India 2015

To continue my year-out tour, after a week sightseeing in Delhi I spent two weeks in a small charity-run hospital in Northern India, in the Himachal Pradesh. Based just at the bottom on the Himalayas, it was one of the most naturally beautiful places I have ever been to. The roads were crazy, the locals were lovely and the food b-e-a-utiful. After returning in the November, I convinced my Mum to go on a three week backpack across India with me in the following January - safe to say I'm 100% sold on India as a country!

In terms of the healthcare system in India, times are very much a-changing. As a rapidly developing country, developments are being made from State to State however it is evident health inequalities are still rife throughout. Government funded healthcare is available to those in poverty, however the quality of some of these services are limited. From my experience, if you could afford to have private healthcare, you did.

A breastfeeding advert on Indian tv!

Maternity Services vary similarly across the country. India accounts for 15% of global maternal deaths (WHO et al 2015), has an under 5 mortality rate of 48 per 1000 live births (compared to the UK's 4 per 1000) (UNICEF et al 2015) and has a neonatal mortality rate 13 times higher than the UK (WHO 2015). The reasons for this are complex, however key factors are access to healthcare services, the urban/rural divide, the prevalence of Traditional Birthing Assistants and less thorough or regulated Midwifery training. Gender inequality, Laws around terminations and different traditions also influence women's birthing experience and the overall culture around birth.

My experience was in a small, charity-run hospital in a small village outside of the town of Palampur.

I was lucky enough to experience two births (within half an hour of each other, typical!) and a lot of Antenatal Appointments in my two weeks volunteering at the hospital. I was welcomed by the most lovely Midwives and Doctors who relentlessly plaited my hair, drew henna tattoos on my hands and told me how unfashionable my Western clothes were. They taught me an awful lot about Midwifery in India, their culture and their beliefs and welcomed me with open arms into their lives. By the time I left, I was receiving marriage invitations from the Midwives, WhatsApp chats with the Doctors and even a handful of dinner invitations!

Here's the main differences that I experienced:
- Medicalisation. Despite not having heaps of resources or expensive machines (no CTGs, dopplers or computers!), they worked in a very medicalised model of care. The caesarean section that I saw performed probably wouldn't have been recommended in England and care was very paternalistic with the Consultant/Doctor taking the lead. Choices were not fully explained and informed consent was rarely achieved. Women birthed on delivery beds (which didn't even have an end of the bed, just stirrups) in a semi-recumbent position, no birthing partners were allowed and every primiparous woman had an episiotomy. No ifs, no buts. (I asked why they do these routine episiotomies, the response was 'Well how else would the baby come out?').

- The Role of the Midwife. Midwives were more like Obstetric Nurses. Although they told me part of their training involved delivering babies themselves and taking a lead in care provision, I saw very little evidence of it in practice. Doctors were at 'the Business end' and Midwives retrieved equipment and did odd jobs in the meantime. There was very little emotional support from Midwives (or anybody at that) for the women but I was informed that this is their culture for hospital births. A review of Midwifery education in India by Sharma et al found that there was a distinct lack of confidence and competence in Newly Qualified Midwives, so I don't blame the Midwives for this. It seems that fundamentally their training programme needs developing which then hopefully will equate to better experiences for women, alongside better maternal and neonatal outcomes.

- Birth location. There is a massive push for births to happen in hospitals and it seems that women tend to consider factors such as cost and proximity to home more than those we would consider, such as maternal experiences, birth attendant, birthing environment, water analgesia etc.. A new 'Midwives on Bicycles' campaign has started to provide homebirths with a safer attendant, however I feel this is more to reduce the number of traditional birth attendants, rather than improve the home birth numbers. Nearly all homes in Himachal have electricity and running water, however that can certainly not be said for many of the other States in India. When considering cleanliness and access to services, this suggests that hospital births may actually be somewhat safer for some women.

