ļ»æEpisode 187 - Midwifery without Borders with Diane Lockhart
Mel:
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host, Dr. Melanie Jackson. I'm a clinical and research midwife with my PhD, and each episode, I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth, and postpartum journey. Welcome to today's episode of the Great Birth Rebellion podcast. I'm your host, Dr. Melanie Jackson and today I've invited midwife Diane Lockhart to the podcast to have a conversation that I feel like I haven't really had since about episode 95 when we had Christine Laurier on the podcast. That was our Midwifery Without Borders episode and my attention was drawn to Diane because she sent me an email one day explaining the work that she's doing in her midwifery career And I thought it was extraordinary. I think she's extraordinary. And if you're a midwife or you're anyone interested in thinking big and broad about possibilities in your career, you want to hear this episode.
Mel:
[1:08] While you're here, I want to take a little break in our programming to let you know how I met Diane. She emailed me because I'd sent out an email to all the people on my mailing list about the Assembly of Rebellious Midwives. Diane responded saying it sounded amazing, but she just couldn't possibly be a part of it because of all of her work that she's doing. She can't actually afford to be part of the Assembly. But Diane is just the type of person who I wanted in the Assembly. Part of the way that I'm supporting the Imani Birth Centre is to offer free membership to the Assembly for the midwives and for Diane there at the Imani Birth Centre. But something you can do if you want to continue working in a woman-centred way to enhance your skills as a midwife, to not feel like the black sheep in every maternity care setting, join the Assembly of Rebellious Midwives. I'm in there. We meet almost every week to discuss research, cases. We've got vaginal club. I'm there. It's the way to connect directly with me. It's the inner circle of rebellious midwives. And I'd like to invite you to join the assembly. All the details are in the link. It's for any midwife all over the world. I'll see you in the assembly.
Mel:
[2:25] This is one of our Wise Women episodes where I showcase wise and rebellious midwives who are doing extraordinary things for women and midwifery. And Diane is a midwife who clearly just wants to help women. And as a result, she started up a free maternity service for women in Ugandan slums. She's been there for years and years and her midwifery and nursing career spans a long time. You'll hear all about her. She's going to introduce herself in a minute. But Diane is proud to share also, and this is what really stuck out to me with her story, in all the years that she's been in Uganda, never has their service lost a woman or baby in childbirth. And that's significant in, as you'll hear, in the location that she's in. Diane will talk to us about the Amani Birth Centre, which is located in Uganda, and they have very few opportunities for sophisticated medical intervention during birth. The women birth physiologically with the midwives.
Mel:
[3:25] And in this interview, you are going to learn about how Diane has set it up and how she keeps the outcomes so great in these circumstances. Welcome, Diane.
Diane:
[3:36] Hi, Melanie. How are you?
Mel:
[3:37] I'm well, thank you. That was a very long bio. really excited about having you here.
Diane:
[3:43] I'm really excited to be here.
Mel:
[3:46] I'm so glad that you emailed me because when I saw your email I thought oh my gosh I have to speak to this woman and then when I did I thought now everybody else needs to know about what you're doing. So if you could yourself introduce who you are and what you're you know a bit of an overview of your career and then we can jump into what you're doing now.
Diane:
[4:10] Okay, so first of all, thank you so, so much for inviting me on. I'm not very familiar with doing all these podcast things, so I feel very important. So my name is Diane Lockhart. I am born and bred in Northern Ireland. I've done all my training in Northern Ireland and that started back in 1989 and I trained as a general and sick children's nurse, so a registered general and registered sick children's nurse I did the old-fashioned training when midwives and nurses they we wore little frilly hats and capes and to be honest with you I think there is no better training that I could have had and I just said to my daughter last night that if I was having to do midwifery again I don't think I would pass I don't think I would be able to do it because Because it's almost like a little mini medical degree now, what is being expected of them. So I staffed in paediatrics for about 10 years, and that was paediatrics and neonatal. And then I decided to be a midwife, and that was when I started my midwifery training. So it was about 1998 I started my midwifery training.
