Midwives for Refugees.

Give me a spare five minutes, and I can always think up some trouble. I've been up all night with a birthing woman, and my brain is now at half mast.....but functioning enough to wander in and out of sense. This means it's able to explore opportunities I'd otherwise know better to avoid!






Lately, I've been exploring the possibility of getting out to the French refugee camps in Calais and Dunkirk. There's not likely to be too many pregnant/lactating women, but it would be nice to offer them midwifery support. Working with NGO's generally means setting aside quite a chunk of time away from family and NHS work. This isn't possible for the majority of midwives. To go out to France, or even Greece, for just a few days, is far more manageable.




Take the idea of a few days in camp one step further....and it grows into a rotation of UK midwives, maybe every two or three weeks, providing on-going support, that doesn't eat away at annual leave or expenses.




Here lies the problem....




To practice in UK, midwives have to work completely under the 'protection' of NHS, or have professional indemnity insurance. Many are members of Royal College of Midwives, but RCM don't offer any cover. Royal College of Nursing has some amount of cover included in it's membership, and this includes some overseas volunteering.




PI insurance would be necessary to practice in France, but we also need to be registered with the French Medical Council...I think. There has been noises that this is not too difficult, but French language is a pre-requisite. There is also the possibility that registering is not necessary for short term voluntary work. I'm awaiting a definite answer from them.




It's also possible that, under EU movement of professionals, there maybe some protection and possibility for us to provide midwifery care without being registered. I'm awaiting more information on this.




I have requested, as a member, that RCM's legal department checks out the situation of UK midwives providing care in France. I'm awaiting the response.


Lastly, the question of MSF (and the like) considering taking a core of our rotating midwives, who are prepared to commit to a certain time over the year (and in short spells rather than a long one), under their umbrella and insurance, has also to be answered.




Lots of waiting, eh?






And while I wait....midwives, doctors, nurses are already out there helping people out, and mostly just providing the most basic of first aid care. Some are working with the NGO's. It's good news that MSF have recently been invited into the Dunkirk camp, which looks to be in a dire state. Other healthcare workers have just gone out there to see how they can help, regardless of legalities and registration. Most will understand that providing anything other than first aid care, or showing an 'intention to treat', leaves them open to trouble. All this red tape, just to care for people in an emergency situation. I envy the guys who will go there regardless, and I NEVER thought finding out exactly what we can and can't do, would be so incredibly challenging.




It is evident, regardless of provision of clinical midwifery, that more caring hands and hearts are needed. The essence of midwifery, and quite possibly most important to those in the camps, is being 'with woman'. Throwing a tantrum that I can't assess for hypertension is simply a symptom of what midwifery has become in our minds and our NHS. First aid care for women who have travelled away from, through, and arrived at varying levels of hell, requires compassion and kindness. Thank goodness those skills aren't yet regulated.


So, 26th January it is! I'm still not sure on numbers. One or two cars, maybe a van, ideally filled with necessary provisions, and heading most probably to Dunkirk. Another team will go out middle, maybe end of February. Things in Dunkirk are extremely fluid at the moment (in more ways than one, given all the dreadful rainfall), so a destination plan will stay fluid, too.




Now, add to that plan of rotational midwives, as yet unable to offer a full compliment of skills.....

.......a large family sized tent where women can come together in the daytime to knit and crochet donated wool into 20cm squares to make blankets, or whatever they want to make.....

......and you can address many issues all at once. Community. Empowerment. Positivity. Skills at crafts. Warmth. Language skills. Contraceptive advice and supply of condoms. Pregnancy tests. Info on domestic abuse and rape. Breastfeeding retreat....and the list goes on.

The tent can be made safe by it hosting a couple of women living there as 'housekeepers'. In any community there are wise women, and I've no doubt we'll quickly identify those who would like to support fellow refugees in this way.

20cm squares, knitted or crochet

I'm not sure I'll be able to get a tent into Dunkirk camp just now, but I can take one and store it, along with furnishings, for when access is able. It will become clear where is best to set up more long term. There's nothing to stop small groups of women (and children) learning to crochet, during my first trip. People are naturally interested, and often want to at least have a go for themselves. So, along with provisions of clothing and medical supplies, I will take wool, already made up 20cm squares, and hooks/ needles.

The less talked about skills of midwifery.

