GLOBAL MIDWIFERY MATTERS 2. Disrespect and abuse in maternity care: a global issue
Third year Student Midwife at Leeds University
This mini series aims to share, discuss and promote midwifery in a global context. Midwifery is a truly global profession and even those of us who work solely in the UK will care for women from many different cultures; these articles reflect the experiences of midwives and students working in both the UK and in Asia, Australasia, Africa and Europe. The first few articles of the series have been developed by students undertaking a global maternity module at the University of Leeds.
GLOBAL MATERNAL HEALTH 1. Traditions and birth in the Philippines
Third year student midwife at Leeds University
This occasional series aims to share, discuss and promote midwifery in a global context. Midwifery is a truly global profession and even those of us who work solely in the UK will care for women from many different cultures; these articles reflect the experiences of midwives and students working in both the UK and in Asia, Australasia, Africa and Europe. The first few articles of the series have been developed by students undertaking a global maternity module at The University of Leeds.
A changing model of rural care
Midwifery Teaching Assistant at Robert Gordon University, Aberdeen
Consider the impact on your pregnancy, birth and puerperium of living in a remote or rural area. A substantial minority of people in Scotland live in such areas, which has considerable implications for provision of health services and the staff at the front line of the profession. In the winter of 2011, Jo Lironi joined the team of midwives at Caithness General Hospital (CGH) in the North East Highlands of Scotland. Four years later, the process to review the model of care on grounds of safety began. This led to the immediate introduction of emergency interim measures while the public health review was initiated. Having left the unit after publication of the review, she reflects on her experience in a rural consultant-led unit and its transition into midwifery-led care.
Water as non-pharmacological pain management in labour
Ann-Marie De Leo
Masters student at Edith Cowan University, Western Australia
Co-ordinator of Master of Midwifery Practice at Edith Cowan University, Western Australia
20(3); ePub: 1 March 2017
The use of Complementary and Alternative Medicine (CAM) in maternity care has risen over the past two decades. An increasing number of women seek non-pharmacological pain management during labour and birth. The use of hydrotherapy - or water immersion - during labour offers women a naturalistic approach to pain relief, and may prove more beneficial than conventional pharmacological pain management. The practice of midwifery incorporates the promotion of physiological birth, and the use of showers and warm baths or pools provides women with an opportunity to experience the natural process of birth, while providing alternative comfort measures to women who opt for non-pharmacological pain relief during labour and birth.
Fathers in Bulgaria: the pioneers attending their babies’ birth
Midwife in the Zebra Midwives collective - the first midwifery practice in Bulgaria(February 2017)
In Bulgaria, it is very rare for male partners to be involved in the process of childbirth. Making fathers allies with midwives is an enormous asset for the movement for change in maternity services in the country.
The value of elective placements
Midwifery Tutor at Kuluva School of Nursing and Midwifery, North West Uganda
Lecturer in Midwifery at Birmingham City University(January 2017)
This article discusses the value of an elective placement, for finalist student midwives, to a range of health care facilities in Uganda. It uses Race’s (2015) ‘seven factors to facilitate learning’ to analyse the effectiveness of elective placements in promoting deep learning and personal development. It is evident from the student evaluation of the placement that both of these outcomes were achieved. However the learning varied, depending on the individual; hence some students focused more on their personal development whilst others recognised the contributing factors which impact on maternity care. The article also identifies that preparation and managing student expectations were key to facilitating a conducive learning environment. This was enhanced by tutor-led interaction and discussion, thus encouraging deep learning. The students’ experience resulted in a greater awareness of the variation in how individuals are valued and of cultural practices.
A midwifery approach to emotional wellbeing and mental health in pregnancy
Community Midwife, Supervisor of Midwives and RCM learning representative at Poole NHS Foundation Trust and Honorary Research Fellow at Bournemouth University(December 2016)
Mental health and emotional wellbeing in pregnancy and early motherhood are important issues for women all over the world, with poorer women suffering the most. In Nepal the maternal mortality rate is around 258/100,000 compared with the UK's 9/100,000. However, the proportion of women dying from suicide is fairly similar at about one in six/seven of all maternal deaths. Professionals are not picking up on over 50 per cent of mental health issues in the UK, despite the recommended routine use of the Whooley questions (Whooley et al 1997). In addition, midwives are reporting stress as a cause of work absence in alarming numbers. We need to get people talking about mental health issues. This paper describes a simple tool to do just that. The tool has been used in two very different settings: rural Nepal and in one of the less affluent areas of Poole in the South of England.