Diane:
[5:28] My passion to be a midwife goes back to when I was about, must have been about three years old, and Santa Claus brought me a nurse's uniform and one of those little plastic nurse's kits. And when I was in school, my composition for the end of year magazine was, when I grow up, I want to be a nurse and give mummies their babies. Now, at that point, I had no idea what a midwife was. But my little drawing was this little stick mummy in a bed and a midwife, stick midwife with a stick baby, handing her her baby. And it never registered with me until years and years into my training. And I thought, you know, even back then, I had this passion to give mummies their babies. It's just been, it's been such an amazing career. I've been very, very fortunate. So I've been working as a midwife for about 26 years. During that time, I worked for two years. I specialised as a breastfeeding coordinator. I did my lactation consultancy exams. I built my way up. I did my degree. I did my postgrad and so on and so on. And then I decided, yeah, it's time to be back in Uganda. again.
Diane:
[6:41] I have traveled to Uganda back and forth since 1989. It was actually in Uganda that it reignited that passion. Ah, this is what a midwife is. Just before I started my nurse training, I got to go on like a mission trip with a group of young people. And I was working in a hospital with the midwives. And I watched for five weeks. I just stood and watched in awe. These student midwives, babies, babies, babies every day. Like they don't have separate rooms. They have a bed with a curtain, a bed with a curtain, a bed with a curtain. And I literally just stood watching these babies emerge each day. And at that point, although I wanted to be a nurse first, I knew that one day I would be a midwife. So here I am now, almost 10 years in Uganda.
Mel:
[7:32] 1989, you said you first went to Uganda. Yes. And then you came back, did midwifery in Ireland.
Diane:
[7:38] I did four years nurse general and paediatric nursing because in those days you couldn't go straight into a speciality. You had to do general nursing first. And then in those days you had to staff for like 18 months before you would go on to be a midwife.
Mel:
[7:55] Well, let's fast forward all the way to now. What are you doing in Uganda? What have you set up? And I feel like as we have this conversation, all of the rest of the story that unfolded is going to build.
Mel:
[8:11] So can you take us to where you are now and what led you there? Because this is, I mean, it's the juicy part, isn't it?
Diane:
[8:20] This is the stressful part. I think when I was at a friend's house last night, and she has one of these spotlights in her bathroom, and I suddenly looked at the top of my head and I went, look at all those grey hairs, where have they all come from? I think that's probably...
Diane:
[8:37] That that's the effect of it so like I said since 1989 I went backwards and forwards to Uganda on a number of occasions different with different teams I went out with a medical team I went out with church teams I went out with various teams and in 2010 and 11 I went out I went out just independently as a midwife and I was working in one of the big private hospitals simply because I knew the doctor who works there. He's actually an Irishman. And I was working as a midwife, but it was a sort of non-clinical midwife, which of course doesn't quite suit me. I have to be hands on, but I was there doing teaching and lecturing and so on with a bit of clinical teaching, of course, but it just wasn't quite registering with me. And I moved, I asked to be moved down to one of the other local government facilities just to help out with that. And that was where I really found this group of women that was in one of the slum communities. Now, a lot of people will say, you can't use that term. It's a very derogatory term. That is the term they use to name the area that I'm working in. And it's called Namuwango slum. And there's a number of slum communities. So even on the map, that's what it's called. and I suddenly started to.
Diane:
[9:59] See that desperate need that I knew was there. But as I had been working in a private hospital, it had sort of overshadowed the fact of why I was actually there. And I suddenly just read just, why am I here? I'm a decent midwife, but I'm working in a hospital where people have lots of money. They can afford good care. And actually, I find there was an elitism within those midwives. You know, 20, 35 years ago, when I first came to Uganda, it was all very, very substandard. It was mission hospitals. It was, they had no gloves. They had no catheters. They'd no anything. Everything was having to be sent from outside.
Diane:
[10:43] But the midwives had amazing skills. I'll always remember those skills right back in 1989. They had amazing skills of instinct and intuition and.
Diane:
[10:56] So I slowly got to know the community that I'm now in and that was where my passion started to arise because I thought these are the women that are most needing those skills. They're needing the good midwifery skills, but they don't have money to pay for it.
