Grace Edwards is the Aga Khan University Foundation Professor for Midwifery Education and Practice for the already running program in Uganda. She has been there since 2016. Having practised midwifery for over 4 decades, she has taken up a couple of big roles. In 1993, she was appointed the Regional Coordinator for The Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) until 2002. That same year she was employed as one of the first consultant midwives in the United Kingdom specializing in public health in Liverpool.
Since 2008, she has worked in the UAE first as the Midwifery Research and Development Specialist at Al Wasi Hospital in Dubai and then become The Assistant Director of Nursing and Midwifery at the Corniche Hospital in Adu Dhabi in 2011. In January 2017 she accepted an Honorary Appointment as professor of midwifery for the University of Salford in the United Kingdom. She will be spearheading the program here in Kenya. I sat down with her to get to know more about midwifery and the program.
1. Please tell us a little about yourself
I am a professor of midwifery and practice at Aga Khan University and have practised midwifery for 41 years. I have been working in Uganda for 18 months as a midwife although I have always maintained my clinical practice in Kawampe Mulago which is the National Referral Hospital. My role covers Uganda, Tanzania and now Kenya.
2. What inspired you to become a midwife and how long have you been one?
In the beginning, I started training as a nurse and halfway through my training I realized that the care for women in labour was so poor. This was in The United Kingdom. I really felt that there was a better way to do it. So I decided that I was going to be a midwife. So as soon as I finished my nurse training I went straight to qualify as a midwife and have worked in midwifery ever since.
3. What has been your experience as a midwife?
I am hoping to change practice since the experience I have gotten in the United Kingdom has developed, since I worked there in the ‘70’s, and it is very transferable here. So there are lots of things here that we can make better and it is not always about resources, it’s about respectful care.
One of the services I would like to see includes treating the women as partners in care rather than treating them like they are sick because pregnancy is not an illness. When the mother comes in she is going to be scared because she has not been prepared for the delivery and midwives can make that better for her. They can make the experience a really positive one for her by supporting the mother and treating them as an equal.
4. What challenges have you face in your career and how have you overcome them?
Coming to East Africa has been different to what I am used to. In terms of practice, it is coming from a high resource country with different issues and problems. There is a phrase that the World Health Organization put forward which is, ‘too much too soon, too little too late’. The high resource countries have ‘too much too soon’ so there is a higher level of the caesarian section, interventions, and medicalized childbirth while here it is the opposite. There is not enough medicalization, no access to care or services so basically here is where we have the ‘too little too late’.
You find that women have to travel for a long way and wait a long time to have specialized care. Sometimes they do not have an understanding of the importance of seeking care especially when things go wrong. So the things I am trying to teach midwives here is to encourage women to access care and to educate them and to make sure that we provide respectable care ourselves.
5. What kind of training do midwives go through and how long does it take?
It depends what country you are in. Here in Kenya, the program we are offering is an upscaling program. It is a work-study program for two and a half years. So we are offering it to qualified midwives and nurses who meet the entry requirements. By upscaling them, we increase critical thinking skills and evidence-based practice. All that is eventually what will go into providing great services for mothers.
In other countries, full-time training would be 3 years for an undergraduate program. Here, most midwives are registered for diploma level. So what we are offering is purely an upscaling program. I am not sure how many schools in Kenya offer midwifery as an undergraduate degree program but in Uganda, we only have one. This makes this program that much more important.
6. What is the role of a midwife?
The midwife is the expert of normal births. Doctors and nurses can deliver the baby, but they also do other things. Mid-wives concentrate on the care of pregnant women and looking after them. That is their speciality. So the midwife is the expert at normal birth and the doctor is the expert at complicated birth. The skill of a well-trained midwife is recognizing when birth is normal and keeping it normal but also being able to recognize that things can get complicated and they need to refer the situation to a doctor.
We talk about what we call the three delays model which is a documented model that talks about how women are not educated to access care. The second delay in the model is that they access care but they do not go to the appropriate facility. The third delay is that they go to the appropriate facility but they do not get the appropriate care. Where midwives come in is that they can refer the women to where they can get appropriate care. They can diagnose and realize when things are not right and they need to be escalated to a higher facility. However, they can also act on their own initiative. They are trained to deal with emergencies effectively and appropriately.
The ideal situation is where the midwife engages with the woman when she is pregnant, looks after her during the pregnancy and then helps her to give birth. By now they have that relationship that the woman feels safe and has somebody that she knows. Then the midwife also helps her after birth to help her get started on breastfeeding. So a midwife offers continuity of care.
7. Apart from delivering children, are there any other roles that a midwife can undertake in a hospital?
Yes. A midwife can do pre-conceptual care, family planning, postpartum care, menopausal care, and gynaecological care. They look at the whole continuum of reproduction.
8. What are the common myths and misconceptions that people have about midwives and the work they do?
People do not understand what the role is. They either think you are a nurse or a doctor. So for instance, my title is Dr since I have a PhD but I am a midwife and I make sure people know that. It is about marketing our role. We can really be invisible.