- Hierarchy. One of the strangest things I found about the Maternity team was the hierarchy. When the Consultant walked into the room, all of us (including the other doctors) had to stand up and say 'Good Morning Ma'am!'. Three doctors would be present during Antenatal Examinations. In turn, each of them would palpate the woman's abdomen, starting from the most junior to the most senior doctor. You did not speak to the Consultant unless spoken to. I suppose this all resonates back to the Indian Cast system and although it's not used anymore, there is still a strong sense of social class structure within Indian society. It was very interesting to see this, however not massively conducive to inter-disciplinary communication or team working!

 

Overall I had an absolutely fantastic experience in India. Although some of the practice was massively different to that in the UK and I initially found it difficult to watch the lack of informed consent, I learnt an awful lot. Experiencing different birth cultures and rituals is so important to me, and I feel it gives a new understanding of birth on a more global scale. India as a country is such a vibrant, exciting and absolutely nuts place, and I thoroughly recommend it to anyone thinking of travelling!

Personally managed births to go: 3 (!!!)

References:
Sharma, B., Hildingsson, I., Johansson, E., Prakasamma M., Ramani, K. and Christensson, K. (2015) ‘Do the pre-service education programmes for midwives in India prepare confident ‘registered midwives’? A survey from India.’. Global Health Action 7, 8
UNICEF, World Health Organization, World Bank, UN-DESA Population Division (2015) Levels and trends in child mortality 2015. New York: UNICEF
World Health Organisation (WHO) (2015) Global Health Observatory country views [online] available from <http://apps.who.int/gho/data/node.country> [31 July 2017]
World Health Organization (WHO), UNICEF, UNFPA, World Bank Group and the United Nations Population Division (2015) Trends in maternal mortality: 1990 to 2015. Geneva: World Health Organization
 

Malta 2016

In 2016, I did a two-week elective placement (followed by an obligatory weeks holiday!) in Malta. I had a fascinating insight into Maternity Care in a country smaller than Cornwall and absolutely loved my time there. I spread my time across the Labour Ward, Antenatal Ward, Postnatal Ward, Breastfeeding Clinic and in the Community. The midwives, student midwives, doctors and all other staff were so friendly and I learnt so much. Here's a snapshot of my time there:

So there's one main hospital in Malta, called Mater Dei hospital which has around 4000 births a year and a 37% section rate when I last checked. It's a huge, modern hospital and is situated right next to the only University in Malta. Because of it's history, Malta is not unlike the UK in many ways, with English as a second language to almost everyone and is used in conjunction quite often!

In regards to maternity care, the main differences to care in the UK that I found were:

- Antenatal care is done almost exclusively privately. There is an Antenatal Clinic within Mater Dei but it doesn't have a great reputation as there are often very very long waiting times. It seems the culture is just that antenatal care is done privately by an obstetrician and it's just kind of taken as a given. Only those who cannot afford it go for free care in the hospital. Seeing a doctor antenatally (and never a midwife) undermines the role of the midwife a little from the get go, as women assume 'normal' care is from a doctor.

- Abortion is illegal as Malta is a Catholic country. Although scans are undertaken, there are no abortions allowed even if the baby has a congenital abnormality. I did a couple of shifts on the Neonatal Unit where a baby with hydrocephaly was receiving palliative care, and had been for almost a year. It was so sad to see and really shocked me, having come from a country where it is very rare that this baby would have been carried to term. Women often take a trip over to Italy if they do not wish to continue the pregnancy, although this is all very hush hush.

- All local Midwives and Doctors are trained in the one University. There were only a few who had been trained outside of this University, but this meant within other countries which was rare and expensive. This means that practises are passed down within a very small skills pool, allowing practices such as breech and twin vaginal delivery to be entirely forgotten and therefore never happened. It also made the relationship between midwives and doctors a little bit 'old school' compared the UK, and practices had not changed at such a fast rate as larger countries. Doctors were ultimately in charge and midwives had less autonomy. However, with international programmes such as ERASMUS and others meaning that international study and experiences were more affordable and accessible to midwives, there is the beginning of movement. I spoke to some lovely student midwives who had just been in Nottingham for a few months learning about midwifery over here. They were fascinated by pool births and home births, which are absolutely unheard of in Malta - watch this space!