Diane:
[11:12] I was only there for two years. I was actually there with voluntary services overseas with VSO. So I only had two years and I went back to Ireland just for a couple of years. My daughter was going into sort of P6, P7 at that point. So I thought we'll go home for a couple of years and then we'll come back out again. I'll have a think as exactly what I want to do about funding, how I'm going to pay for it. And at the end of that two years back home, I was diagnosed with breast cancer. So that sort of put a hiatus on life for a little while. I went through my treatment and so on. And then I came back out again. but during that two years that I was home and I went back into midwifery I think it was just on that cusp of the years where things were starting to change the way I trained as a midwife was we were trained as midwives we were autonomous practitioners we were respected by obstetricians we were responsible for low-risk women and the only time we got the doctors in was when there was a complication. And I was working in community at the time. And unfortunately, I.
Diane:
[12:25] And those chinks of bullying and litigation were starting to come through. And I just started to get this sense that things are getting very dangerous here. And I did have a personality in my field who sort of picked on me for no good reason at all. And it just got to such a head that I thought, I can't do this anymore. This is not what I trained to do. and during my treatment for my breast cancer I suddenly had this epiphany I don't want to be a midwife anymore I'm not going back I'm not missing it I'm not going back I'm not missing this threat of investigation if you put one foot wrong and I was hearing stories of friends of mine who were all under these investigations for I don't even know what reason they were under investigation for, And when I finished that two years of my treatment and so on, I decided I'm not going back. I'm not going back to midwifery. But the time then came where Africa was calling me back. Uganda was calling me back. And I went back to Uganda to work in cancer care. I didn't even work to be a midwife. So that was how I ended up back in Uganda again. And it was during a woman's group that I was running, totally separate to the work that I was doing.
Diane:
[13:50] And I had definitely not wanted to be a midwife. I don't even want to, it made that feeling come up in my stomach where I was going, I can't go back there. It's really terrifying. And I suddenly had these mothers coming to me, but Masao, they call you, if you're a nurse or a doctor in Uganda, they call you Masao. But Masao, Diane, you're a midwife. Why are you not a midwife? Why are you not helping us? and that was the spark that I thought exactly what am I doing here why am I not being a midwife and that was when I I sort of the light bulb moment happened and I decided that I would start up this little facility.
Mel:
[14:33] In Uganda so I mean here in Australia we have largely a public system and women who want to can hire some private services but for the most part if you want to get free care it's high quality and available what's the situation in Uganda for childbearing women how do they usually access care
Diane:
[14:54] So 35 years ago when I first went, it was pretty much all government-led care. It was village clinics, it was traditional birth attendants, and it was midwives, predominantly midwives, because it was so expensive to train as a doctor. And of course, doctors had to go to university, so it was very, very expensive. Doctors were few and far between, and a lot of the doctors that were there were foreigners. Most women would go to these government facilities where there were very few resources. They had a very, very high death rate. But women were delivering naturally, for want of a better word. They didn't have an option. So if the labour was progressing, then they delivered fine. If the labour was not progressing and they were lucky enough to be somewhere that they had a theatre, they were taken to theatre. If they weren't, they died.
Diane:
[15:49] Now, since Uganda has developed, I mean, Uganda is now seen as a middle income country. It's actually no longer seen as a developing country. It has come on leaps and bounds. But the problem is healthcare, all over healthcare, has become a commodity now. It has become a business.
Diane:
[16:09] And unfortunately with that with that need for business and with that desire for businesses and money has come people that train to be doctors because they think it's going to get them money so it's actually got a lot of people in it now who don't actually want to be doctors but they know it's going to be a lucrative business for them so the majority of women still have to access the government facilities which are meant to be free and I say that very very tongue-in-cheek they're meant to be free. Unfortunately, they're not. As well as the fact that the government facilities don't provide the resources that mothers need to have a baby. So when they go to the facilities, they have to bring gloves for the midwives. They have to bring cotton wool to make sanitary pads. They have to bring a blade to cut the cord. They have to bring a piece of string to tie the cord. They have to bring a plastic sheet to lie on on the bed. So not only do they have to bring the resources that are needed.