The facebook page 'Midwives for refugees' was set up to share any information for UK midwives thinking to support refugees and migrants with voluntary reproductive healthcare. In three weeks, it has more than 200 members. It's fantastic to find so many midwives are so eager to help.

First Taste of Africa.

So, a new destination and a new adventure. Some different slants on old stories. Some conquered challenges for them, some new challenges for me, but always challenges. After all, we'll never bring change if we don't face a few challenges. All together, eight leaders, thirty two eager-to-learn carers, all eating, drinking and sleeping maternal and newborn health.

YAY!

This latest trip took me to Kenya. Third time lucky after a couple of cancellations, and the first time for me on African soil. Funded by the Centre for Maternal and Newborn Health at Liverpool School of Tropical Medicine, a retired obstetrician called Richard Kerr-Wilson who is rather more used to African ways, and I travelled out to Nairobi. It was a flying visit (ho ho), whistle-stop tour to deliver obstetric emergency care training, the CMNH way. Packing for way up in the hills (read emergency rations of individually wrapped cheeses and dried fruit/nuts) was quite unnecessary, so I filled my case with more frivolous provisions. I won't go into details here. A lady's case is quite a private affair ( until you get to British Airways security, that is...) but my case was embarrassingly heavy for such a civilized trip.

What did I worry about? I worried what kind of food they'd dish me up, being vegetarian n'all, and whether the accommodation would be isolating or at all scary. I worried how I'd get on with my travel companion, but only slightly, because midwifery depends on the ability to make quick connections, and my companion was a joy to be with. As my flight was the morning after the shootings in France, I worried about the return flight into UK and any security issues developing from that. But so many untoward events have happened just before my flights, and isn't that the safest time to fly?

Nairobi looked quite smart, but we only saw the smart bits, apparently. Our hotel was very nice, and having shared photos with friends, I suspect it's often frequented by UN and UK workers. I'm wasn't sure if all the security barriers made me feel more or less secure. Sharing breakfast with a fellow traveller who grew up in Nairobi, and hearing her stories, was enough to reassure me that security is indeed GOOD.

My first taste of 'Africa' was in the back of a car, through blackened windows. Not wanting to miss ANY of the scenes, I wound the window down and had the warm air whistling around my neck. The great Rift Valley, as it came into view with splashes of sunshine sprawling over it, was like something out of the 'Land Before Time'. It looked amazing, and I valued the reduced responsibility of having to make pleasant conversation with the rather quiet driver.

My first view of wildlife was not really so wild. A small herd of Zebra, and a few baboons sat by the tarmac roadside, with concrete box houses and electricity pylons in the back ground. It didn't quite live up to my expectations. I was mildly disappointed as well, that the shanty areas looked all too familiar to my experiences in other lands. The tidy rows of endless 'garage' size homes, all with TV antennae, were an improvement on the tarpaulin used in Nepal. But had I moved off the track, I suspect findings would have been more disturbing.

Nakuru itself was flat, tidy, and fast flowing, criss-crossed in straight lines like scars (or birth marks, I'm not up enough on the politics and history to decide which) from the army's influence. The town has apparently grown massively in the last few years.



View towards the lake, from my room.

The bed during my stay was comfy enough. There were wonderfully helpful housekeepers. The restaurant was pleasant, although staff were slightly perplexed by their non-meat-eating guest. Neighbouring dogs and passing lorries made for disturbed sleep, at times. I didn't see one mosquito, but a more than adequate net was at the ready (to hang me at any opportunity) and, oh joy, there were no midwife eating spiders. Not even little ones.

My time in the bathroom should have been luxurious given this HUGE relief (and huge caseload of goodies), but the showers were cold or, at best, tepid. When visiting Nepal, I've returned and cried into my hot shower in appreciation of such luxury, and felt so blessed for running water. But I have to confess, as I stepped under that piping hot flow at home this time, I yipped and giggled. The difference? May be no difference, but simply that I'm getting rather spoilt. I only just touched the surface of the struggles in Nakuru. Why should I have expected hot water?

The course accommodation was a rather quirky hotel/ function place. The four breakout sessions after each lecture/ demonstration were held in corners of the same room, and this worked very well. Some of the sessions were specific to Kenya, and I have to say, those Kenyan facilitators were the best people to teach them. I certainly learnt more about HIV protection and aseptic techniques. They have 'hand washing' procedures off to a T.