- High rates of IOLs. For many reasons, often similar to ones over here, but also because they only allow women to get to 40+7 before starting an induction, although many didn't seem to be allowed to even get that far. It does make you wonder if there's a link over there between the private Antenatal care and early inductions...

- Everyone has a CTG during labour. Boo. Hiss.

- Midwives work on the Neonatal Unit too. Their entry-level course is 4 years rather than our 3 years, but includes neonatal nurse skills. Initially instigated because of a shortage of nurses in the past, I found this fascinating. I feel it can only benefit the quality of Midwifery over there, as they would have more detailed information to give to women around Neonatal care. It also massively increased their skillset. Their Neonatal Unit however was the only one in the country, meaning they were massively over-filled. Occasionally a baby would be transferred to Italy for care, however Mater Dei just had to accommodate for babies as and when they came.

- Breastfeeding is massively promoted, and they have the most wonderful drop in breastfeeding support clinic at the hospital for help up to a year after birth. Women could come and spend all the time they wanted with one of the six midwives that worked there. Women-tailored support, advice and reassurance was there in abundance. It. Was. Wonderful.

- Actions such as catheter removal or drug administration (even those that we have on the Midwives Exemption List in the UK) cannot be administered without the direct instruction of a doctor.

- They have a huge problem with gross varicose veins and obesity amongst the natives on the island, however low molecular weight heparin was rarely given to women postnatally, unlike in the UK. I never heard any statistics around postnatal DVTs, but if they were high it would not surprise me!

Myself and a lovely Student Midwife

Having lunch on a day with a Community Midwife to this view!

Overall I had a fantastic time in Malta, and would absolutely recommend it to anyone thinking of taking a European elective Midwifery Placement!

Personally managed births to go: 13

Guest Blogged!

For those of you who didn't get a chance to see, to celebrate the International Day of the Midwife, I guest blogged on the Coventry Unviersity UnCOVered blog. On it I talked about my experience of being a student midwife and the opportunities I've had throughout my training.
Here's the link, if you fancy taking a look:

http://blogs.coventry.ac.uk/uncovered/2017/05/05/call-the-midwives-anna-marsh/

 

 

Personally managed births to go: 15

The RCM Education Conference - March 2017

After entering a competition, a student colleague and I won the opportunity to speak at the RCM Education Conference in Glasgow. We presented in the Japanese presentation style of Pecha Kucha to a large group of delegates who’s professions ranged from University Lecturers, Heads of Midwifery, RCM Representatives and many more.

Our subject was on the Social Media platform Twitter as a Learning Innovation under the following abstract:

Innovations in clinical practice are happening every day, with handheld records becoming a thing of the past and women reaching to the internet for answers as well as just her midwife. Midwifery Education needs to keep up with the fast pace of these changes and utilise them to transform the learning experiences of the Midwives of the future. For many students, Social Media (#SoMe) is the go-to for social engagement, event planning and even problem solving. To harness this within Midwifery Education would enhance learning and encourage thought-provoking discussion around current topics, new research and Global Midwifery. To achieve this, engagement with Twitter should be promoted throughout the educational hierarchy. By making Twitter a compulsory part of registration, students can follow individual University and Faculty hashtags to engage with Lecturers, discuss their learning experiences and participate in #twitterchats to develop their education. Students have instant access to the extensive community of Midwifery including high profile leaders from local Heads of Midwifery, Consultant Midwives to even @LesleyPageRCM herself! The potential for Twitter as the future of Midwifery Education innovation is monumental, however a campaign to maximise its educational benefit would need to be implemented. Starting with collaboration between University Midwifery Societies centralised through the @RCM_SMF, a Twitter policy for students should be established and engagement promoted. If awareness is raised, student involvement will increase, prompting a revolution in teaching and learning within Midwifery Education.

