Roughly 800 women and more than 8,000 newborns die every day, due to largely preventable complications during and after pregnancy and childbirth. If a well-trained midwife had been there, according to a Lancet study in 2014, 83% of those lives could have been saved (pdf).
And as 4,000 midwives from 114 countries gather in Toronto this weekend for the International Confederation of Midwives Congress, the greatest concerns are around global shortages and under-investment in such an essential field of health.
“Good quality midwifery care supports a woman emotionally, psychologically and also physically,” says Fran McConville, technical officer for midwifery at the World Health Organization. “When you feel confident with someone who’s caring for you in childbirth, labour will progress as normally as possible. Well-trained and regulated midwives are really good at identifying problems early. They can tell if the presentation of the baby isn’t right, and they’ll quickly do something about it.
McConville says that where there is no midwifery, in large parts of the world, women are not getting quality care, and are being denied their human rights.
According to the 2014 State of the World’s Midwifery report, a workforce of fully trained midwives was found in only four of the 73 middle- or low-income countries surveyed.
Yael Velleman, senior policy analyst on health and hygiene at the aid agency WaterAid, says health facilities also need to be improved. A report by Unicef and the WHO found that a third of healthcare facilities in low-income countries don’t even have soap and water for hand-washing.
Poor facilities coupled with the long distances that some women need to cover to reach health centres mean many choose to give birth at home, risking their lives.
“There’s also a question about [the midwives’] own exposure to disease,” says Velleman. “What does it mean if they have to take time to fetch water? What does it mean for them if they don’t have clean water to drink or a safe place to go to the toilet? You get a reluctance from women to go and work in rural areas that might not have the facilities.
Midwives talk about not being able to prevent women and children from infection because there is no running water
– Yael Velleman
“[Midwives] talk about the guilt they feel when deaths from infection happen,” Velleman says. “They think, ‘Could I have prevented this?’ Midwifery is a calling, it’s not just a profession, and they care deeply about this.”
- Kamona Sordar, 21, with her baby Boishakhi, born in April, and her midwife, Kolpona Saha, 43, in Chalna Bazar, Khulna, southern Bangladesh
“We always tell mothers and their families to go to nearest clinic,” says midwife Kolpona Saha. “But sometimes due to poverty, bad communications, a religious matter or an emergency, I have to do the delivery in the mother’s home. I have to manage with things around. I find dry clothes to put on the child, use a local blade to cut the cord. Sometimes, it is hard to find a good place to put the newborn so in that case I have to keep them on my lap.
“Kamona was very scared from the first month so my challenge was to encourage her and give comfort to her so that she never lost courage.”
Kamona is full of praise for her midwife. “Without the help of Kolpona, it [would have been] impossible for me to be prepared for the biggest experience of my life. I am very happy with [the midwives’] work. Without them, I would not have survived. I am really thankful.”
- Samuel Nshimyumukita, nurse-midwife, 30, with Ruth Nyirahabimana, 24, and her baby, Uwamahoro Emeline, at Nzangwa Health Centre, Kintambwe, Bugesera, eastern Rwanda
Ruth Nyirahabimana, 24, delivered her second baby, Emeline, at Nzangwa health centre in Rweru, Bugesera, Rwanda.
“I am very happy,” she says. “She is not even one day old. I can’t wait to go and see how her older sister reacts when she sees her.
“A friend of mine gave birth here in the summer and we brought a jerrycan of water with us when she came here. We used half of it and we took the other half home when we were done. That’s how precious the water was. There is water in the health centre now.
“The midwife is a very kind man. He talked to me, he calmed me down. He told me the kinds of symptoms I should look out for and that I should call him if necessary. From how much he cared, I was convinced everything was going to be OK. I saw him cutting the umbilical cord. He cleaned up my baby himself. He was there through the whole process.”
Samuel Nshimyumukita, a nurse-midwife at the centre, says: “I just love my job. I’m doing what I have always wanted to do.
“Seeing a mother who is in pain and then you help her to deliver and you take the baby and give it to her and you see her happy to be holding it in her arms. I feel like I am happier than the mother herself at that moment.”
