Before departure

One of the first practical issues to address for those wishing to work outside their own country is obtaining permission to work and ensuring that they have the correct visa. This can be difficult, as many countries have stringent regulations for issuing work visas and it may be necessary to produce an official letter of invitation from the employing agency or company. Without the correct documents and letter of invitation, it can be complicated to gain entry into the country and obtain permission to stay and work there; therefore it is always advisable to check the requirements carefully before departure. Most embassies or consulates will provide the necessary information and advice on the documentation needed to apply for a work visa.

Attention to health and personal safety is another essential practicality that must be taken care of before departure. In particular, it is essential to have adequate medical insurance cover. Where possible, always ensure insurance cover will allow an unscheduled return home to deal with personal difficulties, as trying to arrange this very quickly from another country can be traumatic. Many agencies or employers will be sympathetic and may include this as a benefit in the recruitment package or terms and conditions of the contract, if one exists. When responding to advertisements for a specific post, these details should be clarified before accepting the position. Critically it is vital to have up-to-date vaccination cover. Information on necessary immunizations, health precautions and so on is readily available from the WHO. Many countries also have a national travellers’ help-line or institution and professional association that will also be able to offer advice.

The issues that are frequently least easy to deal with are the actual feelings and psychological practicalities of working in another culture. Adaptation to working in a different country with different customs, beliefs and traditions can be difficult, even when anticipated. Midwives may find such feelings difficult to accept, as they conflict with their internal view of themselves as a capable, flexible practitioner. A great deal of illness however, can result from the stress of working in such conditions. The potential for such illness needs to be acknowledged by those going to other countries to work, as well as those recruiting staff from other countries. Therefore speaking to and if possible spending some time with someone who has worked in the same area can be very helpful and rewarding. One of the difficulties of preparing for such stress is that it is not easy to predict how well an individual will cope in a given situation at any specific time. The factors that help adaptation are different in every situation. Experience of working in different cultures and countries can help, but each situation is new and must be seen as such.

Increasingly, organizations are providing courses or workshops for health workers who would like to consider this work, to help explore some of these issues before making a definite decision. The International Health Exchange in the UK and the International Red Cross are two such organizations and they provide excellent courses for those intending to work internationally and those wishing to consider it. Information on such courses is often available in quality primary or international healthcare journals. Also there is an increase in the number of university programmes that include elective periods where a short time can be spent in another country undertaking a small project or work experience. Finally The Royal College of Midwives (RCM), the Royal College of Nursing (RCN) and the British Medical Association all have printed materials to help health practitioners who wish to work overseas.

One factor that can influence adaptation to working in another country is the careful consideration of the motives for doing so. As with all career choices, there are varied and complex reasons why someone would choose this particular path. There is no one valid reason for embarking on such a career move, only an issue of individual choice. However in doing so, midwives must apply a certain level of objectivity to ensure the right choice is being made about the suitability, type, as well as place of work that is appropriate for them. It is all too easy to become quickly disillusioned with the new environment if the main motive for seeking this type of work was travel, but the project or place chosen makes travel difficult or impossible.

Clarification of motives is also helpful when faced with unfamiliar, frustrating or difficult situations. Working in another country in a culture that is unfamiliar, is very different from visiting on holiday or for pleasure or interest. However, such work does have its rewards. It can help to develop a wider view of midwifery, motherhood and health. It offers the opportunity for reflection and seeing one’s own practice through different eyes. Most midwives who have done such work feel that it allows them to develop greater flexibility, innovation and self-confidence. Of course, much will depend upon the type of work undertaken, but the advantages and the friendships that develop while undertaking such work often outweigh the difficulties.

Working in a different culture

The requirement to provide culturally sensitive care is embodied in the International code of ethics for midwives (ICM 1999). The main issue facing midwives from another country developing culturally sensitive care is often around difficulties with language and being unable to listen to women’s voices; often transmitted through traditional songs and folklore. Also, in some countries, particularly in Asia, beliefs and taboos surrounding pregnancy and birth can make listening to women’s stories particularly difficult, as they are usually not spoken about directly, for fear of evoking bad spirits or bringing bad luck. Just to acknowledge the pregnancy might be viewed as dangerous. This raises obstacles to both provider and recipients of midwifery care. For example, encouragement of antenatal care, promotion of health in pregnancy, or even advice on planned pregnancies is problematic in a culture where to do so is seen as culturally unacceptable.

