Lucy travelled to Sri Lanka to experience midwifery care
"Weaving through the traffic in a bright green tuk tuk, clinging on to my seat over every bump and bracing myself at every stop; overwhelmed by the smells and noises of busy Kandy in rush hour. I could not help but to imagine how uncomfortable a woman in labour must be undertaking this journey to hospital from a rural village which could take hours due to poor road links.
"For the next three weeks I took this commute 5 days a week to Kandy General Teaching Hospital, Sri Lanka.
"The first day of placement was incredibly overwhelming, the maternity unit is extremely busy with around 1,000 deliveries every month and 30 deliveries on average per day. Fortunately, these are split across 3 maternity wards each containing an antenatal ward, postnatal ward, labour ward, high dependency unit and recovery. There is also a lactation management centre, special baby unit, premature baby unit and neonatal intensive care unit. I experienced all areas of one maternity ward, the lactation management centre and even had some shifts on the special baby unit. The delivery room contained 8 beds, less than 1 metre apart from each other. This meant that women in labour could hear and sometimes see other women labouring and giving birth. These women would labour alone as no birthing partners were allowed in the delivery suite. I cannot imagine the fear that this may have brought to some women, never mind the lack of privacy and dignity.
"One of my main objectives was to explore the ways in which Sri Lanka achieves a significantly lower maternal and neonatal morbidity and mortality rate than in other developing countries. There are many factors which I observed that I felt could contribute to achieving this. It is difficult to be conclusive as I only experienced maternity care in one hospital. Therefore, the factors that I found were observations based on the small part of healthcare I was exposed to.
"Firstly, the resources were actually much greater than I had expected. This is probably due to the fact that Kandy General Teaching Hospital was the second largest teaching hospital in Sri Lanka. Women routinely had three scans in the pregnancy and a further scan on admission, which is actually more surveillance than the average low risk woman in the UK. Women would travel hours from the rural areas to access this service and otherwise could receive basic antenatal care within the community setting. On the other hand, women do bring their own sheets in for delivery and at times there would only be one CTG (a machine that records the fetal heart rate) available on the antenatal ward. Another major problem with resources was the fact there was only 2 theatre tables for maternity and gynaecology, which meant that sometimes there could be severe delays for an emergency caesarean section. This is because the doctors would have to wait for an elective surgery to finish prior to commencing the surgery which could take over an hour. Because of the potential for delay, it meant that doctors were overly medicalising women for fear that if they were to wait before intervention there could be further severe delay. This was reflecting in there figures of only just over half of deliveries resulting in normal delivery.
"Statistics play an important part in terms of patient safety and it is clear that these are documented carefully. I even saw statistics published in public areas in the NICU. Transparency in statistics helps to address any areas of poor practice through auditing and ultimately changes can be made to guidelines. Some guidelines were similar to those of the UK, for example the charts used to plot the levels of serum bilirubin in jaundiced babies were exactly the same. However, not all guidance is evidence-based. For example, the practice of routine episiotomy to prevent ‘any worse’ perineal trauma. The teaching for nurses and midwives was of an excellent standard and covered very similar topics to the degree in the UK. On our last week we went to visit the nursing school. The students were very friendly, dedicated and proud to be a part of their profession. I had a chance to talk with some of the students and have a look through their assignments, which I was very impressed by their knowledge and understanding. Finally, breastfeeding support and advice was incredible in the hospital and during my whole time on placement I did not see one woman formula feed her baby. It was clear that both midwives and women understood the benefits of breastfeeding and this was heavily endorsed with posters in all areas of maternity. This clearly has a positive impact of neonatal health and outcomes.
"I saw some interesting cases such as a woman come in with heavy bleeding and abdominal pain, after the registrar quickly performed an ultrasound scan he diagnosed placenta accreta and could see signs of the placenta separating and there was fetal bradycardia. It was managed efficiently and a caesarean section was performed by the consultant and there were at least 6 units of blood on stand-by, as the woman was at severe risk of haemorrhage. There was a timely decision to perform a hysterectomy due to the volume of and continuous blood loss, which ultimately could have saved the woman’s life. We went to see the woman the next day in high dependency and both her and baby were doing considerably well.
"Although practice observed was generally ‘safe’, I was surprised by the lack of holistic care and withholding basic principles of nursing and midwifery such as privacy, dignity, respect, kindness and compassion. For after all, these cost nothing but can make the world of difference to a woman’s birthing experience. At times, I also witnessed a lack of consent which was quite distressing, as the past three years I have spent empowering women and making them the centre of their care. Admittedly, it was very hard to intervene with a lack of authority and a barrier to the language. I can appreciate that certain behaviours may have been cultural however; I do think these qualities should be universal as healthcare professionals and I found this quite difficult to observe.
"Winning the Edith Cavell Leadership award was an honour and the greatest achievement in my midwifery career to date. One of the topics I wrote about in my application for this award is the importance of leadership in the current climate of the NHS where morale is low and staff report feeling undervalued and overworked. This is definitely something that I could see within the healthcare system of Sri Lanka and appears to be a universal problem in most health care settings. The midwives and doctors were incredibly dedicated to their careers however; some staff were clearly exhausted and discontented. One midwife spoke about how it is not abnormal to get only two days off per month and when the ward has been short staffed she has worked over 24 hours with a few hours rest break in between to cover the unit. Another factor that may contribute to staff feeling undervalued is that there is clearly a system of hierarchy. The midwives followed the consultant around the theatre with a chair, to ensure he could sit down whenever he wished. For me, this just reinstated the importance of teamwork and valuing every single person’s role within the team. As a result of work fatigue, many had aspirations of moving abroad to work, and some had already taken steps to achieve that goal. This is going to be a difficult problem however, as staffing levels are already a problem and it would cause real issues if the hospital were to lose many of their skilled workers. From observing this practice in Sri Lanka, I feel that I have had even more time to reflect on the importance of good leadership skills and being a key motivator within a team. It is everyone’s responsibility to create a positive work place, which in turn, makes happier staff and ultimately impacts good patient care and satisfaction.
"I am extremely grateful to the Cavell Nurses' Trust and the sponsors for the award, NHS Professionals, for the opportunity that they were able to give me. Every single day I learnt something new and the experience has been invaluable as I start my career as a registered midwife. I strongly encourage any student thinking of undertaking an elective placement to do so. You will learn more than just a different culture, health care system and model of midwifery but about your values as a person and healthcare professional. My time in Sri Lanka has allowed a lot of time for reflection of best practice and has really reinstated why values such as the 6C’s (care, compassion, courage, communication, commitment and competence) are so important for the NHS and ensuring good patient care."