Joanna Lake, having been qualified for two years, has recently moved to a remote part of Zambia to volunteer as a midwife in a Missionary hospital.
I have always had a passion for women’s rights and development issues and have long had a desire to work overseas. My first degree was in Humans Rights, but after working administratively for a small charity for a few years, I felt it would be useful to gain a vocational skill that I could take anywhere in the world. So in September 2011 I was enrolled on a direct-entry midwifery course and after qualifying spent two years working in an obstetric unit and as a community midwife.
However, despite my ever-growing passion for maternity care, my midwifery career so far has been far from easy. In all honesty I started my midwifery training with a somewhat naïve attitude. I merely saw the course as a ‘means to an end’; the vocational skill that would open up opportunities for me to play a direct, hands-on role in reducing maternal and infant mortality and morbidity in developing countries. I genuinely thought the hard work would start when I moved overseas! But it was just a few weeks into my first student placement when I realised midwifery is not the dream job that it once was in the UK.
All over social media you can find articles or videos by midwives broadcasting how proud they are to hold such a privileged position. But more and more we are reading blog posts and anonymous articles by midwives who are leaving a profession they once loved. The latest RCM survey “Why Midwives Leave” (RCM, 2016) is testament to the heartfelt cries of a workforce on its knees. This is the dark side to midwifery. One that is, as one anonymous midwife recently described it, forcing midwives to “abandon ship” (Anon, 2016). The truth is, being a midwife in the UK is hard, and at times feels unbearable and impossible.
Midwifery in the UK is certainly not all chatting over cups of tea, cooing over new-born babies or rubbing women’s backs as they powerfully and effortlessly bring new life into the world. Midwives have to work at full capacity every day. There is no room for an ‘off day’, let alone a quiet day. They are wives, mothers and daughters, sisters and friends, having to juggle family-life, marriages, long commutes, shift patterns, irregular sleep schedules and sporadic sustenance. They have to keep a lot of balls in the air but should one drop they can find their name smeared in the mud as quick as you can say “I tried my best”.
Because sadly our culture within the NHS, and particularly within maternity services has become one of blame, scapegoating and defensive practice (RCM 2016). And it’s this dark side of midwifery that very quickly managed to pervade every corner of my life. We all know the impact of staff shortages, litigation rates and increasing workloads and my personal experience is that in the five years since I started my training I have had more sleepless nights and shed more tears over my work than ever in my life before.
As a student midwife I was at the mercy of my mentors who chose to build me up or tear me down, and since qualifying I have been constantly trying to strike the balance between displaying enough bravado to enlist respect from my colleagues and not acting too overconfident at risk of jeopardising the women under my care. I’m confident in the skills and knowledge that I have acquired thus far, I am not so convinced that I will never make a mistake throughout my career. I am only human after all. The truth is I still lay awake at night playing through scenario after scenario in my mind, wondering did I do the right thing, did I give the correct advice and did I document all of the above?
It is for these reasons that I am looking forward to the new challenge of working as a midwife in Zambia. Zambia is a vibrant and forward thinking developing country in the heart of Africa that has made significant progress towards achieving the United Nations Millennium Development Goals (UNDP 2013). Midwifery in Zambia is a sought after, prestigious profession and one that is reasonably well regulated when compared to other developing countries (UNFPA, 2014). Maternity care in Zambia is completely different to that in the UK, but the principles of pregnancy and birth are the same wherever you go in the world!
In the UK women are surprised to hear that a breech baby can be born vaginally but in Africa there is often no alternative. There isn’t a plethora of doctors on standby waiting for the next obstetric emergency, nor operating theatres, staffed and ready to go at the sound of the bleep. In fact, many women in Zambia arrive at the hospital in the late stages of labour, most of whom won’t have had a single scan in their pregnancy. So the midwives there deliver the breeches, the undiagnosed twins, they manually remove placentas and manage PPH’s between themselves, and with the right equipment and training they perform many of these things safely and effectively.
As a midwife in Africa I will be gaining a greater variety of skills than I ever could have in the UK and will be making numerous decisions that would ordinarily be passed over to the senior midwife, obstetrician or paediatrician. I will be going back to grassroots midwifery, forced to trust that women’s bodies can do what they are designed to do whilst having my intuition pushed to its limits when situations fall outside of “normal”. I will be harnessing skills and practices that have been nurtured over decades, if not centuries, as well as demonstrating and teaching many evidence-based techniques that can, and will, save lives.
I cannot, however, ignore the fact that Zambia is an impoverished country. Poverty that means there is a lack of infrastructure, life-saving drugs, quality education and gender equality that all contribute to a maternal and neonatal mortality rate that is hard to imagine when compared with UK statistics. There are no fancy gizmos and gadgets. I’ll be fortunate to have a working thermometer, pulse oximeter and sphygmomanometer to assess the women under my care. In the hospital where I will be based (which has approximately 1,000 deliveries a year) staffing levels frequently warrant only one qualified midwife working each shift, responsible for all maternity cases; antenatal inpatients, the postnatal ward and any labouring women.
Being a midwife in Africa will be difficult. I will witness heartache and injustices on a scale I’ve not seen elsewhere. At times, death will be inevitable. Not acceptable, but inevitable nonetheless, when all means of testing, monitoring and treating have been exhausted in such a resource-poor setting. But when people ask me if I’m afraid I say “no!” … Well no more fearful than stepping onto a busy labour ward in the UK! Because where I will be working the midwives act out of a desire to practice safely and save lives, not through dread of the repercussions of a bad outcome. I look forward to being able to solely focus on the women and babies under my care, being valued for my attempts to help improve their situations, rather than feeling like someone is waiting for me to trip up. For me, this is a long-term commitment. I intend to wholeheartedly give my all to every woman I care for, because in Zambia, unlike in the UK, my all will be enough.
Anon, 2016. The secret life of a midwife: I feel like I work in a factory, not on a maternity ward [viewed 15 November 2016]. Available from https://www.theguardian.com/commentisfree/2016/mar/21/secret-life-midwife-factory-maternity-ward
RCM, 2016. Why midwives leave – revisited. London: RCM
UNDP, 2013. Millennium Development Goals. Progress Report. Zambia. Lusaka, Zambia: New Horizon Printing Press
UNFPA, 2014. State of the world’s midwifery. New York: UNFPA