The opportunity allowed us to develop our confidence and communication skills from what was my first ever Conference presentation. We loved the chance to promote something that we are passionate about and encourage all healthcare professionals to get on Twitter, under the hashtag #GetYourTweetOn.

 

 

We are really excited to present a similar presentation at the Coventry Faculty of Health and Life Sciences Conference next week!

 

 

Personally managed births to go: 17 

Shanghai 2015

After Tanzania, the next leg of my accidental-year-out trip was to Shanghai, China.

China has always been on my ever-expanding list of must-visit countries, and I was certainly not disappointed! An undeniably monumental culture change from a small town in Africa, Shanghai is a buzzing metropolitan like no other city I've ever seen. According to the Chinese Government, the population is 24 million people in 2015. When you compare that to the population of the UK as stated by the UNDP as 63.4 million in 2014, the city is phenomenal! I explored quite a lot during my 3 week stay, but I'd still say the city felt small and cosy, not as if more than a third of the UK population was living there! Clearly I had some more exploring to do...

For two weeks of my stay, I volunteered at a day centre for people with learning disabilities in a suburb of Shanghai. Classes for around 30-40 adults ran in the morning and afternoon, teaching a range of lessons including music, Chinese crafts, life lessons, reading, cooking and many more! Although no one there could speak any English and I could speak no Chinese, I had such an amazing time and met some great people. Non-verbal communication, basic sign language and smiling a lot seemed to get me by just about!

Around classes and at the weekends, I did a lot of exploring and sightseeing including historical temples, famous gardens, museums and galleries. As well as this, I made some great fellow European volunteer friends as well - two of which actually just visited me in England over the summer for a week. If you ever fancy trying some great (if not a little interesting!) food, learning how to cut paper in ways you never knew possible or just embracing some fascinating culture I'd sincerely recommend visiting Shanghai.

 

The centre had several classrooms, a multi-sense room and a fully functioning kitchen for both western and Chinese cooking.

 

 

 

 

They were very excited to show me Chinese baking!

 

Never have I been in such a positive place with such positive people.

 

Such a city of beautiful contrasts!

 

About as close as we got to seeing a real Chinese panda!

Statistics as reported by the Chinese Government - http://www.stats-sh.gov.cn/tjnj/zgsh/nj2011.html
UNDP statistics - http://report.hdr.undp.org/
More information on volunteering in China with the organisation that I used - http://www.lovevolunteers.org/programs/china


Personally managed births to go: 17

New Year

Tomorrow is the first blank page of a 365-page book. Write a good one. - Brad Paisley

I think in terms of the day's resolutions, not the years'. - Henry Moore

We will open the book. Its pages are blank. We are going to put words on them ourselves. The book is called Opportunity and its first chapter is New Year’s Day. - Edith Lovejoy Pierce

One resolution I have made, and try always to keep, is this — To rise above the little things. - John Burroughs

Be always at war with your vices, at peace with your neighbors, and let each new year find you a better man. - Benjamin Franklin

For last year's words belong to last year's language And next year's words await another voice. - T. S. Eliot

A new heart for a New Year, always! - Charles Dickens



Whether your New Year was spent out on the tiles, on the banks of the Thames or on the sofa with the ones that you love, I hope it was filled with happiness, positivity and dreams of the bright future ahead.


Personally managed births to go: 17

Merry Christmas!

 

Have a very Happy Christmas!

 

 

May all your days be as wonderful as Coventry University's Elinor Clarke's knitted boob!

Tanzania 2015

In September 2015 I went volunteering in the fantastic  town of Arusha, Tanzania. The place, the people and my overall experience were like nothing I've ever known. Little old me, stepping off the place onto the African continent for the first time, had no idea how much of an incredible place I was about to visit.

