Finishing the story

“Often people say prostitution is the oldest profession in the world. But it isn’t. Midwifery is the oldest profession in the world, because the word midwife means ‘with woman’,” says Gillian Smith, the Royal College of Midwives’ director for Scotland, “And the gender of who’s providing that care is irrelevant, but it’s all about being with women. If you look at older cultures, or at cultures in different parts of the world, birth is very much seen as a woman’s event, and I think in some of the other cultures they’re much further behind us in involving husbands and partners in it.”

Smith’s eyes were opened in 1985 by a three-year secondment from Greater Glasgow Health Board to the Dhofar region in southern Oman. “I was the first person to do ultrasound for pregnant women in the south of Oman. I forget that in my bio,” she says. Last week, International Day of the Midwife gave people an opportunity to pay tribute to the profession. It carried the strapline, ‘changing the world one family at a time’, recognising the work midwives do, not just delivering babies safely, but before and after the birth.

The experience was somewhat of a culture shock. The processes of obtaining a driving licence, or “even worse”, a liquor licence, were lengthy and the maternity hospital was guarded by an Askari with a WW2 rifle. For Smith and colleagues, used to talking to women and their relatives through their life-changing experience, the biggest barrier was language. “You arrive there with this idea that there’ll be people able to speak English, because we’ve become a bit conceited about our language. We knew a few words, and it became clear very quickly that the nurse midwives who were translating for us were not telling them what we wanted to say to them, they were telling them what they wanted to say.”

Smith’s Arabic quickly developed after the arrival of an ultrasound machine, “because as you pointed out things on the ultrasound they would tell you what the words were in Arabic. That close contact with them was how you learnt the language. We went out and held clinics under the trees, taken in by helicopters and small aeroplanes.”

The ultrasound machine also engaged men. “We had a couple of doctors whose wives delivered, and they were the only men I remember seeing in the birth unit. It was something the men left the women to get on with. The machine came a bit after me, and suddenly the men started to take an interest, because they could see their babies inside.”

There was no provision for post-natal care. Smith first encountered female genital mutilation in Oman, a subject she now advises both the Scottish Government and Police Scotland on. “Almost all our female children in the south of Oman, in Salalah where I worked, had it carried out in the ward before they went home. Brand new babies. The first I would know about it was you found an empty cot and you’d hear a baby screaming in the bathroom. And the local surgeon, because that’s what they called them, she’d be in there with a razor blade, turmeric to put on it and they would bind the legs together. If we didn’t catch them at that point, we could sometimes catch them on the way home, because you’d see this wee baby with its legs bound and you’d call them back, and at least if we caught them you could get antibiotics into them, we could make sure they weren’t bleeding too heavily and we started to do some education around it. It doesn’t show up in the statistics, and wasn’t done in the north of Oman, it was the south, but it was something that the men never talked about. It was something that the women did. I think with regards to FGM it remains that; it’s women doing it to women, the men don’t even discuss it,” she says.

Despite this, Smith says it was a bigger culture shock coming home to Scotland. After being treated as an equal to her colleagues in obstetrics, paediatrics and anaesthetics for three years, she returned to a time of clinical grading. People dismissed her experience abroad as “skiving off”, rather than vital life experience. “It sounds a bit trite but a woman will always need a midwife, she may also need an obstetrician, and she may also need a GP. Depending on their condition they may also need a physician. The cohesive team approach is the more important thing, because we can’t argue amongst ourselves who this woman belongs to, or who this baby belongs to. I remember a Nigerian obstetrician once saying to me, because I was always having an argy-bargy with my boss, ‘you know, Gillian, at home in Nigeria we have a saying that when two big elephants argue the ground underneath gets trodden on. We cannot allow the women to be that ground underneath,’ I think that’s really important.”

Recent research led by Professor Helen Cheyne at Stirling University has found only 30 per cent of British women are happy with the care they received in post-natal wards. In England, the NHS needs up to 5,000 more midwives, the RCM says.