Diane:
[17:12] There are very many of the facilities, there are no medicines,
Diane:
[17:16] there are no emergency medicines like oxytocin and ergometrin and things like that. So even in those facilities, they can go. And the only option is to be referred to one of the higher hospitals, which again are government-led. They do have theatres, but again, they don't have resources. They don't have a good number of doctors. I think there's one doctor per.
Diane:
[17:43] 4,000 head. That is just off the top of my head. Something ridiculous. It's in the thousands anyway. So there's a very, very significant lack of doctors. And unfortunately, in those facilities, they tend not to get paid well. They tend not to get their pay on time. And they don't have the resources to work with. The main referral hospital that we use has a couple of hundred deliveries a day. And they have one theater. They have one theater. They frequently will have a few hundred women on the wards at one time, whether they be in labor, whether they be postnatal. And one of the hospitals has one theater that does all of the obstetrics and the gynecology. So we could refer a mother with an obstruction and there could be 20 women in a queue before her.
Diane:
[18:37] The other side of the fence is that if you have any money, you can go to one of these private facilities. Now, according to somewhere in America, for example, where they're having to pay huge amounts of money to get into care, Ugandans don't. It's for an American to go into a private facility in Uganda, it's very, very cheap. But for women who are living in our community where for those who are working I think I would say over 60-70% are not working but for those that are working you're looking at about, maybe two American dollars a day as their salary so when as soon as you go into the hospital you have to pay money and you it tops up every day you literally pay per day that you're there you pay for the resources so you could be coming out maybe with a couple of thousand dollar bill from these private facilities.
Diane:
[19:29] So if you have the money, you can get reasonable care. But the problem is, it's, I mean, literally you walk across the road from one of the hospitals and you're into a slum community. You cross five minutes and you're into one of the most expensive hospitals. So there's a very, very big disparity. And that was why this woman just drew my passion.
Diane:
[19:52] Just to hear their stories of what happens when they go into the hospitals, the numbers of babies they've lost you know you could still have maybe women that have had five babies they've maybe lost two or three of them and there was a fear of birth there was not just a normal anxiety that that many women have going into give birth they're anxious of course it's an anxious time but these women were terrified and that was where the name Amani came for because Amani is Swahili for peaceful and our motto is birth without fear. So that was the whole purpose of it was to try and at least alleviate this fear that they have and try and encourage them to come to the facility. Because of this fear a lot of women were not attending the facilities, they didn't have the money to pay the bribes, they didn't have the money to pay for the resources so they would stay at home.
Mel:
[20:45] And is that what happens? So either they pay money to go to one of these facilities and get whatever care is on offer and whoever is available.
Diane:
[20:55] Yes.
Mel:
[20:56] Or else without that money, they're giving birth at home. Is anybody coming to them traditionally trained or professionally trained or do they typically expect to give birth on their own?
Diane:
[21:11] Most will give birth on their own. Sometimes there's a lot of little illegal clinics down in the slum. There's a lot of nurses and midwives who can't afford to pay for their registration. So they buy some drugs and they run drug shops. They run, you know, like little small pharmacies. And what they will do is there may be trained nurses or midwives, but they just can't afford to keep up their registration. So they open these drug shops again because it's fast money. So there's a lot of things that they try and fill in their time their their care with um but a lot of them will deliver at home normally just on their own even going to the government facilities and this is where we you know i've got to be very careful the money that they pay into these facilities is not an official fee it's more of uh there are 20 women in front of me i am very badly in need and therefore please you need to save my life there's a facilitation they call it a facilitation and that is how women get to jump the queue which just means that the women that don't have access to that facilitation they're left at number 20 in the queue with an obstructed labour or a baby that has already died and.
Mel:
[22:33] The government just turns a blind eye to this or is this kind of well known and they just allow it
Diane:
[22:42] It's well known. That's all I'll say.
Mel:
[22:44] Yeah, sure. And you're there, you know, there's a lot of, it sounds like there's health workers who go and work illegally, but you're there legally. You've sought registrates in Uganda and midwifery is regulated in Uganda. Is that right?