I liked Tanzania, can you tell?
 
In terms of Midwifery however, it was probably the hardest experience I have ever had. Resources were poor, the culture is very different, and the outcomes were not always good. Coming from a country with some of the highest standards of care and healthcare provision to this was quite the shock for me. Doctors led the care. Kindness and compassion was rare. Beds were shared by up to 3 people, regardless of whether they had a live baby in their arms or not.
 
The hospital was the biggest in the town. Women usually birthed in their homes, especially those from the tribes in the surrounding villages, meaning they usually only came into the hospital if something had gone wrong. The ward had about 12 births a day. Running water was not always a given and gloves were used on a only-if-absolutely-necessary basis because they were hard to get hold of. It was hard.
 

 The delivery room complete with three beds and the adjoining utility room for equipment cleaning. 

 

 
 

 

Some lovely student midwives who took me under their wings and laughed when I told them we were allowed to deliver babies and undertake vaginal examinations as students - apparently that's unheard of over there!

 

 

 
 

 

Babies were not labelled at birth, merely wrapped in a 'kanga' blanket which the mother provided. This meant that the single resuscitaire on which babies were stacked after delivery was always beautifully coloured.   

 

I cannot deny that it was not an easy place to volunteer, but it really opened my eyes to birth and midwifery in it's rawest form. There were no assisted deliveries, because there was no equipment to do so. Women birthed and it was expected that it would all be normal. Surprisingly, whether that be to do with the lifestyles of the women or the culture and expectations of birth, it usually was. Intriguing.

The one caesarean that I saw was due to eclampsia and there was a little bit of oxytocin thrown around if a woman's labour really was slow. Everything else was just normal birth, with entire belief in the physiology of women from both the professionals and the women. 'Birth will happen. And then you will breastfeed. Your mother did it, you will do it.' - the mind-set of every single woman. It was mind-blowing.

 

It made me think quite long and hard: about our own culture around birth, what influences the differences between their style of thinking and ours. Why have we gone our way and them theirs?

 

 

 
 
For more information on volunteering in Maternity in Tanzania, see the companies I used below:
http://www.thegreenhouse.co.tz/volunteer.html
http://www.lovevolunteers.org/programs/tanzania
 
 
Personally managed births to go: 17

Mindfulness

In the press, the concept of mindfulness is often seen as a bit hippy dippy. A bit crazy. Exclusively for Buddhists whilst crossing their legs in that impossible over-the-knee madness. I'm sure you need double jointed knees for that manoeuvre. 

But we are mindful every day. It's a part of being human. It's just recognising it and harnessing it to utilise it for better things and self development.

            'Mindfulness is about being fully awake in our lives. It is about perceiving the exquisite vividness of each moment. We also gain immediate access to our own powerful inner resources for insight, transformation, and healing.' - Jon Kabat-Zinn, Professor of Medicine Emeritus at the University of Massachusetts Medical School

Whenever you take a moment to reflect, as we in the healthcare system regularly do, both formally and informally, you are being mindful. Whenever you assess how well something went, how you could improve the situation, the role that you played, you are developing your insight and preparing for transformation.

See. You are doing it.

But how can we apply this to our lives? How can we actively be mindful to develop ourselves?

Just take a moment every day to actively think mindfully. Reflect on something, appreciate who you are and what you have, think of all the ways in which you are happy. Some choose to do it for ten minutes every morning, some choose to do it like the Buddhists in that mad seated position that my legs will never be able to do. I do it whenever I'm washing up. And I like it.

Give it a go. I dare you.

To read more about it, have a little look here. I know it's in the stress, anxiety and depression section, but everyone has mental health and that should be cared for.
http://www.nhs.uk/conditions/stress-anxiety- depression/pages/mindfulness.aspx 

Personally managed births to go: 17