One way to overcome such cultural barriers is to work with the local community, especially women’s groups and community or religious leaders. Where such leaders are usually men however, this can raise other gender-laden issues. Gender training or gender sensitivity courses may help the midwife to find a way to work with or through male leaders in a way that will empower women, although it is always essential to first identify, together with the women, what strategies women currently use for dealing with such issues. Assisting the male leaders and the community to consider general household practices and beliefs, and the effects that these may have on childbearing women, is possible, and where this approach has been used it has had positive results (Mullay 2006).

When working on empowerment issues it is important to remember that notions of empowerment are also culturally bound (Portela & Santarelli 2003). Women from different cultures have different ideas about what they see as empowerment (Chitnis 1988, Collins 1994, Dawit & Busia 1995). Given the opportunity however, women from all cultures have clear ideas about what they think would assist them to give birth in a way that is safe and yet culturally sensitive.

Use of appropriate technology

In addition to adopting the right approach to providing such care, midwives also need to concern themselves with the appropriate use of technology. Careful consideration is necessary when taking new technology from one country to another. For example, in many industrialized settings it is no longer considered essential to give iron supplementation routinely to well-nourished pregnant women. In under-resourced countries however, haemorrhage before, during and after birth remains the major cause of death owing to poor nutrition and social deprivation (WHO 2005a). In these situations, faced with high maternal mortality and high levels of under nutrition, it is clearly appropriate to have a protocol that promotes routine iron supplementation to all pregnant women.

Importing systems, technologies and tools without ensuring they get appropriately adapted can adversely affect the quality of care. Although in themselves the tools may be good, if they are not adapted to meet the cultural complexity of the country, they may be ineffective, or used in an inappropriate way. For example, there is almost universal acceptance that the partograph is a useful and effective tool, yet in some countries or cultures the counting of time is not in units of minutes or hours, and even the idea of charting events on a graph can be very difficult. Midwives working in an international arena therefore, need to ensure that the technology they take with them is appropriate and that correct training and systems are provided for its effective implementation and use.

Beware the ‘expert’

Although the above practicalities of working in a different country are of concern for all midwives, it is particularly problematic for those working as international midwifery consultants or expatriate project workers, trainers or managers. The temptation to allow oneself to be seen as the ‘expert’, the one who knows all, is sometimes difficult to avoid. In the eyes of the new community, women and local midwives, there is a serious risk of being perceived as the expert who knows all. Such views can leave the midwife seen as an outsider, precluded from being accepted into the local community and therefore denied access to their knowledge and cultural systems.

The issue of being viewed as an outside expert is particularly problematic when working in countries that do not have recent experience of personal autonomy or personal responsibility. In countries that have a particular political tradition of being controlled from the centre, women may feel more comfortable seeing the consultant midwife as an ‘expert’, dictating the actual activities of care to be provided. Those not familiar with democracy or participation in decision-making may feel slightly afraid or unsure when introduced to participatory approaches. Therefore locals may initially resist or misinterpret requests for their views and opinions, or may not respond to opportunities to share their ideas with the newcomer.

Equally, for the consultant faced with enthusiastic individuals eager for change, tight work schedules, needs that often far outweigh resources or expectations that they will be the one to sort out the problems, can be daunting. In such situations it can be difficult to hold firm to principles of facilitation and participatory approaches to decision-making. In these situations, advocacy can easily stray into paternalism (or maternalism) and then only the voice of the ‘expert’ midwife is heard. The midwife’s role is always to encourage women to find their own voice and as far as possible ensure that it is the local women’s voice that is being heard; for the international consultant this includes the voices of the local midwives. The key skills for the consultant midwife are listening, supporting and participating in the daily lives and tasks of those they work with, be they receivers of care, or working colleagues.

Finally, the role of the consultant midwife can be lonely; therefore anyone taking on this role should ensure that they have a good personal support system from family, friends or long-standing colleagues (preferably ones with similar experiences).

