The international day of the midwife has been celebrated on the 5th of May since 1991, with 50 nations globally recognising this special day. Midwifery is a very different profession as you move around the world. Some midwives work in very medicalised environments surrounded by the latest technology, whilst others in less developed countries have very little in the way of resources.
Midwifery care has been shown to improve outcomes for women and families, when women engage in antenatal care, have a qualified birth attendant and receive good quality postnatal care.
Midwifery is certainly not a career for the faint hearted, even in developed countries, as it places high demands upon both the midwife’s physical and emotional capabilities. Midwives are there at the most joyous and wonderful moments of people’s lives, as well as the most devastatingly sad times too. Sharing the highs and lows of life makes midwifery both challenging and demanding as a career.
Midwifery in the UK compared with Malawi
Midwifery in countries with limited resources can provide a whole set of different challenges to those in the UK. Malawi is a landlocked country, between Tanzania, Mozambique and Zambia in East Africa, where midwives, nurses and doctors are in short supply. As such only 7 out of 10 women have a qualified practitioner with them during labour and birth and often midwives are caring for 5-7 women in labour at the same time. A direct result of few qualified midwives, combined with extreme poverty and scare resources, means that women and babies in Malawi have one of the highest chances of dying in the world during pregnancy and childbirth.
To demonstrate the difference, one of the practising midwives at My Expert Midwife compared a typical working day at a birth centre in the UK to that of a midwife working in a birth centre in rural Malawi.
The entrance to Chipatala Birth Centre in Malawi
The entrance to Huddersfield Birth Centre
A typical shift at a birth centre in the UK
Arriving at work at 06.45, I have a cup of tea and sit down in the midwives’ tea room ready to take handover from the nightshift.
07.00 Handover from the night sift to the day shift. They’ve had a busy night as five babies have been born and there are only 2 midwives and one midwifery support worker. We are also expecting two more women to come in for assessment to see if they are in labour. There is two of us on the day shift and we quickly assign ourselves to particular women and their babies, as well as prepare for the women coming in.
08.00 I have briefly said hello and introduced myself to 2 of the women, checked the controlled drugs and taken two more phone calls, when the doorbell rings. Its one of the women who rang earlier. As she is shown into one of our pool rooms I quickly make a visual assessment, she looks like she’s in labour, so I go to her quickly.
08.45 After assessing Amy it appears that her labour is established, and she will be staying at the birth centre to have her baby. She will need one to one support from me, so I hand over care of the other women to my colleague. I chat to Amy and her family to establish their plans for labour and birth and run the water pool, whilst admitting her onto the computer system where all the information and documentation is held.
09.15 I am called out of the room as my colleague is worried about one of the babies we have. Their breathing is quite rapid, I agree, and we call the neonatal doctor to do a further assessment. There are also women needing breastfeeding support and others wanting to go home, but they will have to wait as I can hear Amy in the pool room, and she needs support.
10.00 Amy is requesting more pain relief. We discuss the options as she has already told me she would prefer not to have pethidine or an epidural. Amy decides to have gas and air, so I get this set up and help her to use it effectively.
10.20 There’s a knock on the door, my colleague needs some advice and some drugs double checking, but I can’t leave my room as Amy sounds like she is pushing in the pool and needs me. I ask my colleague to call the on-call community midwife to help out, as we’re starting to struggle with the workload now.
11.05 Amy pushes her baby out into the water pool and I gently help her to bring him to the surface, unravelling his cord from around his neck and under his armpit. He looks into her eyes and blinks astonished at the light he can now see. The room is filled with emotion. This is Amy’s first baby and her mum is here too. Three generations are now in the room. I feel a little tear in my eye, I still marvel at the miracle and beauty of birth. Mum and baby are well, and I blend into the corner of the room to give the family some privacy and to complete the documentation.
13.00 I have finally completed all the tasks, such as delivering the placenta, stitching, cleaning up, weighing and labelling the baby. We are lucky, have the luxury of sterilised or one-use equipment here to help prevent infections. It’s time to do the documentation. I grab a cup of tea and a slice of toast whilst in front of the computer.
14.15 Now I have an opportunity to discharge the women who want to go home. This can be quite a lengthy process due to the amount of mum and baby checks, as well as lengthy documentation.
16.00 Another baby is born in the water pool with my colleague. We are now full and don’t have any more rooms so I’m rushing to discharge postnatal women, so we don’t have to close the birth centre.
17.30 Two women and babies have gone home, so I help the midwifery support worker to clean the rooms ready for the next admissions.
