Childbirth in the Global Village: Implications for Midwifery Education and Practice

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The midwife orchestrates the drama of birth. Her role is multifaceted, she provides her empirical skills, shepherds the baby from the world of the ancestors to that of the living community, and guides the woman over the bridge to motherhood, able to accept responsibility for a new life.

Childbirth in the Global Village: Implications for Midwifery Education and Practice

However, the nativity story has Mary without woman-towoman support when giving birth to Jesus. There are 13th century altar paintings that clearly show Joseph out of place in the scene. Others show Mary supported by women or angels.

Birth was celebrated as a peak experience in the life of the family, but above all in the world of women. It strengthened the bonds between women and between families, and in early America, turnabout help was devised by women in neighbouring farms, knowing that they in their turns would provide and receive help at a birth.

The advent of wealth seemed to require the menfolk to spend money on their birthing wives and this meant retaining medical men, for status. Obstetrics became the ticket for these GPs to build up their practices. There would be one woman assistant and the husband might be called in.

Much research has been devoted to birth positions and has neglected movement. The upright posture is known to reduce pain and make for an efficient labour while increasing blood flow through the placenta. Often, and in very far flung communities, a rope or equivalent has been provided for a woman to pull on. Midwives have used their own bodies to cradle a woman in labour and rock with her. When the barber surgeons involved themselves with birth in the 17th century, they exercised a detached curiosity about the location, morphology, and function of the female organs.

They devised their instruments, for the dismemberment of a dead or obstructing fetus or its baptism as it died, for caesarean section CS to deliver the baby of a dead mother, and dilators to force the cervix open. Chamberlen, the inventor in of the obstetric forceps, would use the instrument for the delivery of live babies under a sheet with the mother blindfolded. Women, the midwife among them, were excluded. Midwives have always used massage and touch with which to diagnose, manipulate, and comfort.

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While the male doctors also used touch for manipulation and diagnosis, they took pains to avoid being detected looking at the female genitalia. The tendency in the West is to help other ethnic groups to adapt to our methods, ignoring the fact, borne out by historical review, that it is our culture of birth that is the aberration. Advocating routine episiotomy and forceps delivery for all births, Dr Joseph de Lee of Chicago denounced midwives as relics of barbarism. Even spontaneous births were conducted with the mother supine in the lithotomy position, the baby appearing through a space in the drapes, which covered much of her body.

Alone with the professionals, she became faceless, desexed and depersonalised. In cultures worldwide, midwives are specialists in touch.

Touch is used in medicalised birth too, but in contrasting ways and conveying a different message. When sophisticated technology is employed, touch may not take place at all, and machines replace the human hand. Working conditions and staff shortages in hospital maternity units severely limit the possibility of providing adequate care for women in labour. Ours is the technology of control: If her dura mater is pierced during the induction of epidural analgesia, she may be obliged to lie flat on her back in severe head pain, barely able to bond with her baby.

Women are systematically trained, if unintentionally, to distrust their bodies and surrender responsibility for them. Traditional communities relate the rhythms of birth to sunrise and sunset or to household and communal activities. There is a real value in social childbirth if we can recreate it in modern conditions, discovering what is relevant to our own society. Knowing as we do that continuous woman-to-woman care in labour reduces the need for major interventions in the natural process, we must recover this invaluable resource — probably in the doula movement. Untether the mother from the machine, find the birth dance afresh, and let women move at will again.

Teach our midwives to be, as in traditional cultures, the ones who hold, cradle, touch, massage, nurture and sustain, and revalue these precious midwifery skills. Beating about the bush: In order to learn how best to serve the needs of any particular ethnic or cultural group, it is necessary above all to listen to the people belonging to that group.

It is not possible to provide appropriate maternity care without also understanding as much as possible about the local environment, such as geography, food, infrastructure, and economic activity, as well as language, customs, ways of thought and ways of being.

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I question whether the World Health Organization WHO and other groups involved in the global Safe Motherhood Initiative or similar, are approaching the problem of reducing maternal mortality in the most appropriate way. Although what I have to say may not be original, I cannot overstress its universal importance. I became a midwife after taking a degree in the history of Africa. For many years I have run a self-help group in the Suffolk village where I live for women who are having their pregnancy care in the national system. The purpose of this is to give them strength, to enable them to make their own choices, and for couples to be in control of their births.

This is where, attending many labours, I learned to listen to women and learned the basic physiology of birth, better than in my midwifery training. Becoming an independent midwife has enabled me to treat women as individuals, which for lack of time is no easy matter within the system. Time spent one-toone with women in labour reduces obstetric interventions; the responsibility is shared, and many of the women regarded as high risk deliver normally to the benefit of their health, and cost is reduced within the system.

I will describe a project with which I am involved in Uganda. Our methods differ from those which hitherto have interested ministries of health, global organisations, and nongovernmental organisations. My objective has been to combine and integrate modern and traditional maternity care, and if this were to be possible, by example to reduce maternal and neonatal mortality and morbidity worldwide. Maternal deaths presently approach annually, most of them avoidable.

The countries of the West are remarkably unwilling to share their wealth with the the poor of the world. The United Nations Development Programme reports that in recent years the poor have become poorer while the West has accrued more wealth. The implications for the care of the pregnant are huge, and this is very apparent in Uganda. A small country in sub-Saharan Africa, Uganda has a population of approximately 23 million. A civil war, which destroyed much of the infrastructure of the country, officially ended in , but fighting at the borders has continued.