International Confederation of Midwives (ICM)

One of the main actors in the global arena working to improve maternity services by empowering of midwives, especially through strengthening professional associations and promoting good practice, is the International Confederation of Midwives (ICM). ICM, a non-governmental organization (NGO), was started by midwives in Belgium in 1919 as the International Midwives’ Union. The purpose of the union was to ‘improve the services available to childbearing women through campaigning for a stronger, better educated and properly regulated midwifery profession’ (ICM 1994, p 1).

In the early 1960s ICM gained accreditation by the United Nations (UN) as a NGO in official relations, which means it can be part of official UN consultations. ICM works closely with UN organizations especially World Health Organization (WHO) and United Nations Population Fund (UNFPA) as well as with United Nations Fund for Children (UNICEF). ICM now has more than 85 member associations that cover approximately 72 countries. ICM Council admits new members on demonstration they meet the criteria for membership and payment of a membership fee, calculated against the number of midwives in the association and taking into account the economic situation of the country.

ICM has a small but friendly office that relocated from the UK to the Netherlands in 1999. The office welcomes both visitors and enquiries from midwives and midwifery organizations from anywhere in the world. Information on the history of the ICM, along with other information and leaflets, is obtainable from ICM HQ (see Useful addresses). The ICM also produces a regular newsletter free to its member associations, but is available to individuals on payment of a modest subscription.

The global Safe Motherhood Initiative

The global Safe Motherhood Initiative (SMI) was officially launched in Nairobi in February 1987. WHO, UNICEF and the World Bank as well as many NGOs, associations and multi- and bilateral aid agencies and ICM, have supported the global programme from the beginning. The impetus for this initiative was the outrage that many maternal deaths are preventable and that MCH programmes, at that time, focused mainly on the child and ignored the health and well-being of the pregnant woman. The slogan used in the early days being: ‘where is the M in MCH?’

The aim of SMI was to achieve a reduction of 50% in the global number of maternal deaths by 2000. Initially, SMI advocates envisaged that the goals of SMI would be achieved through empowerment of women. This point was further strengthened following the International Conference on Population and Development in Beijing and the UN Conference on Women Platform of Action, Cairo 1995, both of which called for the rights of women to be further strengthened and respected. Since 1987, various strategies have been employed to achieve the goal of safe motherhood and more attention has been given to the right to health and adoption of a rights based approach to health policy (Cook & Dickens 2001). Consequently there was an increase in strategies that focused on improving the sociopolitical and legal status of women, increasing their access to wealth and ending gender discrimination, especially in education and access to healthcare. However, the target set for 2000 was not achieved.

In 1997, to mark the tenth anniversary of SMI a technical review was held in Colombo, Sri Lanka to consider and document lessons learned (Starrs, IAGSM 2000). At this review a number a key messages were agreed – as a call for action. One of the major key messages was a call for ensuring all women have access to a ‘skilled attendant’ at birth (WHO UNFPA UNICEF World Bank 1999). A skilled attendant is a professional health provider with midwifery skills (Box 55.1) (WHO 2004a); to most people this is a professional midwife, someone who has the competency for provision of normal care, is able to manage or initiate first-line care for emergencies and is linked to a facility where specialist obstetric and neonatal care is available for management of complications and cases that fall outside the midwife’s scope of practice.

The call for ‘skilled attendants’ for all women came about as a result of perceived failure to reduce maternal deaths by employing a ‘risk approach’ to antenatal screening, whereby pregnant women identified as having risk factors were provided with specialist obstetric care. Criticism of the risk approach strategy for reducing maternal mortality focused around the lack of specificity, sensitivity and predictability of the risk factors used. Even though it is known that some women with certain histories and medical conditions have a potentially higher risk than others for developing a pregnancy-related complication, research shows that a significant proportion of life-threatening problems occur in women identified as being at low risk when using most of the risk-scoring systems. The failure of the risk approach and risk scoring to directly reduce maternal deaths does not mean that antenatal care does not play a significant role in maternal healthcare and identification of problems. Indeed much research has been undertaken that shows the effectiveness of a more focused approach to antenatal care.