Reflections of a midwife in a German refugee camp
Research Assistant at Hannover Medical School and Independent Midwife(November 2016)
In response to the Syrian war and other conflicts, a large number of refugees arrived in Germany in summer 2015. Unprepared for the arrivals, many communities had to set up emergency accommodation to bridge the time between their arrival and the allocation of permanent housing. In a remote camp with up to 1,700 residents, Marina Weckend set up a midwifery service to reach out directly to women and their families. The service was facilitated by the German Asylum Seekers’ Benefit Act, which states that all maternity care, including referrals and prescriptions have to be accessible and free of charge for asylum seekers. In this article, Marina recounts the stories of three families whose experiences highlight the meaning and importance of health care access, acceptability and equity, particularly for women and families with a background of displacement.
Postnatal care from an international perspective
Independent Midwife in the USA and UK(July 2016)
The postnatal period, defined as beginning with birth and ending after six weeks, is a time of major adaptation at all levels - physically, emotionally, socially and psychologically. In the United Kingdom (UK), we put a lot of emphasis on birth preparation and how to look after yourself optimally before the birth, but once the new baby has arrived there is little support or emphasis on self-care. The focus after childbirth is primarily on the baby, with not much thought given to the mother, who is usually discharged from midwifery care on day 10, and whose partner is often back at work after a week or two. In other cultures there is much more emphasis on caring for new mothers, and this article will explore some of the different attitudes and approaches to postnatal care around the world, exploring the postnatal period from an international perspective.
Kraamverzorgster - specialised maternity care assistant
Midwife at St Georges Hospital NHS Foundation Trust
and winner of the Jelf Medal Award from King's College London(July 2016)
Postnatal care differs around the world and, in many Western countries, the debate involves optimum hospital stay after birth and the required visits afterwards, if any. Whilst UK postnatal care is at breaking point and struggling, in the Netherlands, they think they have had the answer to good postnatal care for centuries: the 'Kraamverzorgster' or specialised maternity care assistant. Providing family-centred care in the woman's home, between 24-49 hours, divided into several hours per day in the first 10 days postpartum, the kraamverzorgster is in the unique position of making a difference for mothers and babies and picking up on any pathology that may arise early on. Whilst kraamzorg seems like an obvious answer to improve postnatal care, there is a surprising lack of evidence on the benefits that kraamzorg can offer. Nevertheless the Dutch are convinced, and see kraamzorg as essential for every mother and baby.
VIEWPOINT Zika: an opportunity for change in Latin America?
Anna Maria Speciale
Technical adviser, Department of Global Outreach, American College of Nurse Midwives(April 2016)
The Zika virus is pushing women's rights and women's health to the forefront, in Latin America and globally. Strategies to resolve the Zika crisis require not only health system support but also political action
EMERGENCY TIME: CARING IN CONGO
Midwife working for Médecins sans Frontières in Shamwana, Democratic Republic of Congo(January 2016)
Midwifery practice in rural central Africa is full of joys (an abundance of twins, births by candlelight and resilience and stoicism that would leave even the very experienced birth practitioner speechless), but also a lot of challenges (every obstetric emergency in your wildest nightmares and worse) that are compounded by a lack of access to a skilled birth attendant. Women here have a strong culture of traditional practices and remedies, and hospital is often not the first port of call. Caring for women who cannot, themselves, consent to emergency life-saving caesarean sections, is a cultural aspect that we accept and respect as medical professionals working in the Democratic Republic of Congo (DRC). In a busy maternity ward in a low-resource setting, in a hospital supported by emergency humanitarian medical organisation Médecins sans Frontières (MSF), just how are obstetric emergencies managed - and are the outcomes what you would expect?
