Nada travelled to Ghana to observe the difference in midwifery practice
From the beginning of my midwifery degree I had been working towards doing an elective placement abroad. It is a desire that had grown from spending time volunteering with street kids in Rio de Janeiro and working for the British Council as an English teacher in La Reunion for 2 years prior to starting my midwifery course. Meeting people from diverse cultures to learn and share knowledge inspires me; the main driving factor behind wanting to become a midwife.
After researching organisations to fund my third year elective, Cavell Nurses’ Trust stood out to me. The Trust is founded on the principles that Edith Cavell established as a nurse; that of pure compassion, determination and courage to provide equitable healthcare to all in the face of wartime adversity. Such principles underpin my own values in modern day midwifery practice to provide quality, individualised care and support to all women and their families. I therefore applied for the award for ‘Outstanding Student Midwife’ to not only fund my elective placement to Ghana, but to be affiliated with the incredible work that Cavell do.
Much to my surprise, I won the award based primarily on my dedication to advancing the midwifery profession by supporting asylum seeker and refugee women through the Maternity Stream of the City of Sanctuary in Leeds. My role here is multifaceted. I support the women in a befriending capacity and conduct interviews with them about their experiences of accessing maternity care in the UK. These narratives will soon be published on the City of Sanctuary website for a wide range of people to access. The aim of this project is to enhance the limited knowledge and awareness of the childbirth experiences of asylum seeking and refugee women, as their stories are not usually shared publicly. As a consequence it is hoped that changes will occur in opinions and professional practice, especially in the maternity care that is offered. The personal and professional satisfaction that this volunteering role offers me is incredible; it is a great privilege to have built long-lasting relationships with such inspiring women. It has also motivated me to strive towards a career as a specialist BME midwife.
I chose to spend time in Ghana as I had the privilege of supporting some pregnant Ghanaian women living in the UK. Listening to their experiences of being pregnant and giving birth in Ghana made me want to explore midwifery practice in this country first hand; improving my cultural competence. For example, the women spoke of labouring together in the same room hospital room with no pain relief - a stark contrast to the practice which I am accustomed to in the UK. I felt that practicing midwifery in unfamiliar, contrasting settings would help me to better understand how women are supported in less developed countries and why. This would surely put my own practice into perspective. I also wanted to enhance my practical midwifery skills by learning from the Ghanaian midwives who care for women with some complex health needs- such as HIV and malaria- in under-resourced settings. I expected that the midwives would have to rely on their basic midwifery skills in order to provide safe care; again, contrasting to the UK where there is a reliance on modern technology to improve childbirth outcomes. In brief, I anticipated an altogether more ‘grassroots’ approach to providing midwifery care where medicalisation is kept to a minimum and women are encouraged to follow their own labour rhythms.
I organised my three week elective through Work the World who arranged my clinical placements on the labour wards of three different hospitals- two district hospitals and a regional hospital. Throughout the placement I was given plenty of opportunities to observe the differences in midwifery practice and get involved in providing care for women and their babies. Being in a different hospital each week meant that I could compare and contrast different midwifery practices. To my surprise, there was a lack of standardisation in practice. For example, midwives from one hospital would routinely administer misoprostol to each woman after delivery to prevent postpartum haemorrhage, whereas midwives from another hospital agreed that this practice was not evidence based and thus unnecessary.
What was observed consistently however, was how outdated and medicalised the midwifery practice was. Women were encouraged to lie on their backs throughout labour and delivery whilst the midwives tried to precipitate birth through oxytocin augmentation. This contrasted to my expectation that Ghanaian practice would be holistic and woman centred. As I built trusting relationships with the midwives by sharing my knowledge and proving my worth as a competent student midwife, I was able to question these routines and offer advice on how to improve practice. This reinforced my own midwifery principles and developed my confidence in acting as an advocate for the women’s rights. I soon realised that there was some resistance to change however, leaving me feeling frustrated. This is not to say that all midwives and students were unwilling to learn different practices- some medical students from one hospital asked me to give them workshops on neonatal resuscitation, episiotomy and suturing. I felt privileged and proud to share evidence based knowledge to inform their future obstetric practice. Handling resistance to change in general however, was an important learning point for me and one that resonates throughout the literature on doing an elective placement abroad: instead of trying to change practice, you should focus on developing your skills.
Despite these fundamental differences in practice, the midwives allowed me to support women in the intrapartum period according to UK standards and deliver their babies under minimal supervision. Such autonomy allowed me to put my midwifery skills into practice, as well as manage cases that I would not otherwise be involved in in the UK. For instance I delivered pre-term twins, a baby in the breech presentation and independently resuscitated a baby. Going forward as a newly qualified midwife, these experiences have improved my confidence in adapting to stressful situations and managing uncommon deliveries without medical input. Such situations also highlighted that Ghanaian midwives are more autonomous and self-sufficient than us due to the shortage of skilled obstetric staff, but unfortunately their skills are sometimes inadequate.
From a midwifery skills perspective, I imagined that most of the Ghanaian midwives would be skilled at managing obstetric emergencies such as shoulder dystocia and neonatal resuscitation. This perception was based on the fact that Ghana has a high maternal and neonatal mortality rate, thus one would expect extensive training in these areas to improve the mortality ratio. After being involved in these emergencies in all 3 hospitals however, it became evident that some midwives and doctors are lacking life-saving knowledge and skills. From discussions with the midwives and reading The State of the World’s Midwifery report, I learnt that the reasons for this are multifaceted. Most Ghanaian midwives train in government funded universities where funding is inconsistent and often dependent on the political and economic climate of the country. Consequently, there is insufficient training equipment, inadequate teaching staff and little opportunity for clinical practice. Even though the Ghanaian midwives do their best to improve maternal and neonatal outcomes with what knowledge and skills they have, they are somewhat hindered from providing safe care from the outset of their careers. Realising this has put my own practice into perspective and I feel extremely privileged to be a midwife in the UK.
Despite the differences and challenges in midwifery practice, this elective placement was invaluable to my personal and professional development as a newly qualified midwife. I feel that I attained my learning objectives and much, much more. Immersion into the Ghanaian culture has simultaneously improved my cultural competence and helped me to understand how midwifery is practiced in a less developed, under- resourced country. As an aspiring BME midwife, I will be able to put this knowledge and experience into context when caring for African women in the UK by tailoring care to their cultural needs. The experience has made me a more self-reflexive person through endlessly questioning my moral, ethical and cultural beliefs when caring for others. I have also grown in confidence in terms of speaking out for women’s rights and relying on my midwifery skills to practice under minimal supervision. I am now eager to take this knowledge with me on my future career as a midwife.
I would like to thank Cavell Nurses’ Trust from the bottom of my heart for giving me the life changing opportunity to practice midwifery in Ghana. It is a fantastic organisation who has supported me endlessly throughout the preparation for the award and my elective. I would also like to give a big thanks to all of the inspiring women from the Maternity Stream of the City of Sanctuary, Rose McCarthy and Mel Cooper - it is thanks to all of you that my passion for supporting asylum seekers and refugees was ignited and will continue to grow.