Midwives of the future

A story from Nepal

I was working as a nurse-midwife at the primary health care level in Jhapa, a rural Eastern part of Nepal for three years

The facilities in this area are minimally equipped. Women are very vulnerable and need to travel for more than two to three hours to get access to a health facility. Health outcomes of women in rural areas are worse compared to those in urban areas and we encountered challenges to reach women for antenatal check-ups. Early marriage is also big problem where I live and work.

As a government employee working in the peripheral area I received a two months training focusing on delivery. The youngest person I assisted to deliver was only 15 years old. This is when I realized childbirth does not start with labour 12 hours before giving birth, but it is a whole cycle: women need to get prepared for birth long before, during, and after delivery. We need to provide the best skills and I realized in order to do so I need more than a two months long training.

In 2017, I decided to enter the midwifery BA programme at the Bir Hospital Nursing Campus, at the National Academy of Medical Sciences in Kathmandu. We are 14 students in my class. Theoretical teaching in the classroom is combined with practical sessions in the skills lab using MamaNatalie and other mannequins. I am in my third year and was supposed to graduate this year but because of Corona I am at home since January. We had only a few online classes, but four out of 14 students did not have any internet – so we are really behind with our studies.

At my University, we had a midwifery teacher from the UK, named Margaret Walsh. In contrast to the other lecturers, who are nurse-midwives - she was the only midwife. She was someone we all looked up to. She taught us to apply all steps to support women: to inform them about their rights, accept a woman’s boundaries, that we need to bond with her, connect with her and share her pain.

Since being a midwifery student, I reflected very much on my previous practice: At the time I started to work as a nurse I was only 19 years old and there was a lot of pressure on me. At the primary healthcare level you are totally alone and there is no one to help you, no one to look up to. I did a lot of deliveries but at the time my focus was on the outcome only: I had to make sure that the baby was delivered without complications! But since studying midwifery I realized we need women-centred care. Birth is a totally physiological process and the woman’s rights need to be preserved, we need to ensure respect and dignity.

As a midwife I have the responsibility to advocate for women’s rights

As a midwife you have not only the responsibility for the childbirth but also neonatal health, routine check-ups, pre-conception counselling, and postnatal care up to 21 days after the delivery. Where I live and work, women do not know what their reproductive rights are - even if she is being treated bad she won’t know! As a midwife I can now also advocate for her rights, support her and teach her, so that she can inform others that one needs to be treated with respect.

The midwifery programme in Nepal exists for four years and so far, we have only nine registered midwives in the whole country but only few are working clinically. The midwifery programme was established to reduce maternal mortality and morbidity, but until now there are no established staff roles for midwives, no placements and no work plan. There is also no career path as we do not have further midwifery education. “We are kind of in a dilemma, as the government of Nepal is not doing anything and due to Covid we cannot advocate for our programmes and needs.” It is somehow a sad situation: to know that maternal mortality is high, there are midwives, but we do not have any future it seems.

I will go back to my previous job working in the Eastern and rural part of Nepal at the primary care level. I understand the grassroots level and I think this is where I can make a difference. I dream to work independently as a midwife and to establish a real midwifery-led setting. “… during my [previous] education I did not have any kind of role model, …or someone to look up to… [I did not know] …how a midwife should work, how a midwife can help, how a midwife can be more beneficial and how she can be a role model. I want to work in that kind of way so that future midwives have someone to look up to and they [realize] this is how midwives should work, this is a way how midwives help a woman during her delivery process, during her childbirth, during her antenatal to the postnatal period of time. And this is how a woman is respected…”

So far, we have only seen a midwife-led unit in a video during our studies. Seeing such a positive environment was beautiful. I want to create something like this – where midwives can upgrade their skills and where women can feel safe and more relaxed.

For now, I want to work in the rural areas for some years and gain more experience. But afterwards I want to gain further midwifery education and become an educator and teach midwives of the future.

A story from Uganda

My stepmother inspired me to become a midwife

My stepmother works as a nurse-midwife and told me about the opportunity that I could enter the midwifery programme at the Lira University. The programme exists only since 2016; beforehand the system was only allowing females to become midwives in Uganda.