Nshimyumukita says that none of the previous health centres he worked for had water. “Mothers were obliged to carry their own. It’s not easy to not have water in the delivery room. Now we have clean water that we can wash with, but also the mothers can wash before they go home. It makes our practice not only easier, but safer. I hope the children will be vaccinated and grow up healthy.
“It’s something I have seen in my career now. You bring them to life but then if you don’t feed them well, they will die from malnutrition or their growth will be stunted. My hope is that they will grow up with good nutrition.”
- Rebekah Mclaughlin, 23, and her baby James with midwife Helen Faux, 46, at Liverpool women’s hospital
In Liverpool women’s hospital, the biggest of its kind in the UK, 20 babies are born a day.
“You use water every day in my job,” says midwife Helen Faux. “If we didn’t have it in this hospital, we’d probably have to shut down. There would be outrage, we’d be turning away mums. Soap and water are the first line of defence against infections. We use it for everything, from taking blood, to washing our hands during invasive procedures, and things like filling the birthing pool.
“Aside from the normal routine things, it’s about providing emotional support to the women too. Each baby and each person is different on this ward.”
New mother Mclaughlin says the first 24 hours of being a mum have been a learning curve. “But it’s been fab,” she says. “I had an emergency C-section. It was quite a lengthy process but apart from that it was all right. The midwives go through everything in the pre-natal checkups – breastfeeding, bottle feeding, changing nappies, bathing.
“If I didn’t have the midwives supporting me, I would probably have been an emotional wreck. I can’t imagine what it would be like [delivering in a hospital without water]. Everyone should have the right to basic things – without that you take away your dignity. It puts a pain in my heart a little bit to think that things aren’t perfect for other women. James can have a bath today and we’ll be going home today. Hope for the future? As long as he does something that makes him happy, that’s fine by me.”
- Nurse-midwife Kennifer Samu, 26, and Ruth Anderson, 19, with her first child at Ngokwe health centre in Machinga, Malawi
At Ngokwe health centre in southern Malawi, there are no proper toilets or bathrooms. Though the Deliver Life project, funded by the UK government, the health facility will achieve access to clean piped water and sanitation facilities, which can’t come soon enough.
“We have no tap water so we usually draw water from a nearby borehole, which is quite tedious, says nurse-midwife Kennifer Samu. “The government installed water tanks that harvest rainwater but during the dry season, they are empty. In the maternity ward, we have two water buckets but sometimes they get dry, which causes problems. We try our best to keep the water buckets full all of the time.
“We do not have bathrooms indoors. This means women who have given birth have to walk outside the ward and clean themselves. For those who have just given birth, that impacts on their dignity. The toilets intended for the patients are in bad shape.
- Open bathrooms used by pregnant women, Ngokwe Health Centre; Ruth Anderson (seated) with women waiting to be discharged with their babies
“We normally have six to seven deliveries every day as this health centre supports many surrounding villages,” says Samu. “This means that within a day, all six pregnant women have to use only two beds our small maternity room has. We have had many cases where some women had to deliver on the floor due to lack of space.”
Anderson says she brought three pieces of fabric with her when she came to the centre, one to cover the baby and the other two to clean herself during and after giving birth. “I also brought with me a plastic foil used during birth to hold the water and blood to keep the bed clean as the ward only has two beds. I brought a basin which is used for bathing and in my case, it was used to carry urine as I was not able to move after giving birth.
“Yesterday when I was having contractions, I visited one of the toilets and they were all occupied. I ended up visiting the nearest bush to relieve myself. It was scary but I couldn’t hold it. A lot of women do that as well. Worst still, when I had given birth, I had to use the basin I brought to defecate and my mother had to get rid of the waste. I felt so sad. My dignity was lost as there were other women in the maternity ward who saw what happened.”
- Colleen with her newborn baby, Soraia, and midwife Joanne Yan, at Ottawa Birth and Wellness Centre, Canada
First-time mother Colleen gave birth at home. Afterwards she visited the Ottawa Birth and Wellness Centre with Soraia, her new baby daughter, for a checkup with midwife Joanne Yan.