Although Scotland has been training and recruiting more, Smith argues that any sickness absence sees a midwife taken out of a post-natal ward to shore up the labour ward. “The post-natal ward is where women particularly need support, help and guidance, and actually, that initial time can make the whole difference in their feelings and approach. Huge things that Harry Burns talks about like attachment, and if we don’t have initial time there where we can support parents, and I’m saying dads as well as mums, then that is a major issue. So we’re not finishing the story.”

The recipient of a recent RCM innovations award told Smith of a midwife called Shirley who sat with her and her second baby at 16  through the night, to support the start of her breastfeeding.

“She said, ‘if she hadn’t sat with me for five hours I may not have breastfed, but as a consequence of that, I am now a breastfeeding peer supporter, employed by the council’. She was taken off her mother at six years old because her mother was an alcoholic, and she came from a really poor background. She says, ‘as a consequence of me breastfeeding and breastfeeding my four children, 14 members of my immediate family who all came from a poor background have all breastfed’. And then there’ll be another 14 from that, and another. So it’s that kind of ripple effect. I think that’s the real impact. Changing one family at a time, that’s not someone standing there pontificating about the benefits of breastfeeding, and she didn’t take control, all she did was build up the confidence in that girl to be able to do it herself. If we don’t have enough staff and the right staff in post-natal care those stories won’t be there. When did we last hear of Shirley sitting down for five hours? We were saying to ourselves we need to trace Shirley, because she’s impacted on an entire family.”

Although normally women will want to go home to their family and home comforts within 12 hours of birth, Smith says, “the people who are staying in longer are the people who need the greatest level of care, and if the staffing levels are not enough to provide that then we are doing them a disservice. The thing that’s difficult for us is not only do the women not feel fulfilled but the midwives don’t feel fulfilled. They come home, shift after shift, tired and demoralised because this is not what they signed up for. They signed up to support women.”

As well as the “false picture” painted by the Government funding 75 per cent of internships, there may also be an over reliance on bank staff, according to Smith. The current system of workforce planning ‘establishment’ is based solely on what is affordable, she argues. Smith remains optimistic the introduction of the midwifery workforce planning tools, postponed till late summer, will make a difference. “Without them you don’t have the evidence,” she says.

The RCM has also been developing Postnatal Resource Allocation Modelling (PRAM). “We recognise that post-natal care is in a period of threat, so we wanted to look at designing a desktop modelling tool that told you how your level of care could impact on your quality or costs.” PRAM has been piloted in Lanarkshire, Tayside and Reading. Smith hopes it will be piloted in Glasgow soon ahead of a September launch.

Scotland’s partnership approach, with midwifery included in the Children and Young People Bill, puts the country “way ahead of England”, says Smith. A supportive chief nursing officer and midwifery adviser at the Scottish Government has helped. “We’ve had really positive support and buy in around the Scottish Patient Safety Programme; and the Maternity  and Children’s Quality Improvement Collaborative is the first time this has been done in a whole country approach in the world. So the whole world is watching us,” she says.

Smith also says the current administration at Holyrood has shown positive support. “Many of the changes that have been made in maternity services, and in particular in midwifery, is because we have worked with the women to make those changes. The women have driven the agenda with us. So they’re less likely to think things are being done to them. I have to say Alex Neil knows exactly who I am!”

The RCM and others are currently on a three-year voluntary midwifery twinning exchange. Welsh and Northern Irish midwives are going to Uganda, English midwives to Cambodia, and Scottish midwives to Nepal. The Nepalese minister for public health told Smith: “I used to work in a very remote area of Nepal and VSO sent two nurses and a midwife, and when the midwife arrived no other woman died in childbirth.” The RCM hopes to build on this work.

International work is reciprocal for Smith; changing the world one family at a time, but also being open to change in yourself.

“When you work abroad there is always a piece of your heart that will remain there. I’ve only got to hear about Oman and it instantly conjures up for me the women. They say that the women in the south of Oman are amongst the most beautiful in the world. The dialect is quite different, and they think that they might be part of the lost tribe of Ethiopia, who have migrated. It was the warmth of the women.