By Ninha Silva, MARCH Centre Blog Editor (MSc Public Health Candidate)
To celebrate this year’s International Day of the Midwife, we wanted to hear the voices of the profession, so we spoke with two midwives, currently MSc students at LSHTM.
Maria Garcia de Frutos moved from Spain to UK nearly 14 years ago and has been practicing midwifery for 5 years. She started working in a deprived area of East London and since then she has been working with vulnerable women. Maria worked with the NGO Doctors of the World with undocumented migrants in London and also in a refugee camp in Greece. Maria is currently doing her MSc in Public Health.
Maura Daly completed her midwifery training in the birth center and school Maternidad la Luz, located in the U.S.-Mexico border, where she also worked as a midwife for 3 years after completing her training. After that, Maura moved to California and started her own homebirth practice whilst working as a clinician at Planned Parenthood. Maura has been working with the Doctors Without Borders (MSF) since 2013 and has been in missions in South Sudan, Yemen, Nepal and Sierra Leone. Maura is currently pursuing her MSc in Public Health for Development.
Midwifery is one of the oldest professions in the world, dedicated to the wellbeing of the woman, however, its history is marked by neglect, ambiguous laws and fascinating transitions through time and across the world.
In the last decades, the profession started gaining attention in the fore of reproductive health and since then it has been increasingly considered as one of the pillars in the efforts to decrease poor maternal and child outcomes around the world. This started when the Millennium Development Goals (MDG) focus towards maternal and child health, together with the ambition to increase universal health coverage and access to reproductive health, led to a sudden realisation that there was a huge international deficiency of healthcare force.
In 2006, the World Health Organisation (WHO) published the report Working Together for Health that alerted not only for the shortage of healthcare workforce, but also to the uneven distribution of health workers within regions, inside countries and around the world. Data arising in the years following WHO’s report, showed that there was a global shortage of 350,000 midwives around the world.
When asked to share her thoughts on these numbers, Maria says “it is part of the process, first we identify that we need to have a qualified person to attend births, then we start qualifying people and the numbers will start increasing”. Speaking more specifically about NHS, Maria adds that “the real problem is retaining midwives. I think that it is important to train and provide midwifes, it is important that every woman has access to a midwife, but it is also important to deal with the retention problem”.
For Maura, context plays an important role in the shortage of midwifes. She explains that in the United States “there is not enough midwives because people don’t know what a midwife is. It’s just not a career that is obvious to people. In the low and middle income countries, I think there are just not enough midwives because there is not investment in it”.
Despite the decrease of global maternal mortality rates and neonatal mortality, from 1990 to 2015, the number of mothers and newborns dying from preventable causes are still alarming. Most of the deaths could be prevented with the presence of a midwife, however, WHO data shows that in some regions nearly 40% of the births are not attended by a skilled professional and approximately 13% of these women do not receive postnatal care in the first 24 hours after birth.
The UNFPA’s State of the World’s Midwifery 2014 reports that a committed investment in quality of midwifery services could prevent approximately two thirds of maternal and newborns’ deaths around the world. “I hope that the large funders can see the importance of it. This is a solution that will last beyond a five years’ cycle. It will last for the length of the career of that midwife and all the women she will touch”, says Maura.
Beyond catching babies
The International Day of Midwife, 5th of May, was launched in 1992 by the International Confederation of Midwives (ICM) with the aim to bring awareness about the work of midwives and the challenges around this profession. The yearly call for action is usually celebrated with a theme that the ICM brings forward. This year’s theme “Midwives, Mothers, Families” intends to reinforce the importance of working in partnership to improve health outcomes and ensure quality of care.
The ICM definition of midwife leaves much space for interpretation on what constitutes the role of a midwife. Midwives normally provide a range of support services to the pregnant woman, to her family and at community level too. Maria explains that as part of her job with vulnerable pregnant women, she was required to follow the women antenatally and postnatally and work with the social services, psychiatric services, children centres and legal agencies when necessary.
Maria believes that midwives also have a social responsibility. “Midwifery has such a privileged position in the political arena, in the community level, national and international level. We have a privileged position because we have access to so many women’s life and their families and we get to see how they live, the inequalities. Midwives have an opportunity to advocate for women, so we should use that power we have to influence political will. Women’s reproductive health should be even more in the political agenda and with our privileged position we should be doing more”.
The challenge now, says Maura, is “being able to translate the power of midwives and the ability of midwives to policy makers for them to understand that well trained midwives have the ability to make a dramatic improvement in the lives of women, particularly those more vulnerable”.
It is precisely this sense of social responsibility that motivated these two midwives to go back to studies. After years practicing midwifery, Maria realised that she needed “more tools to make a bigger impact in the lives of women. I hope to be able to make bigger impact than what I make at the clinical level. It [the MSc] has already enabled me to have a broader picture in so many areas.”
For Maura, there was a need to explore the interaction between public health and midwifery. She explains: “the lessons I have learned as a midwife about that interaction, how valuable that could be and how midwives are so important all over the world, does not necessarily translate to the higher level, so I wanted to be able to talk about that to more people and I thought that Public Health could help me doing that”.
In this day, it also seems imperative to discuss the work culture of midwifery and how that impacts the wellbeing of these healthcare professionals. A 2015 NHS Staff Survey showed that approximately 50% of midwives in England were affected by work related stress and 69% felt pressure to attend work despite not feeling well to fulfil their jobs. The weight of these numbers are certainly dependent on context, however, it is symptom of a much bigger problem of the health systems and affects midwives around the world.
Maria shares: “This is a stressful job, with a lot of responsibility. Sometimes the outcomes are not so good and they create stress, and working in shifts takes you to a complete different world. So, there are many different points from where stress builds up and I don’t feel that there is anything in place to relive it. You go through a lot of emotions…and it would be helpful to have support of a specialist. It would be helpful if the maternity department had in-house support not only for midwives, but for doctors too”.
Maura adds that “when you get started you just think about the happy parts and you don’t really think about the terrible parts. As a clinician you are just taught to be stoic but there isn’t a lot of support. But that is the case for all medical providers. We are just not allowed to be humans or vulnerable.”
When asked what the most important factor to deliver good quality of care is for her, Maria answers: “time and flexibility”. She continues: “Women have different needs. Also, you are sharing a very important moment of a women’s life, a very intimate moment, and you need to build a rapport. You need time. If you have time, you have the resources and the money. Because if you have time to do your job properly, it means that there are many midwives around you, and you don’t have shortage of staff.”
Maura’s message for this year’s International Midwife Day is that: “in countries, such as the UK, it is important that they take care of their midwives. These are the women and men that receive whole generations of a country, so they should be taken care of. For countries where midwifery it is not seen as a very strong craft, I would suggest taking a second look at how midwives have the ability to reach so many women and improve the lives of women and children everywhere.”
I would like to say thank you to Maria and Maura for taking time to discuss with me and contaminating and inspiring me with their passion for midwifery.
Happy International Day of the Midwife.