“I think I was too busy to even prepare mentally for the birth,” says Colleen. “I was trying so hard to get everything done before the due date and she came a week early. But I managed to get the important things done.
“But even before that, how I tried to create a birth environment took a lot of months of planning. I found Joanne. I had a lot of trust in her. So she was the first person on my birth team that I chose. After that I got a photographer, a doula [a person who supports women during childbirth], and we bought a house. When we bought the house I envisioned where the birth would take place. So everything came together in the end.
“I’m a clean person and my doula wanted to make sure that everybody in the room knew I’m a clean person. So we made sure we laid out a lot of towels and clean water. I rented a birth pool. So of course the water that goes into the birth pool has to be clean as well. I was too relaxed in the pool so they had to pull me out. My midwife’s medical background put me at ease. I was confident in her skills and her abilities. She’s so gentle with everybody. So compassionate.”
- Parboti Rani Dhali, 45, with Shokla Mondol, 19, at Dacope Upazila Health Complex, Chalna, Khulna, southern Bangladesh
Midwife Parboti Rani Dhali works at the Dacope Upazila Health Complex in Chalna, southern Bangladesh. She has been a midwife for more than 20 years. “We had a real water problem before. The toilets weren’t good and all the people suffered from poor sanitation and poor hygiene,” she says. “Now the water problem is gone so patients, and hospital staff all are getting the benefits. There is a latrine for new mothers, which is hygienic, but the toilet in the labour room is still in poor condition. Also we have limitations with sterilisation. A new water supply and toilets have improved our environment a lot.
“With Shokla’s childbirth, there were no complications except the limitations with our labour room equipment. Shokla is a strong woman and she cooperated with us very smartly. She and her baby are in perfect shape.
“Because of the improved toilets and hygienic environment both mothers and babies are in a good hospital environment. The cleaner is doing the job seriously, cleaning three times every day. It is much better than before.”
- Midwife Bimola Kobiraz, 29, delivers a newborn baby to mother Hera, 20, at Dacope Upazila Health Complex
First-time mother Shokla Mondol, 19, says she has been in contact with the health complex since the start of her pregnancy. “I did my regular checkups along with my mother. The doctor used to tell me how to prepare: that I should save money, buy fresh cloths for me and baby, also the doctor told me to keep away from heavy jobs. I took precautions all the time. I never missed any checkup and took my food regularly following a perfect diet as told by the doctor.
“When I entered the labour room, I saw all the nurses wearing nice white coats and gloves. The room and its environment looked safe. I heard all the instruments were sterilised, also the bed and room seemed clean. So it was a good experience for me to give birth to my first child in this hospital. I can’t imagine giving birth to my baby in another place, without enough water and good hygiene.“Parboti helped me to bring my child into this world. From then till now she is looking after me and my child regularly with great care. She told me how to feed my boy, what to do when he cries and many other things. I am really grateful to Parboti for her support and care.”
- Sada Juma Njuki, 26, and midwife Daniel Paul, also 26, holding baby Jafary in Kiomboi district hospital, in Iramba District, Tanzania
Sada Juma Njuki, 26, in Kiomboi district hospital, Tanzania, says that although she has had complications with this pregancy, the nurses have been very supportive. “Everyone looks motivated and happy to help. If I had gone to a small health centre near my home, I would not have managed to deliver my baby.
“I have enjoyed my stay in the hospital because the maternity ward is always clean, we have mosquito nets, everyone sleeps on a bed and, above all, we have tap water nearby and nice toilets.”
Nurse-midwife Daniel Paul is pleased with the WaterAid work that has restored piped water to the hospital in Tanzania, added water storage tanks and an incinerator, and renovated a home for expectant mothers.
“The work being done here at the hospital truly makes me feel good because I’m seeing change and the work is going on very well,” he says. “Personally, when I think of a baby getting sick, it is really paining me because all I can think if it were me during that time, if I had got sick, I could not be here today.
“I chose to be a midwife so that I can help the woman who are pregnant, the women who are breastfeeding and also the newborns. I believe that if I help these women, they are a big help to the nation.”