I had a lot of anxiety at the beginning because the expectations on me were high. As years passed by, I became passionate about my studies and by now I am super proud to be a male midwife. Besides, the government is sponsoring 90% of my education, which is like the icing of the cake.

In Uganda, males can be in the OB/Gyn department if you are a medical doctor or a scrub nurse -but being a male midwife is something new. When I tell someone that I am a male midwife, they say: “What? You can’t be a male midwife. Maybe a ‘midhusband’, or a medical doctor…!” Even in my family they call me ‘doctor’.

The Bachelor programme consists of four years of studying at the University, followed by a one-year internship. We are 70 students in my class, but only very few males. What I like most are the practical sessions in the skills lab and using MamaNatalie. The theory is important, but when I put the theory into practice, that is how I won’t forget it and it makes me feel really energetic. We also have a student association, which came to life only three years ago and I will be the president next year. We are planning many activities and also want to set-up a midwifery association in the future.

Since March the University was closed because of Covid and I only returned last week, as I live in the far South and the University is in the North. We only had few online lectures but as the internet is not strong enough we could not continue online.

In Uganda we are often forced to improvise due to limited resources

In Uganda I have encountered several challenges so far. What we learn is not necessarily possible to put into practice, simply because resources are limited. Sometimes oxytocin is missing, or catheters are missing…and we are forced to improvise. You feel bad, but in the end the only thing you can do is to focus on the mother. In addition, being a male midwife is a new concept in Uganda and I have experienced situations where mothers or staff did not accept me as a midwife.

When looking at how things are done here – in the hospitals but also outside of it – and if you look at the statistics on how many women and newborns are dying in Uganda, I know that if I am using my knowledge and skills in the future, I can save lives and that is something, which makes me really happy.

I look up to some of my lecturers and I am in love with Sheena Byrom, a midwife and real role model I am following on social media. My dream is one day to have a family I can make happy and to become a midwifery professor in the future. We need to do more research and so we can change the narrative in Uganda!

A story from Chile

“Once I finished high school I was lost in the void of decisions…

I had no idea what I wanted to do in my life. I had a lot of pressure on me because I had really good grades. So my family was saying: you can become everything…but you must be a doctor!” I took a year off and that is when I found out that I could be a midwife. What really attracted me is that you get really close and accompany the women all their life. We are also doing family planning, so you will see them every year and they are not just patients, but people! I like getting to know the people I work with.

As midwives we have legal responsibilities in Chile and we are viewed as an authority. We provide services through the entire life cycle, from gynaecology to family planning, neonatology and deliveries. We practically see women from birth until they enter the menopause.

“I am also a feminist – and of course you can be a feminist in every field – but I feel like being a midwife I can be in really close contact with the women and help them to empower themselves, so they can take their decisions with all the right information.” Especially now that here in Chile we are trying to go back to a more natural delivery with less medication and hospitalization. When someone gets pregnant all decisions are taken away from you. We try to turn that around and make sure that women can take their own decisions. In Chile the birth is very medicalized. In the public health service the caesarean section rates are around 50% and in private facilities they are up in the sky. Caesarean section rates even go up shortly before vacations – that is very common. The doctors do not want to be woken up during the night. And it is also cultural: doctors tell women that the vaginal birth is very painful, and the women are afraid and prefer to plan an operation instead.

Midwifery education in Chile is embedded at the University – I am at the Universidad de Chile - and you study for five years, whereas during the last year you conduct internships at the hospitals. You can indicate preferences but, in the end, the random online generator allocates where you do your internship. Due to Covid, however, my internship got cancelled as all hospitals closed down for students. I was supposed to finish my studies at the end of this year - but now I am still waiting for my placement. We also had a “social revolution” in October last year – so some of my classmates are still finishing their fourth year. “So, all is really messy – but we are doing it!”