MIDWIFERY: HOME AND AWAY
Specialist midwife at Guy's and St Thomas' NHS Foundation Trust(January 2016)
The challenges faced by birthing women and maternity healthcare professionals in developing countries cannot not be over estimated. The experience of a midwife in a rural Tanzanian hospital described in this article gives a small insight into these challenges. With intermittent electricity, no running water, three beds, 20 births per day and lack of midwifery or obstetric education, morbidity and mortality rates are high, and teaching is difficult. Conversely, where monitoring is minimalistic and time limits are not applied, ‘normal birth’ is truly the norm and the trust in women to grow and birth their babies is consistent and commendable. Reflection upon midwifery in developing countries can help inform attitudes and practice in the UK.
Antenatal GBS screening: an Australian perspective
Registered nurse and midwife at Gosford District Hospital and BUMP (Birth Utilising Midwifery Practice) research assistant at University of Technology Sydney(October 2015)
Women in Australia are offered a variety of options for screening and treatment of group B streptococcus (GBS), depending on which health service they are engaged with, including a risk-based approach or universal screening. The difficulty for midwives when addressing the evidence supporting these differing policies is that there is no unified national policy on GBS screening in Australia. Furthermore, the Australian population is a discerning one, questioning the implications of procedures and exploring all options. This paper discusses the varying evidence and limitations that midwives need to be aware of in order to inform women, empower their decision-making and provide holistic woman-centred care.
Providing hope: midwifery teaching in Bangladesh
A midwife and nurse from Nottingham who specialises in HIV. She has previously worked for Médecins Sans Frontieres (MSF) in South Sudan, Haiti and Bangladesh(October 2015)
Bangladesh is recognised as a resource-poor country that has made some very positive steps to reducing maternal mortality over the last decade. However the death rate of women directly caused by pregnancy and childbirth still remains much higher than countries such as the UK, often due to lack of access to good quality and affordable basic health care. In this article, Anna Kent writes of her experiences teaching obstetric emergency clinical skills to Bangladesh’s first ever student midwives. The students were recruited from rural villages to complete a three-year fully funded Midwifery Diploma Programme at one of seven education centres across the country. The goal of the programme is for the students to eventually return and practise as midwives in their home communities, enabling greater access for women to good quality basic health care, directly reducing maternal mortality across Bangladesh.
Making it happen: a programme of education in Kenya
Community midwife at St George’s Hospital, London(September 2015)
The number of mothers and babies from the developing world who die in pregnancy and childbirth remains unacceptably high. However, concerted efforts over the last 20 years to reduce the number of deaths have produced significant results, leading to a steady fall in maternal and neonatal mortality rates since 1990 (Unicef 2014). One initiative that is having an impact is the ‘Making it happen’ programme funded by the UK government and run by Liverpool’s School of Tropical Medicine. A ‘skills and drills’-type course covering obstetric and neonatal emergencies is delivered to health professionals across Sub-Saharan Africa and Asia. This article describes the volunteer experience of a UK midwife helping to facilitate a course in Kenya, which has some of the world’s poorest health outcomes.
Towards midwifery education and regulation in Nepal
Senior lecturer in midwifery at the University of Wolverhampton(September 2015)
This is a short reflection of four wonderful weeks spent in Nepal supporting, advocating and strengthening the existing work of the Midwifery Society of Nepal and the Global Midwifery Twinning Project (GMTP) with the Royal College of Midwives. Although Nepal is on target to achieve reduction in its maternal mortality rate for Millennium Goal 5 there is still no registered protected title of ‘midwife’. In order to establish a strong midwifery workforce in Nepal, the three pillars that need to be highlighted are midwifery education, midwifery regulation and professional midwifery association. The four-week programme led by GMTP volunteers helped towards building capacity in leadership, advocacy and campaigning skills in Nepal.