Additionally, in most developed countries in the United Kingdom, the midwife provides all the care for pregnant women. So when we ask them to see the doctor they ask what is wrong. They think something is wrong since they know the midwife provides normal care. In developing countries, people think you have to have a doctor to look after you because they think it is better. It is not necessarily better. It is about understanding the different roles and understanding that most women have normal births.
9. Midwifery has been there for centuries, are midwives still needed in this time and age?
Childbirth has gone on for forever. People have had children since the dawn of time. The word midwife means ‘with woman’. So it means supporting a woman through the crucial part of her life since it is the biggest thing that can happen to her. We need to understand that most women have normal births and the midwife whose skills are in normal birth is the most appropriate to handle the situation while also working with the doctors in case of a complication. However, even after, mothers always need a midwife to help them in recovering from childbirth, breastfeeding and establishing a bond with the baby and pain relief discussions. All these are done by a midwife.
Some nurses are skilled as mid-wives but unlike midwives, they do more in the hospital. As a midwife, your speciality revolves around the needs of a mother and her child. Nurses have very diverse roles; they can look after the elderly or surgery recovery patients. They do not have the specialized skills to look after a new mother all the time.
10. Tell us more about the BSc Midwifery Programme offered at The Aga Khan University.
The program started in 2015 in Uganda but will start in August 2018 here in Kenya. It is concentrating on the critical skills and critical thinking of midwives. So we are very keen to understand the Sustainable Development Goals (SDG) in terms of health and ensuring that the midwives come out of the program as leaders so they can also contribute to these SDG’s.
To apply, you need to meet the entry requirements, which are country specific. You will have to submit an online application form along with supporting documentation. The program only takes in between 25 to 30 applicants and starts in August of each year. Our students can apply for scholarships and eligible students may inquire about the fee structure while applying.
The bachelor’s degree is a work-study program, which allows midwives and nurses to continue working while studying in order to achieve higher-level qualifications. It is a two-day week program that provides adequate theory and clinical practice hours. We as faculty, support them during the entire process. I actually go to the clinical area with my students in Uganda.
11. Will the program offer job placements after the program is over?
We cannot guarantee jobs since jobs change every day but having a bachelor’s degree in midwifery is a very covetable qualification. We found that in Uganda, every single student has been promoted. So they are all working on the next level in their places of employment. However, there were 2 that we did employ since they were really great. Additionally, most people come from their own jobs so they just get the opportunity to grow there.
12. What advice would you give to someone who wants to pursue a career in midwifery?
It is the best thing you could ever do. Being with a woman and having her be the centre of your care is fulfilling. It is a very happy career, most of the time. However, sometimes the baby may not make it but we teach midwives to be able to take mothers through that experience. They make the experience as painless as they can by helping the mother understand the reasons it happened.
13. What do you think is the state of maternal healthcare services in Kenya and in the other countries you work in?
There are some resource and equipment issues so it causes problems with the provision of care. There are not enough midwives which is why I am focused on training more midwives. Also, there are not enough drugs. By developing skilled critical thinking skills in the midwives, we can help them lobby for better services and better care for women.
14. What will be the impact of increasing the number of skilled midwives on some of these issues?
There is so much evidence that shows that having more skilled midwives in the workforce reduces maternal mortality and that is key with these regions we deal with. For instance in Uganda, 336 pregnant women out of 100,000 die. To give you a perspective of how bad things are, in the United Kingdom there are 9 out of 100,000. By introducing skilled midwife services we can deal with the three major causes of maternal mortality which is postpartum haemorrhage, infection, and preeclampsia. And we teach midwives how to deal with such issues.
15. What is your take on how best hospitals can improve maternal healthcare services?
Look at the SDGs since they are the drivers until 2030. And there are so many reports that acknowledge these goals. Kenya, Uganda, and Tanzania have had sustainable development plans so we can reduce maternal mortality. And the World Health Organization has very clear directives in terms of which way we should go in terms of maternal health care.
They just published two important papers, one is Anti-natal Care for Positive Anti-natal Experience and the other one is Inter-Partum Care for Positive Postpartum Experience that guides midwives and medics on how best to provide respectful evidence-based care and they are very good documents. There is very good guidance out there and if we follow that guidance we can work towards reducing maternal mortality.
The Aga Khan University’s School of Nursing and Midwifery in East Africa are offering a midwifery program here in Kenya set to start in August 2018. They now have campuses in Kenya, Uganda, and Tanzania with the Ugandan Program having started in 2015. It is an upscaling program where midwives and nurses who meet the entry requirements get the opportunity to boost their skills and credentials. The program will run for two and a half years so the students will study for 5 semesters of 18 weeks per semester. It will entail 2 days in a week of study time involving the theoretical and clinical practice of midwifery. To apply visit the Aga Khan University admissions page.