I have always been good in working fast. But as a midwife you really have to be fast! You need to follow all steps but sometimes you need to take very quick decisions. That is still challenging at times. After the fourth year you are allowed to work clinically as a “technician”. Due to Covid the hospitals were in desperate need of healthcare workers, so I started to work at a maternity while waiting for my internship to start. So many things were happening there! Emergency caesarean sections, forceps, so many things – but it was the first time I did not have pressure to be a good student and I was not evaluated while doing my work, I was just working, and I suddenly had responsibility. I gained a lot of confidence during this time!

“I have one teacher who is specialized in neonatology. She is so gentle. She is like a mother to everyone. And she knows a lot (…); and she is a really, really good teacher! I want to be someone as knowledgeable as her, but without forgetting the human side of medicine. (…) We have that issue here that midwives sometimes forget that they are working with human beings. And they are cold to the people. And she wasn’t. That’s how I would like to be in the future and do not forget the human side.”

I do not want to stop here but I would also love to get my master’s degree and study abroad and maybe do some research or teach – but not full time. I always want to work as a midwife – and in my free time travel the world and climb mountains.

A story from Malawi

Nobody in my family is in the medical field and it is only me sharing medical stories

Initially I wanted to become a medical doctor. When I was ten years old I went to the hospital and met a doctor and started to ask questions; and when I reached 18 years I realized I could actually do it. This is when I applied for medical school, but was unfortunately not accepted. I decided to enrol for the combined nursing-midwifery programme at the Daeyang University in Lilongwe.

I am very interested in maternal and newborn health and sexual and reproductive health in general. Midwifery gives me the position to actively contribute to it and not only being interested in it. Further I have the opportunity to create a human and humane birthing experience.

Our programme is divided into two years of nursing, followed by two years of midwifery. We are 33 students at my college out of which six are males. Although we are fewer in number it is perceived as normal that also male midwives deliver babies in Malawi. The program is quite serious and comes with a lot of formalities and respect. You can almost call it “bureaucratic” – you cannot study it without proper rules, routines and policies and something I really like about my studies.

We have a specified time period of theoretical learning, which is followed by a lot of practical education. I am not really a fan of long classes because I feel it is tiring to the point where I do not really get something out of it …”but practical sessions are really rich with information and you get to understand how things work and… I loooove that! The practical and the theory side are well balanced”. A challenge we are however facing is that we need to reach a certain number of case studies including complicated deliveries. Being present during a high risk or complicated delivery, such as a twin or breech delivery, is nothing we can influence. But nevertheless we need to reach a certain number and that is really hard.

Thinking back, I did not really get to enjoy the first two years of my school. “Nursing is quite cool …but midwifery is way cooler! … As much I have been devoted to our programme, I am extra-devoted to midwifery. I will go deep into midwifery and soon get to start my postgraduate studies in midwifery.

The main reason on why I chose the programme was the joy of being the first person of seeing the baby and introducing the baby to the mother and saying: “Hi, this is your baby, a boy, and he was born at 3.30 today…that feeling is an amazing feeling … and is actually a very big dream coming true.” As a midwife “…I am part of a life changing experience… initiating a whole new live is a real privilege I must say.”

I should have graduated in a few days from now. But due to Corona all educational facilities were closed at the end of March and we had to go home, regardless that we were close to finishing our studies. After a few weeks the school introduced online learning. It was a good development, but we are facing technical challenges in Malawi: the internet is not very good and also very expensive. Hence, the learning was not constant and not very efficient and effective. Overall, we had no school for six months and only continued face-to-face classes mid-September.

“Every time I get to deliver a baby … I usually tell my mom.” Last time was last week during my midnight duty. I had delivered a baby and the mother asked me to name the baby. I was really shocked but went ahead and named the baby Alinafe, meaning “God is with us”. I immediately had to tell my mom and she got really excited. I did not only have the privilege to deliver the baby, but to hand it over to the mother, and to give it a name it will carry forever. This was truly amazing!”

While being stuck at home I started a small health promotion project in front of my house and together with my cousins: I set up a bucket of water and soap, wrote some signs on the back of old calendar sheets and invited people to wash their hands. The time of Corona made me realize that midwifery is not only about giving birth, but it is way more than that; it is about creating a really good environment for women and their babies.