The Five Ts of Transformative Midwifery

Thursday September 25, 2008: 15:40 Kalabaklabakan Mountain Clinic

I type this on 50% computer power, and once that 50% is gone, it may be another 5 days of brown out before I can charge up again! There was a typhoon over the weekend and since Saturday we have only had power for 3 hours.

Now that I have more birth experience under my belt, I can truly consider myself a ‘barefoot midwife’. It is good to have some time to sit and reflect upon my experiences, and on the general situation here in Barangay Trinidad. With two very different cases of gestational hypertension and a tragic case of undiagnosed twins who didn’t survive, my recent experience has been more indicative of local maternal and infant health statistics. It is one thing to read that a community has a maternal mortality rate of 1/100 and an infant mortality rate of 0.8/100, but to directly experience the conditions, political, economic, cultural, geographic, that contribute to these shocking statistics is a life-altering experience.

It is simply not enough to practice as I was trained. Not to deny that at the University of British Columbia I had one of the best midwifery educations in the world, that is a privilege of which I am keenly aware; rather it is not enough to simply practice. A midwife in the Third World context must go beyond her calling, to be one with the women in all aspects of their lives, to be changed by their experiences, and to struggle as they struggle for systemic changes. It is only through mutual support and encouragement that we, as women, can tackle at the roots the conditions that give rise to so much hardship and suffering.

As a response to my recent experiences, I have brainstormed what I call the ‘5 T’s of Transformative Midwifery’.

The first T is Track. Track refers to the provision of typical midwifery care, in particular, antenatal care. It is essential for the prevention of crises to track all of the pregnant women in the community, whether or not they present for midwifery care. Through word of mouth it is possible to learn of who is pregnant and where they live. To track I am envisioning a large wall map for a visual aid and reminder of all current cases.

The visual wall map works in tandem with the second principle of track, which is to have regular rounds of home visits for all pregnant women. Home visits are imperative for a number of reasons: a) women will actually get the care if you go to see them at home – if left to attend at clinic visits this is far less likely as work often takes precedence over personal care, b) at home visits you can see the conditions of the home and judge the poverty of the family and how they will deal with a need for expensive hospital or doctor visits, c) walking the distance to the home allows you to assess the emergency transport situation and make an informed recommendation on transport and safest birth location.

Finally, tracking includes a third step, the documentation, compilation and interpretation of local maternal and infant health statistics. From the patient record, a central database can be created to monitor the common health problems and health outcomes of the community. An example for Trinidad is the incidence of goiter and the success of implementing educational programs on the consistent use of iodized salt. As a mountainous area, iodine is lacking in the diet, and many women suffer from goiter.

The second T is Treat. As midwives we are valued for the care we can provide childbearing women and their families. In a rural, Third World setting the preventative care we provide can save women from extremely costly and difficult doctor or hospital visits. Early and effective treatment of common illnesses can save women from serious illness or even death.

The focus on prevention goes hand in hand with the use of locally available herbal remedies. Encouraging each woman to have an herbal garden is a great way to boost her self-care and make effective use of local and free resources.

The production of locally-relevant patient care guides is the third aspect of treat. The liberal use of images helps in a context where the vast majority of the population stops their schooling between grade 3 and grade 6. Disseminating correct information is important, so the production of patient education materials works in concert with the training of the Community Health Workers, who can engage in door-to-door outreach and oral education.

The third T is Transport. This is perhaps the most challenging of the five Ts. Planning emergency transport in a rural, mountainous setting is extremely taxing and yet of vital, lifesaving importance for childbearing women and their infants. Each woman needs to have a transport plan in place from the first weeks of pregnancy until after delivery. This plan needs to be shared with family and neighbours.

Encouraging the People’s Organization (PO) to have a centralized transport plan will assist all women in the PO and allow for faster and more coordinated emergency transport. Encouraging the PO leadership to meet and discuss the particular needs of childbearing women and their infants could be a positive step in breaking the silence that seems to exist when it comes to the particulars of women’s health. I have noticed that this is even a weakness within the Community Based Health Programs that women’s health concerns and training in women’s health care seems to take a back seat.

Knowing when to transport is a challenge, especially when travel takes over 2 hours and the hospital fees are very expensive for the family to bear. The decision over whether to transport is truly a cost-benefit analysis; when a family has to sell animals and order their older children to leave their schooling or paid employment to mind the younger children and perform the household duties, it is not just a matter of dialling 911. The role of the midwife is to provide leadership and skilled knowledge in the decision to transport, judging the seriousness of the situation to the best of her ability; however, the role of the midwife must also be to respect the family when they decide not to transport and take risks that as a privileged midwife from a First World country, it can be difficult to accept.

The fourth T is Train. All community members benefit from the principle of a ‘Health Worker in Every Home’; hence training one woman from each family to provide care for common discomforts of pregnancy, how to support a woman in labour, and how to care for common newborn concerns would be a boost to the health of all.

More intensive training for the community health workers (CHWs) on the common illnesses and health issues of pregnancy, on childbirth emergencies such as breech and shoulder dystocia, and warning signs of pregnancy and labour and when to transport would be of major assistance to the midwife and to the women of the community.

Providing targeted community training and public education on how to prevent and treat the most common health issues identified through the first T, Track, would help to improve the incidence and outcomes of these health problems.

Finally, working in cooperation with local Hilots (traditional birth attendants) and inviting them to all educational events and opportunities will raise the level of care for all women in the community. Respectfully asking the Hilot to send someone to fetch you when she attends deliveries gives the midwife the opportunity to observe practice. Watching the Hilots work gives midwives insight into local traditions and allows the midwife to make small and achievable suggestions for improvement and change while learning about the rich culture of childbirth among the women in the community.

The fifth and final T is Transform. The last T, but perhaps the most important! Ultimately the roots of the health crisis lie in economic exploitation and political and social oppression. Midwives have a history of taking action on behalf of the women we care for; now more than ever we need to take that action in an organized and coordinated fashion, to address the economic and political roots of women’s ill health.

Joining the activities of the PO, using the contact made with women during the course of midwifery care to encourage women to join the PO, and increasing the participation in mass organization at the community level is a good first step.

Attending rallies, carrying placards, making speeches, writing press releases and statements on the conditions of women in the community are some positive ways to raise the consciousness of the community. Making it known that, as a midwives, we deplore the lack of public health care services, decry militarization in the community, and are outraged by backward and corrupt land ownership and grossly inadequate wages and unsafe working conditions allows community members to understand, through our actions, the link between poverty, oppression and the health crisis in their communities.

We must, as health care workers, take sides; we cannot remain neutral, for in this struggle for life there can be no neutrality. To be silent is to give consent to those who steal life from the poor. To take action is to say I stand with the poor; I am on the side of justice.