There has been a substantial recovery under the present government and, among other services, health has been effectively decentralised. This has boosted the morale and efficiency of health workers.

When I arrived in Uganda, a Ministry of Health official allowed me to accompany him on field trips to meet traditional midwives. They were hard to find, and there was no question that I needed the two excellent interpreters who still work with me. The Safe Motherhood Initiative of the WHO decrees that all women should be delivered by skilled attendants, who are supposed to beWestern-trained, not traditional midwives.

This was based on a false correlation made between the type of care and the outcome, typically in countries such as Sri Lanka, which are very different from Uganda, having had a stable infrastructure and general education. They were given instruction, but never asked how they conducted their own practice. Western-trained staff have been indoctrinated in ways inimical to the traditional to an alarming degree.

A very useful scheme of referral to hospital has received limited audit, with the opportunity to audit all outcomes sadly missed. On the other hand I have learned much about the management of complicated labours from traditional midwives. I have attempted, on the one hand, to give appropriate modern training to the TBAs when they would have a genuine use for it, but on the other, also to allow indeed, encourage them to share their methods, their experience, and their local knowledge with conventional trainees.

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In many ways, this merely reflects my practice here in East Anglia: We know that when caring for the pregnant in this small group of villages, we must do preventative work. Since nutrition is vital, we encourage the consumption of the locallygrown millet, which contains iron, but which is more likely to be sold for profit.

We need to address the problems of malaria and HIV. Knowing that women bent on a career in midwifery will move to the large centres, we concentrate our efforts on encouraging nursemidwives to become traditional midwives. They will know the village women well, will listen and give respect without which the women will not relate to them and accept their advice , and most importantly will provide continuity of carer. The purpose of the classroom we use is to help traditional midwives to teach both traditional and modern ways to the mothers. The Ngosi system of gathering funds on an ad hoc basis to pay for care can be very useful, so long as the money is not lost to corrupt practices.

I believe that combining traditional and modern approaches to care, along with a large scale return to home birth, would reap the global benefits to which I have referred. Antenatal and newborn screening for sickle cell and thalassaemia — will the NHS plan deliver? My work is in public health, which is both a science and an art. This meeting has already emphasised the need to use the best of Western medicine, while not discarding traditional ways and attitudes.

A screening programme must pay attention to the sensitivities of the groups at which it is aimed, and must be culturally and socially acceptable.

I have personal experience of seeing cultural taboos respected while Western practices are being successfully introduced. Large migrations, especially from the Caribbean and Africa, increased the size of the affected urban populations. In the s and s, the politicians refused to regard the issues of SCD and thalassaemia as national, and they returned them to lobbying groups as local problems to be resolved. This went on for 20 years while the prevalence of the conditions increased apace, providing clear evidence of need. As it was proved that screening was effective, the focus fell on this rather than on treatment.

Others conceal their disease for fear of losing their jobs. The situation was aggravated by media misunderstanding of the aims of antenatal screening as a result of some poor practice, and by high profile deaths in police custody. While the initial hospital-based model created dependence, patient empowerment and recognition by the NHS of the importance of social aspects have led, in some places, to a more patient-focused model of care.

There is good evidence that neonatal screening reduces mortality and morbidity from SCD, and antenatal screening can lead to informed choice, with the option to continue affected pregnancies, bearing in mind the variability of SCD. Thalassaemia major is more predictable in its clinical course. Preconceptional and antenatal screening were not at first proposed for implementation in the NHS plan, whereas newborn screening had been supported by the National Screening Committee for several years. Chapter 13 of the NHS plan in July committed the government to the implementation of effective and appropriate national linked antenatal and neonatal screening programmes for haemoglobinopathies HBO for women and children by Presently, there are estimated to be more babies born with HBO in the UK than with cystic fibrosis, a condition of which there is far greater awareness.

The number of births of babies with SCD identified by screening programmes in was Gill and Klynman, Nonetheless, support and attitudes to screening in the communities at highest risk is variable. While women may wish to know whether they may carry an affected child, the difficult question of termination of pregnancy causes doubts about such a programme.

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Summary Is the experience of childbirth becoming 'globalised'? Is the encroachment of the western medical model dehumanising a profoundly human experience? If so, what can midwives and midwife educators do about it? These are the questions at the heart of Childbirth in the Global Village which highlights the role that globalisation plays in changing childbirth practices and its implications for midwifery practice and education. Built around the vivid personal stories of women and midwives experiencing childbirth in four very different cultures Childbirth in the Global Village will resonate with the experience of midwives everywhere and makes a strong case for redesigning the midwifery curriculum to reflect the interconnectedness of childbirth, midwifery education and practice around the globe.

Table of Contents 1.

The Defining Characteristics of Globalisation 4. The Nature of Modernity: Society, Development and Risk 5. Characterising African Rural and Urban Society 6.

Childbirth in Malaysia 7. American Women in Childbirth 8. Women in Childbirth in England 9. Symbolic Exchanges in Childbirth: Reflections from the Case Studies The Influence of Science and Medicine Cultural Implications for Midwifery Education and Practice The Midwifery Curriculum

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