WHEN EARLY AND OFTEN COUNTS Low dose - high frequency: simulation training for midwives in low-resource countries reduces neonatal deaths from birth asphyxia
Project manager and principal investigator for the Safer births project, and anaesthetist at Stavanger University Hospital, Norway(September 2015)
In 2000, Millennium Development Goal 4 called for global deaths in under fives, to be reduced by two thirds by 2015 (United Nations Millennium Declaration (UNMD) 2000). Birth asphyxia - failure to initiate or sustain spontaneous breathing at birth – causes up to one million neonatal deaths per year (Ersdal and Singhal 2013). A high proportion of these are in low-resource countries. In 2009, a group of doctors and academics from hospitals and universities in Norway and the United States wanted to find out if the Helping babies breathe (HBB) simulation-based programme for midwives in low-resource countries helped reduce newborn fatalities in a hospital in Tanzania. I was one of those doctors and our research showed that when teaching switched from a one-day programme to a low-dose, high-frequency model, emphasising immediate basic steps, there was a significant increase in the number of infants stimulated at birth, and a 40 per cent decrease in early neonatal mortality.
Global access to antenatal care: a qualitative perspective
Senior research assistant in midwifery studies at the University of Central Lancashire(February 2015)
Global strategies to reduce maternal mortality include the ambitious goal of achieving universal access to antenatal care by 2015. This target is unlikely to be achieved, especially in developing countries where antenatal coverage is often less than 50 per cent. Although much is known about the types of women who do not engage with antenatal services, there is limited information about their reasons for non-attendance. By summarising a variety of findings from qualitative studies, this article seeks to identify relevant issues. It highlights some of the problems of applying a standardised model of antenatal care in countries where resources are limited and belief systems are at odds with westernised understandings of pregnancy and childbirth.
Reaching out: caring for women prisoners in Western Australia
Lecturer in the Master of Midwifery Practice at Edith Cowan University, Western Australia(January 2015)
Incarcerated women are a vulnerable group with complex needs in pregnancy, birth and early parenting; and this is further complicated with a drug and/or alcohol addiction. Prior to the establishment of an antenatal outreach clinic in a Western Australian prison for women, pregnant inmates received fragmented antenatal care. Some of the women did not disclose drug and alcohol issues for fear of involvement of child protection services, and some refused to be transported for care to maternity hospitals for antenatal appointments. This is the first antenatal care clinic for pregnant women to be established within a prison population in Western Australia.
Australian midwifery students and the continuity of care experience – getting it right
Senior lecturer in midwifery at Griffith Health Institute and Griffith University, Queensland(September 2014)
The evidence base supporting the value to be gained by women and babies from receiving continuity of care from a known midwife is growing; it is essential, therefore, that we nurture the future workforce to work within this model of care. The Australian National Midwifery Education Standards mandate that midwifery students provide continuity of care to 20 women as part of their practice requirements. The educational value to students and the degree of preparation this provides for future work patterns is well acknowledged. There is also growing evidence that women, too, benefit from having a student follow them through the pregnancy journey. This paper examines the experience of some students working within this model and comments on the importance of providing a flexible programme delivery model and supportive midwifery educators in order to sustain and develop this innovative approach to completing clinical practice requirements within a midwifery education programme.
Cultural safety in New Zealand midwifery practice Part 2
Midwifery lecturer at AUT University and caseload midwife in Auckland
Senior midwifery lecturer at AUT University, Auckland and locum caseload rural midwife in Northland(July 2014)
Midwives in New Zealand work within a unique cultural context. This calls for an understanding and appreciation of biculturalism and the equal status of Mãori and Europeans as the nation’s founding peoples. This paper is the second of two papers that explore the notions of cultural safety and competence. Exploration and discussion take place in the New Zealand context, yet have transferable implications for midwives everywhere. This second paper focuses on midwifery education and practice.