Diane:
[22:58] Yes, yes. Very, very much so. And very much needed. I know that there's a lot of midwives in other countries, you know, rich countries that complain because they have to be regulated. I personally am very much in the middle of that in that I believe that there needs to be some sort of regulation of midwives practicing, especially in a country like I'm working at the minute, because without any sort of regulation, there is no guarantee that the training that somebody has is going to be able to manage in those situations where you have the emergencies. Like any midwife will know, the skill of midwifery is not in delivering the baby. And I know that people hate that term delivering the baby, but for want of better words, there is very little skill in actually assisting a baby out of a woman.
Diane:
[23:58] The skill is in knowing what to do when it doesn't happen as it should do. And that's, I think, where that regulation is needed because so many people in many countries are practicing. And nine times out of 10, babies come out perfectly fine. But it's that one case, like I'm sure everybody's been hearing the recent free birth stories that have been circulating social media. You know, those mothers have every right to do that. But as midwives, we have chosen a career where we can help prevent that happening. And we don't have to be there all the time with our hands inside and examining people. And we don't have to be there in that space. For me, I sit behind. I sit and I watch and I observe. I do my observations. I do my monitoring. But it's still the woman's space. So I am very much middle of the road. But somewhere like Uganda, there has to be regulation. There has to be a level of training to save these women's lives.
Mel:
[25:03] I agree with you. I think regulation keeps the profession safe but also helps women to know what the minimum expected standard of a midwife is. Yes, exactly. So that when women say, I want a midwife, they know they're getting one that is trained, that's professional, that checks and balances. So, okay, so Uganda, we've got kind of a tiered system that a little bit relies on bribes and that whoever can pay gets care.
Diane:
[25:33] Facilitation.
Mel:
[25:34] Facilitation.
Diane:
[25:37] Facilitation.
Mel:
[25:38] One bribe, facilitation. And this is kind of a social, cultural thing that's been kind of, that's developed through maternity care. The problem is, is that there's a large number of women who can't afford to get care that they need. Yes. And that means they have to be alone or, I guess, seek the care of maybe another unregulated health care provider.
Diane:
[26:05] Yes.
Mel:
[26:06] So then you set up Armani Birth Centre in, what's the name of the slum called again?
Diane:
[26:15] It's called Namuwangu Slum.
Mel:
[26:18] Namuwangu Slum.
Diane:
[26:20] And it's the railway line. There's a railway line. It's very commonly known as the railway slum.
Mel:
[26:27] The railway slum.
Diane:
[26:29] Yes.
Mel:
[26:29] And you've, you built this thing. So this is what is astonishing to me, is that you opened this place, really not even wanting to be a midwife, but I feel like you felt a responsibility to this. And you just think, I just have to, I can't not. And I hear you. I have been at points in my career and probably, you know what, I feel so responsible to this podcast now. If there was a day that I thought, oh, my gosh, I don't want to keep going, I know for sure that I would be like, but you have to because it's a necessary and important thing and you have the skills. So the fact that you don't want to is almost irrelevant. Yeah. So you went ahead and tell me about how this whole thing started. You have a space and you have locally trained midwives and you care for women and babies in this birth center in the slum. So how did this happen?
Diane:
[27:33] Well, again, we go back to the regulation and the training. And I knew that I was trained. And people don't go into midwifery and stay in it if they don't have that heart for it. Yes, we have lots of midwives who are practicing as midwives, but they don't want to be practicing as midwives. My, the whole thing about being away, of course, is you need to get paid for something. So the work that I had gone to do was actually to do a research with one of the cancer organizations. And that was based on my experience having just been, has just survived breast cancer.
