

It was with that vision in mind that saw RANZCOG President Dr Vijay Roach, Vice-President Dr John Tait and members of the RANZCOG Global Health Committee attend July’s Pacific Society for Reproductive Health (PSRH) conference in Papua New Guinea.

We gathered the thoughts of some of those who attended.

Dr Mary Bagita, Chair of the Local Organising Committee, President of the PNG Society of Obstetrics and Gynaecology and RANZCOG Pacific Associate Member

Considering that the conference actually eventuated was significant in that PNG had just hosted APEC in November, 2018 and therefore securing funding was a challenge. On top of that, we were not expecting large numbers to attend because of perceived safety and security concerns, and high costs of travel and accommodation in PNG. However, my colleagues and I were pleasantly surprised at the turnout of more than 300 participants from all over PNG and the Pacific, and also a few facilitators and guest speakers who travelled from the UK, USA, the Philippines, and Bangladesh. Attendance and participation by UN and WHO representatives from within PNG, the Pacific, and the region was another highlight signifying the importance of this meeting.

Whilst RANZCOG is already playing a significant and important role in the Pacific, the RANZCOG President’s attendance along with the Vice-President and members of the RANZCOG Global Health Committee was another stand-out for me. Dr Vijay Roach’s opening address and subsequent participation and involvement in the meetings, and his open dialogue with us made me feel that there are more exciting times ahead between RANZCOG and the Pacific.

The level and quality of presentations has continued to improve over the years, so it was quite exciting to see so many good papers from across the Pacific, especially from midwives, with some good research coming from the Solomon Islands. The conference topics included maternity care, rural health, cervical cancer, gender-based violence affecting reproductive health, family planning and adolescent health attracted lively debate and discussions. The family planning debate was a highlight on the last day of the conference.

Bringing PSRH participants to the APEC Haus for the opening night was a very memorable occasion. Set at the Ela Beach beachfront this iconic venue, built in the shape of a lakatoi (traditional Papuan sailing vessel), specifically for APEC 2018, was the perfect opening venue. Guests were treated to traditional dancing, a dinner buffet, and contemporary music provided by talented local musicians/vocal artists. We were privileged to be addressed by the deputy Australian High Commissioner, Ms Caitlin Wilson, who also presented a message from the Australian Minister for Foreign Affairs and the Minister for Women, Ms Marise Payne. Speeches were also presented by Mrs Janet Sios (patron of the local organising committee, an accountant, and also a local businesswoman of high standing in the community, and co-director of Paradise Private Hospital, the first private hospital in PNG), Mr Bruce Campbell (Director and Representative, UNFPA Pacific Sub-regional Office in Fiji), Dr Pushpa Nusair (PSRH President), and Dr Paison Dakulala (deputy Secretary, National Dept of Health) who represented the Minister for Health and HIV/AIDS. An exciting night indeed.

On the second night of events, invited participants were treated to ‘a reception for Champions of Women’s Health’ hosted by Her Excellency, Ms Catherine Ebert-Gray, US Ambassador to PNG, Solomon Islands and Vanuatu. Also in attendance at the reception was the Solomon Islands High Commissioner to PNG, His Excellency Mr Barnabas Anga. It was a privilege and honour to have met and liaised with the Ambassador almost a year before the PSRH conference and an equally exciting night of food and drinks, meeting and networking with our leaders and also with clinicians on the ground from remote, rural, and urban areas. The reception was held at the Ambassador’s residence and her enthusiasm and eagerness to acknowledge the work of reproductive health workers and to be a part of this conference was both laudable and admirable. A humbling experience and a truly wonderful and memorable night.

The most satisfying component of the conference was all the positive feedback we received from everyone telling us how well-organised and enjoyable the conference was and also that they were well-looked after. To know that people came from far to attend this conference and left with memories worth their travel is indeed extremely satisfying.

I would like to acknowledge the teamwork of the local organising committee and all the many people who assisted in the background, and the many sponsors and donors whose support was key to running a successful conference.

The theme of the conference was ‘Pacific Experience for Pacific Solutions in Reproductive Health’. I felt that the main take-away message for this conference would be to use the Pacific experience/research/data to find solutions in reproductive health appropriate to the Pacific and/or to each local setting. To see what has worked or is working in other Pacific nations that can be used in our own settings, and also to offer what is working in our setting to other Pacific nations. To share our research findings and collaborate on some areas of common interest. And also, to use global evidence adapted to the Pacific setting. The topics of discussion during the conference and the pre-conference workshops were those that were thought to be of importance to PNG and the Pacific.