Major global actions under the Safe Motherhood banner

Global Initiatives including Breastfeeding and Baby Friendly Hospital Initiative (BFHI), Saving Newborns Lives (SNBL)

Midwifery identities

Listening to midwives at many and varied conferences and meetings worldwide, it would appear that the global concerns of midwives and the constraints they face have changed little since Kwast & Bentley published their paper in 1991 (Kwast & Bergström, 2001, Odberg-Pettersson et al 2007, Sherratt 2007). Their seminal paper, presented at the ICM pre-congress workshop in 1990, detailed the constraints and problems facing midwives worldwide, which include both the shortage and maldistribution of midwives, as well as the economic and training problems facing midwifery in many countries.

Education of midwives

The education of midwives has been a matter of long-standing debate and concern in many countries, for a variety of reasons. While education and in-service training for midwives in some countries is weak, it must be remembered that education and training is only one element to ensuring that providers are competent; there must also be adequate and appropriate supportive supervision. Moreover, there must also be a functioning health system to support service providers and create an environment where midwives are able to carry out their function correctly, including ensuring their safety and proper remuneration and career pathways.

As previously stated, in some countries, the preparation of midwives may follow on from nursing. While there may be good reasons for this in some situations, there are also a number of disadvantages, particularly where nursing does not have a sufficiently strong public health basis. In some situations, the midwifery-following-nursing model can result in midwifery being seen as an adjunct to nursing. The consequence of this can be that midwifery is too often afforded very little time within the nursing curriculum, as happens in both resource-poor countries and highly industrialized ones.

Increasingly, because of the global shortage of human resources, as outlined in the World Health Report 2006 (WHO 2006a), many countries are or have turned to semi-skilled or multi-purpose workers to fill their human resources for health gaps, especially for provision of healthcare at the community level. Where multi-purpose providers exist, there can be role confusion, as well as overlaps or even gaps in continuity of care for pregnant women and their newborns. For example, sometimes community health workers, or multipurpose public health workers provide the prenatal services work completely separately from midwives who offer intranatal care. Often these multipurpose workers have minimal midwifery input into their curriculum. Some midwifery experts agree the move to increased use of multipurpose workers, coupled with incorporating midwifery into nursing curricula, has led to an ever-spiralling decrease in midwifery standards. The teaching of midwifery being weak, leads to practitioners who have limited midwifery competencies who eventually find themselves as teachers, ill-equipped for developing midwifery competencies in others. For Kwast and Bergström, midwifery, as a specialization, has in many low-income and resource-poor countries become reduced to maternal and child healthcare, or obstetric or maternity nursing (Kwast & Bergström 2001); many others would echo this. These multipurpose practitioners are often unable to perform the full range of midwifery competencies, in particular the essential life-saving skills. Given the short time the curriculum allows for developing midwifery competencies, coupled with the low case-loads because of low utilization of healthcare professionals and/or health facilities, it is little surprise that many of these multipurpose and community healthcare workers also lack confidence and are unable to perform midwifery skills outside of the hospital environment, or without supervision. This issue becomes even more problematic as less and less time is available for developing specific midwifery competencies due to increasing demands on their curricula for additional content related to HIV AIDS and other relatively new public health concerns, such as SARS and avian flu.

Everyone will agree training must be skills-based. However, many training programmes in the past have failed to take account of the fact that midwifery is essentially a practical profession, where practice is underpinned by evidence, scientific principles and knowledge coupled with sound practical application using critical thinking skills (Penny & Murray 2000). The skills required by the midwife may vary from country to country, depending on the specific needs of the country. However, ICM (2002) have now developed a list of international evidence-based core competencies – essential competencies (Fullerton & Thompson 2005). During the First International Forum on Community Midwifery, participants agreed that the ICM competencies should be used as the international benchmark for assessing midwifery competence (Odberg-Pettersson et al 2007). It must be remembered however that in some situations additional core competencies, that may not be seen as usual for midwives in the UK, are required as standard (essential) for all midwives in many resource-poor countries. For example, being able to undertake a manual removal of the placenta or being able to apply aortic compression competently as shown in Figure 55.1 and outlined in the WHO manual Managing Complications of Pregnancy and Childbirth (WHO 2000) may be the only way to save a woman’s life in some countries. Midwives from industrial countries therefore should be aware that, in some resource-poor settings, midwives may find themselves in a situation where knowledge and skills alone are all that are available to save the woman’s life. Training for these and other life-saving skills must therefore focus on achieving competence, which implies use of critical thinking skills, as well as sufficient opportunity for hands-on-practice. Very often in some countries, although the theoretical knowledge may be taught well in the initial pre-service programmes, there is too often little or no opportunity to practise the skills in the clinical situation. As a result, all too frequently, newly trained midwives find themselves lacking in confidence and competence in many of the core midwifery competencies.