19.00 Handover to the night staff, we apologise that it’s a bit messy, but things are calmer for the start of their shift and there are some empty rooms now.
A Postnatal recovery room at Chipatala Birth Centre
A birth room at Huddersfield Birth Centre in the UK
A typical shift at a birth centre in Malawi, witnessed by voluntary worker Sue
At 11:20pm, Traditional Birth Attendant, Maggie (daughter of the Chief), calls me and two students, Hanna and Lucy, into the birthing room. Having witnessed a birth last year, I was so thrilled to be invited again. The mother is on the floor and the light from one candle and a small flashlight lit the room. Maggie handed me the gloves with a huge, knowing smile and in a combination of broken English and Chichewa, it became clear that she wanted me to deliver this baby under her watchful eye. I was so honoured and blown away by this gesture of trust, intuitive understanding and connection. She was choosing to make a dream of mine come true, even though I had never fully communicated this to her. Yet, she knew – I could see it. It was only seconds before the head started to crown. The baby was face down and after several pushes, the nose was visible. Mama was in pain, but not screaming – just moaning softly and breathing hard. It was no easy task to get the head out, but we kept reassuring her that she was almost there. Several times, she looked right into my eyes and I told her with my thoughts; how beautiful and powerful and amazing she was and that I knew she could do this. Maggie was a steady, loving presence standing over us – calm, no fuss and just letting nature unfold. Everything felt perfect and the way it ought to be – no bright lights and IVs or beeping monitors and fear. Just women together in the candlelight doing what our bodies were designed to do – bringing and creating life and nurturing each other.
Maggie, a lay midwife at Chipatala Birth Centre
Within a minute, the first shoulder popped out and several pushes later, I was holding the most perfect, beautiful little girl in my gloved hands. I was awestruck, squatting on the floor with my hands being the first to touch this new and perfect life and welcome it into the world. I wanted to cry – pure joy, awe, wonder, and gratitude! I was in Malawi with 5 powerful, amazing women in this room and now there were 6 of us. I cannot explain the feeling, but it’s something that will never leave me.
I continued to hold the newborn girl as Maggie tied off and cut the umbilical cord. As she cut the cord with scissors that had probably cut the cords of hundreds of newborns, I thought of the clean birthing kits we had brought for the clinic. After tonight, we’d give them to her, and she’d have sterile razor blades, gauze, string, and gloves for the next 150 births. It would have been impossible for us each to have gloves on right now – the scarcity of supplies gone. Somehow though, perhaps the timing was perfect because it felt especially monumental that she gave me the one pair of gloves she had for this birth. We swaddled the baby and Lucy and Hanna took over her care. Her cries became louder and stronger which was good- she was breathing deeply, and her lungs were clear.
Our focus returned to the mama. Maggie took my hands and showed me gently how to massage the mother’s belly to induce further contractions to pass the afterbirth. Through my eyes and thoughts, I shared my love and admiration for this woman as her eyes met mine again. She passed the placenta intact and Maggie and I headed outside, down the leafy trail to bury the afterbirth… her in her bare feet, walking a path she had walked thousands of nights before this one. Her work was done - another healthy life in our world.
The mother stood up upon our return and got dressed as if nothing monumental had just happened. We carried her baby to her in the next room and the two lay together on the bed. Maggie and the girls went to bed and I stayed up with the new mother. She was hungry and thirsty, so I got her water and gave her two protein bars that were in my backpack. These chocolate bars made her grin hugely when she tasted their sweetness and we giggled giving each other the thumbs up.
I asked to take a photo of her with her little girl and when she saw my phone, I realized that she wanted to make a call and let her. It felt amazing to be able to allow her to call her family and let them know that a new life had entered their family safely. I felt so blessed and euphoric in that room with her.
Nine hours later, this mother would have walked 15 miles to her home, but we were headed that way and I drove her. Before she left, she asked me to name her baby, but that was an honour I told her that I did not want to take. She had already given me such a gift by allowing me to witness and deliver her second born child (her first daughter was born at age 16). I assured her that I’d never forget her or her baby. I’m amazed by the strength and nobility of Malawian women. After giving birth a few hours before, they walk back into their lives and are probably collecting wood and cooking and caring for their families immediately. This birth will never leave me – it was as birth can and should be – so natural, so perfect and so right!
Birth in each birth centre happens the same way, but the resources available are clearly different. In the UK we are lucky to have access to midwives and medical teams if needed. In Malawi, resources can be as thin on the ground as trained healthcare professionals and therefore contributes towards outcomes for women and babies being poor.
A family photo with their midwife and a volunteer when leaving Chipatala Birth Centre