Umbilical cord prolapse in primary midwifery care in the Netherlands; a case series Part 2
Sabine van der Wolk
Both medical students
All at Leiden University Medical Centre
Obstetrician and director of an obstetric emergency training company in Boxmeer
Jos van Roosmalen
Obstetrician and professor in international safe motherhood at Leiden University Medical Centre and EMGO Institute Centre(July 2014)
We aimed to gain insight into eight cases of umbilical cord prolapse (UCP) reported by primary care midwives in the Netherlands. Diagnosis-to-delivery interval (DDI) and risk factors were identified. Six cases occurred at home. Risk factors were found in four cases, but only two (unengaged fetal head) were known to the midwife prior to birth. One infant died of severe birth asphyxia; the other infants recovered and were discharged in good condition. The DDI varied from 13 to 72 minutes (median 41 minutes). The shortest DDI was found in the two cases of UCP occurring in hospital and birthing centre. In the six cases of UCP at home, DDI ranged from 31-72 minutes. The DDI is increased when UCP occurs at home, but no association with a less favourable perinatal outcome was found. Continuing multidisciplinary training is encouraged and guidelines should be developed and implemented.
What is a midwife? A survey of pregnant women in Abu Dhabi
Dr Grace Edwards
Assistant director of nursing and midwifery-clinical programmes manager
Midwife in the women’s health centre, both at Corniche Hospital
Dr Deena Elsori
Assistant professor of biology and coordinator of the public health programme
Dr Makhtar Sarr
Assistant professor of statistics, both at Abu Dhabi University(June 2014)
Evidence suggests that, throughout the world, there is a lack of understanding of the midwife’s role. It has previously been found that most pregnant women in Dubai did not understand the role of the midwife and felt safer being cared for by doctors. This paper presents findings from a survey conducted in Abu Dhabi, where midwifery is well established, which sought to explore whether the role of the midwife is generally acknowledged and understood. Overall a lack of knowledge of the role and scope of practice of the midwife was evident amongst a third of respondents. Since midwifery care has been shown to provide high quality maternity care, marketing and promoting the role of the midwife both to service users and to other professionals is crucial.
Cultural safety in new zealand midwifery practice Part 1
Midwifery lecturer at AUT University and caseload midwife in Auckland
Senior midwifery lecturer at AUT University, Auckland and locum caseload rural midwife in Northland(June 2014)
Midwives in New Zealand work within a unique cultural context. This calls for an understanding and appreciation of biculturalism and the equal status of Mãori and Europeans as the nation’s founding peoples. This paper is the first of two papers that explore the notions of cultural safety and competence. Exploration and discussion take place in the New Zealand context, yet have transferable implications for midwives everywhere. This first paper provides a background to practice in a bicultural country where cultural safety strategies were introduced over 20 years ago to help reduce health disparities. The implications of these strategies are examined. The second paper will focus on midwifery education and practice.
Celebrate midwifery - in Nepal
Integrated team midwife, supervisor of midwives and RCM learning rep at St Mary’s Maternity Hospital, Poole, and visiting faculty at Bournemouth University(June 2014)
This paper describes a workshop which was supported by the Iolanthe Midwifery Trust and facilitated in Nepal. The groups were introduced to the concept of emotion work in maternity care and ways of using reflection to manage it in themselves. A practical element was used, following the belief that engaging the right side of the brain in craft frees the left side to work optimally on logical/rational thinking.
Virtual day of the midwife: a global ‘pyjama party’
E-learning and social media consultant(June 2014)
The Virtual International Day of the Midwife (VIDM) (www.vidm.org) is an annual online conference designed to break down traditional barriers to continuing professional development (CPD); provide online opportunities for international midwifery networking; and model open access communication and collaboration practices. Whilst the VIDM is designed to reach midwives all around the world, issues of access to the Internet, language and cultural differences prevent some midwives from attending, especially those who live in resource-poor countries. Nevertheless, the VIDM has successfully demonstrated how CPD can be delivered to midwives in a flexible and cost-effective way, as well as bring them together in a truly global open and collaborative environment.
MIDWIFERY BASICS: MIDWIFERY SUPERVISION 8. Supervision of midwifery practice: the New Zealand context
Midwifery advisor at the Midwifery Council of New Zealand and a doctoral student at AUT University(June 2014)
Midwifery supervision is the 13th series of ‘Midwifery basics’ targeted at practising midwives. The aim of these articles is to provide information to raise awareness of the impact of the work of midwives on women’s experience and encourage midwives to seek further information through a series of activities relating to the topic. In this final article of the series, Susan Calvert uses the New Zealand context as an example for midwives to be able to gain an understanding of practices at an international level.