Figure 55.1 Aortic compression.

(Based on WHO 1996a.)

With the above in mind, many countries including Western countries such as the USA, Canada and New Zealand, have successfully introduced direct entry programmes into midwifery, while others are exploring the issue. Direct entry programmes have been well established in some countries such as France, the UK, and Holland as well as Chile and Indonesia to mention but a few, for many decades. Some feel that such programmes offer a greater opportunity for midwives to be acknowledged as autonomous practitioners and true partners in the team required for safe pregnancy and childbirth (Box 55.3). Such programmes would also allow developments based on a fitness-for-purpose model (Fig. 55.2). The fitness-for-purpose approach to curriculum planning looks at the required competencies of a midwife for that particular situation or country, and helps countries develop innovative and tailor-made programmes to suit the specifics of their own nation; as for example done by Canada, to address the specific midwifery needs of their First Nation’s (aboriginal) population (NAHO 2004).

Figure 55.2 Fitness-for-purpose curriculum model.

Attempts are being made to strengthen the skills of midwives in many countries. However, this is complicated by the fact that identification of who is a midwife is not always easy. For example in a survey across the 10 countries that make up the WHO South-east Asia Region, there were approximately 18 different categories of worker providing maternity services, of which only seven had the word ‘midwife’ in their job title (WHO SEARO 1996). Some, such as the border midwives in Bhutan, had only 3 months’ training in midwifery and provide delivery (intrapartum)-only care, while others had 1-year midwifery after nursing programme and in Indonesia, midwives follow a 3-year direct entry diploma programme. At a recent regional meeting on nursing and midwifery, from data presented in the various country reports it would appear the situation has not changed and there remains a lack of clarity as to which cadres of maternity workers are truly competent in midwifery.

As outlined in the recent International Forum on community midwifery, one of the main difficulties facing the preparation of midwives is the lack of sufficient numbers of appropriately trained midwife teachers (Odberg-Pettersson et al 2007). Many countries, including some European countries, are currently without a standardized approved preparation for their midwife teachers. This is not new however and has been recognized as a problem for many years. It was partly the debate about strengthening midwifery education and in recognizing the needs of midwive teachers in some countries for additional teaching material, which led WHO to fund the development of the midwifery modules for safe motherhood.

Finally, issues around the omission of research from the midwifery curriculum also remain hotly debated. The lack of research appreciation and research skills in the formal curriculum in many countries is recognized as being detrimental to the preparation of critically thinking midwives. Lack of research training hampers development of the needed documentary evidence from operations research to show how best to strengthen midwifery and midwifery practice in under resourced countries. Midwives must have the capacity to be both proactive and responsive to the needs of individual mothers and babies. Without midwives who are active researchers, not simply research assistants or data gatherers for medical research, engaging upon midwifery research is difficult. Yet without such endeavours it is impossible to build up a sufficient evidence-base to midwifery practice. It is imperative therefore that each country has a mechanism by which some midwives are able to receive adequate preparation not just as expert clinicians and teachers, but also as researchers. Such research is not only essential for midwives and their clients, but is also needed by governments and other decision-makers, to assist with improving maternity services and care. What is needed to bring this to fruition however, yet lacking in too many under-resourced countries, is strong midwifery leadership coupled with sufficient management capacity, including and especially workforce planning, to be able to build an effective midwifery workforce.

Employment and the need for a positive practice environment

Another major problem facing many midwives worldwide includes issues surrounding employment and the environments in which midwives work. Changes such as the rise in HIV and demographic changes and increasing migration to city dwellings (bringing with it the demise of family support networks for childbearing women) will require different approaches to the provision of maternity services.