I loved the impromptu additions of little bit of rhythm and quite a lot of laughter to help drive home the learning. By the amount of leg pulling in my direction, I suspect the team members had never met a 'Veggie', but it was a great ice-breaker and made me lots of friends. The waiters were vigilant in pointing me to my daily source of protein.

Without exception, all participants were there to learn. They weren't just there because they were ordered by bosses to attend. There were some thought provoking (read scarily concerning) moments, and beautiful conversations along the way.


Learning was a two way thing, and with this project, it's measured by testing participants before and after the training, and then visiting the workplace some weeks later, to see what knowledge they have put into action.



Teaching WHO partograph. The guy in the
yellow Tshirt was a Midwife, and extremely
 wrapped up in his 'caseload woman'

Time keeping is always a major issue, especially on the longer training days. It's important for the participants to move swiftly around each of the four work stations, as most stations are allocated just 20 minutes. Anne, our time keeper, had the patience of a saint.

I find teaching the WHO Partograph so rewarding. It's where the real midwifery skills come into play, and emergencies are then avoided. I was impressed with the group's ability to define positions of baby from the presenting part, and their understanding of the three 'P's (power, Passenger, and Passage).

It wasn't any surprise to find myself BANGING on about

….Neonatal resuscitation.

….....Golden minute for baby.

….Encouragement of Mum's own birth hormones.

In this medicalised world of child birth, we don't often enough allow Nature to work FOR us. It should be a basic understanding that if there are limited drugs available to prevent postpartum haemorrhage, you do everything in nature's book to encourage a good maternal hormone response. Yet, we overlook the obvious, or don't get taught it in the first place. Protected time for baby on mother's skin straight after birth will impact on baby (and Mum) for months to come. ABCs of neonatal resus are so simple, but moving onto chest compressions before getting air successfully into the lungs, is pointless, AS is leaving a baby in a wet towel. These things are so simple to perform, when understood.

And, as ever, perineal suturing methods left a lot to be desired (excuse the pun!)

When I travel with the LSTM maternal and newborn health team, I'm providing emergency care training, but I do not believe it can be in isolation from good midwifery. While lectures don't always lend themselves to this, the follow up conversations can explore best and safe practice in midwifery.

This teeny baby, fifth in line to his family throne, was born at 36weeks.
Fast labour. Sent direct to neonatal Unit, to share a resuscitaire in the
 office with three very poorly babies. I think he'll have been fine.

On the last day of the course, Richard and I were lucky enough to be shown around the local hospital. It was sparse, but clean. I felt awe at what they were achieving with such few resources. Two women to a bed, even very poorly women. The delivery area was so cramped for space, even if there were staff for emergency procedures, I'm not sure how they'd fit in. Polythene sheets on a simple couch. All couches facing the door, meaning women were overly exposed. When they had so little, how could I suggest dignity should come into the equation? But it should.



Growth restriction and prematurity seemed to be the order of the day (two themes factoring greatly in the new Sustainable Development Goals), and the maternal mortality rate has started to increase, though they are not sure quite why.

Kenya has managed to reduce it's maternal mortality rates from 584 to 510 in 100,000 (World Bank figures) in just four years (UK figure is just 9, to give you some perspective).

Visiting the neonatal unit was by far the saddest part of my hospital trip. A third of all babies don't go home. Having said that, I saw the most scrummy...and almost healthy...42 day old twins born at 28 weeks gestation. They were having skin to skin time with their mum. That is the most amazing little story. How does that happen? And how are they now? I dearly hope they've made it home.

This is a busy unit, with 25-30 births a day. C section has reduced lately from 15 to 12. That's fantastic news. It worries me what these mums will do next time...and the next time...after section. Hospitalisation isn't the only answer. We need more midwives.

Wish I'd seen this work place before the course. (Take note, LSTM)

And...how could I go to Africa without visiting the parks? On the last day we visited Nakuru lake. I didn't expect the place to be so lush. A fresh carcass showed evidence of lions, but we weren't lucky enough to see them. There were just a few pink flamingo on the lake, because it had recently 'shifted' after volcanic plate movement, and the water was too deep for an adequate algae supply. The flamingo had flown to find tastier soup. We spent quite a while on the boggy peat, among the graveyard of trees and amazing bird sounds. It was incredibly moving, and the peace was breathtaking after such a busy and demanding course.

And then Home. Too soon. Great trip. Such potential for even better obstetrics and midwifery. And such lovely warm people. More friends. More learning.

Thank you.