The Pacific Islands of Melanesia, Polynesia and Micronesia share common cultural sensitivities that affect reproductive health in a similar way, and I believe it’s important to continue talking about these issues in order to improve care to women and their families. A conference involving all cadres of health workers working in reproductive health is unique, and I believe gives a larger voice to the health issues affecting women and their newborn infants.

Dr Arthur Elijah, Local Organising Committee member and RANZCOG Pacific Associate Member

The local organising committee didn’t think there would be more than 250 participants at the conference, so it was indeed very pleasing to have more than 350 participants from within the country and from about 15 other Pacific countries including Australia and New Zealand. Most of the facilitators of the pre-conference workshops have been conducting these workshops for PSRH for some time so it was great to have them volunteer their time, resources, skills and experiences yet again at this conference. All the workshops were well attended. The conference wouldn’t have been what it was had it not been for the presence of every single participant that attended. And to think that they were all here with one goal, an honourable one – to improve the lives of women, girls and their families, most of whom are unfortunate, was most rewarding.

Representation from reputable organisations such as WHO UNICEF, UNFPA and RANZCOG was remarkable. It was very encouraging to have representatives from WHO Regional Office and other relevant UN agencies participate in the conference. Not only did they present important information and data that would inform health service planning but being there also gave member countries the opportunity to establish links and networks that are important for future working relationships.

While RANZCOG has always provided support to PSRH both financially and through the participation of its fellows, the presence of President Dr Vijay Roach and Vice President Dr John Tait and all the other “friends” of PSRH that are associated with RANZCOG was an encouraging and comforting visible evidence of RANZCOG’s continuing support and endeavours to strengthen the bonds of relationship which is critical for PSRH.

It was also pleasing to have prominent midwives such as Ms Ann Kinnear, past immediate CEO of Australian College of Midwives and Professor Caroline Homer AO, midwifery professor and researcher, attend the conference. Professor Homer’s speech as the Brian Spurret Orator was inspirational.

As advocated by the theme – Pacific experience for Pacific Solutions in Reproductive Health – the conference hoped that participants would learn from each other’s experiences and be made aware of the innovative approaches that have improved maternal and neonatal outcomes when employed in resource challenged settings. An example that comes to mind is the bebi kilok (baby clock trialled and promoted by UNICEF) that sounds an alarm when it detects hypothermia in preterm and low birth weight babies. Other examples are the waiting houses for high risk pregnant women and incentivising supervised deliveries in Milne Bay PNG, making modern methods of family planning more accessible to women and adolescents in the Solomon Islands and kangaroo mother care in the Philippines.

Is it important that conferences like PSRH are held for several reasons:

• Nearly all Pacific Island countries don’t have established CPD programs for all cadres of health workers so PSRH provides opportunities for learning and re-learning important and necessary skills.
• PSRH also provides opportunities to share experiences that can be used to improve outcomes in other member countries; and
• PSRH provides the forum where quality data can be shared and used to identify the most important gaps and to find solutions that would have the biggest impact.

Vice-President Dr John Tait

����TV has a responsibility in the Pacific and it is very important for us to be supportive of the Pacific and their events. One of the great things about the PSRH conference is the interdisciplinary nature of it, particularly with the significant number of midwives who attended.

The highlights for me were the speakers, the engagement of attendees in the many discussions which took place and the admiration you gain for health professionals in the Pacific as they confront and work in difficult conditions.

President Dr Vijay Roach

Dr Roach commended the inclusivity of the conference, and pledged RANZCOG’s ongoing support for the Pacific to “walk alongside you”.

He also drew inspiration from a quote from Professor Homer’s oration: We all need a booster vaccination of hope, energy and commitment and we need a good dose of courage. Because we know that we cannot leave anyone behind. Our countries and our communities will only be strong and powerful when we leave no-one behind. When we have gender equity at all levels, when all our girls and boys are educated equally and have equal access to high school and further education, when our women can safely choose if and when to have children, when our mothers can give birth safety and our babies grow up to be strong and confident members of the community. I know we can do it.