Mass urbanization, with its overcrowding, increased poverty and deprivation often leading to higher crime and violence, has resulted in an increased concern for the safety of midwives at work. Civil conflict, an increasing phenomenon in many parts of the world, also brings specific issues for midwives and the provision of quality midwifery care. Coupled with the likelihood of poor nutrition, poverty, and other factors that usually accompany civil conflict (the lack of access to medical care), the health of women and their newborns are at greater risk and so the midwife’s role becomes even more crucial. Sometimes the midwife is the only professional healthcare provider that women and their families have access to. However in these situations, both holding and obtaining equipment and drugs become a major issue for the midwife. Midwives in some places have been subject to violence against them because militia have thought they have drugs, which they need for their fighters. Such violence against midwives however is not just a feature of resource-poor countries or in conflict situations. Midwives working in large urban and periurban areas in almost any country of the world where there are high levels of drug-related crime, face such risks on a daily basis.

Demographic changes due to internal migration and increasingly to displacements of populations from conflict areas and/or natural disaster areas, bring with them an explosion of demands on the health services. The resulting economic burden laid on communities means that obtaining adequate remuneration for all public sector workers is a major issue. South Africa for example is facing such problems since the move to free healthcare following the political changes that marked the end of apartheid. Coupled with the effects of mass urbanization and the rise in HIV AID, South Africa is struggling with an overstretched health service, where demand exceeds hospital and district budgets. Midwives working in similar situations are being faced with many of the same problems (Box 55.4).

Finally, in many countries, despite the challenges placed on public services, setting up of independent community practice is difficult and is often devalued. Even some Western countries, including the UK and some states in the USA and Canada and Norway, are facing similar problems with independent midwifery as insurance companies can be reluctant for a variety of reasons to pay for this type of service. Often the reason for these problems relates to the close association of insurers with the medical profession, who are not always supportive of midwifery-led care. As funding of healthcare becomes increasingly reliant on insurance scheme, this is likely to become an increasing problem.

The success of the midwives in The Netherlands, Canada and New Zealand to have their services recognized as a legitimate option for pregnant women, does however offer hope (Donley 1989, Donley 1995, Smulders & Limburg 1995), but it should be remembered that these successes were as a result of hard-fought battles. In each case, although circumstances may be different, the force of medical opposition was enormous and the midwifery profession had to unite and work in partnership with women to achieve success. In both Canada and New Zealand the force of women’s support was paramount. This can be achieved only if women are free and able to offer this support – free in that they are not excessively burdened with malnutrition, ill health and poverty. Unfortunately in some countries, women’s status is low and many women are still being denied freedom to demand what should be a basic human right – the right to access care during pregnancy, childbirth and for the important months after, from a competent professional midwife.

Scope of midwifery practice increased in some countries

Increasingly, turbulence, war and political upheaval are posing new problems for midwifery. Violence against women is more than ever on the international agenda, despite the UN Convention on the elimination of all forms of discrimination against women (UN 1979) and the Declaration on violence against women (UN 1993). According to a large-scale scientific study conducted in collaboration with WHO it was revealed that between 10% and 50% of all women reported they had been subject to physical abuse by an intimate partner in their lifetime, much of the violence beginning in and around pregnancy (WHO 2005b).

Female genital mutilation is still a concern in many countries, as is the damage inflicted on women as a result of lack of appropriate healthcare in pregnancy and childbirth. Morbidity, especially pelvic floor problems, incontinence and vesicovaginal fistulae, and the provision of appropriate and safe reproductive healthcare for refugees and displaced persons, are perhaps the most pressing concerns for research and innovations by midwives. Such occurrences call for midwives in those countries to extend their practice into the broader sexual reproductive health and rights’ arena. Midwives in some of these countries are being trained to undertake limited surgical procedures such as performing a caesarean section and repairing vesicovaginal fistulae, as well as carrying out medical abortions and menstrual regulation. Therefore, despite the catalogue of challenges facing midwifery and midwives worldwide, there are signs that midwives are increasingly being seen as key workers and the current climate is favourable for strengthening and making midwifery more visible.