Diane:
[28:11] And unfortunately the money for that proposal didn't come and that was why I after six months of being there I was going oh crikey what do I do I've given up my work back home somebody's living in my house this money is not going to come through now to pay me what do I do so I do come from a Christian background and it's it's very much okay you know let's just see how it rides here, if the good Lord helps me. If I'm meant to be here, I'm meant to be here. I had started, as I say, to run this women's group. And one of the things they were saying was that when they went to the facilities, they couldn't afford to take the resources. So I go back to what I was saying about they have to take gloves, they have to take cotton. And I was hearing these stories and I was just suddenly being struck by. But that's such a simple thing that's like five in my money five pounds of money would suffice them going to a facility and allowing them to take gloves so officially if they go to a facility if they have their own belongings then they're not turned away they might some midwives they mean these this facilitation it's not all midwives or doctors that ask this but they know that if they pay it that they're going to get seen quicker.
Diane:
[29:32] So my initial thought was, I can't just suddenly be a midwife. I'm not registered. I'm not in with the Nursing and Midwifery Council.
Diane:
[29:40] I have no facility. I can't just go down and start doing midwifery with women. But what I can do is I can start providing what they need to go to the facilities.
Diane:
[29:51] It would be five pounds a head. That wouldn't be very much to raise. So that was my focus. And I thought, let me see if I can raise a little bit of money to at least provide them with the things that they needed. Now, in those sort of countries, you have these kits called mama kits. They are so valuable. And in those mama kits, they are sterile packs. They're a plastic sterile pack. And in that pack. They have cotton wool to make pads. They have gloves. They have plastic sheets for the bed. They have everything they needed, just not drugs.
Diane:
[30:25] So I had a friend who was working with an organization that provided these for free. So all of a sudden I didn't even have to raise the funds. This woman said, I'll give you the mama kits for free. So I was able to put that money into renting a little small room. I had a very good friend who was doing an online midwifery course. She's Canadian, but she was doing this online course with America and she came on board and we got this little small room where we could keep these mama kits. And what we would do is we would do some antenatal teaching. These mothers could come when they came for their mama kit. We could just sit them down one-to-one. Now, if this happens, if this happens, you must go to the hospital. You must either come and see us or you must go to the hospital. And that was how that started. And very, very slowly, the women started coming on a regular basis. I started just like a little antenatal clinic, wasn't doing any clinical apart from listening with a Doppler, having a feel to see if the baby was breached or not, and doing a blood pressure. And slowly by slowly, all of a sudden, these women, they started arriving at the door with a head emerging.
Diane:
[31:36] And I let it go. This room was literally eight feet by eight feet, maybe eight. Yeah, it was about eight feet by eight feet. It was literally a little small concrete room. I did have a bed in it. And I suddenly realize, oh, crikey, this is, I either completely stop, I close the door and I go back to Ireland and I stop this or I go forward with this. And that's what I decided to do. so I went and I registered to register in Uganda you have to do a full placement in one of the government facilities it's a very long process but I went I kept the little the little room running, tried as much as possible not to let anybody come in and deliver I tried as much as possible to get them into the car and take them to the facility but very often they didn't want to go so they would wait until the very very last minute so I got registered and then I was legally allowed to allow these women to come. And slowly by slowly, within the first year, we delivered 80 babies within that little small room, little concrete floor, a bed and a desk. And still in that room, we had 100% live birth.
Diane:
[32:50] At that point, again, it was the crunch, do we proceed with this or do I go home?
Diane:
[32:57] And again, we pushed and we said, let's just keep it going. Because at that point, we'd become known and we'd other local midwives had started to come in and help and we got a we raised some money and we got the building that we're now in so and we're now outgrowing it How big is that building.
Mel:
[33:16] You're in now?
Diane:
[33:18] The building that we're in now was previously being lived in by a family. It was a bungalow. It was somebody's house. So it's like, it's maybe if you were to look at it as a bedroom, as a house that somebody lives in, it would be a three-bedroomed bungalow with like an outhouse. So we had a small unit out the back that is being run as the actual, the general clinic. And then the birth center bit is the three-bedroomed bungalow.
Mel:
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Diane:
[34:57] Who's working in a month? So as the time went on, obviously we had to raise money. I'm not a fundraiser. I cannot stand fundraising. I'm a midwife. I want nothing to do with money. But what we started to find was that actually to run a facility where there was low risk women was very cheap. I work as a volunteer, so I didn't need a salary. My friend was working as a volunteer, so she didn't need a salary. So with that, we got one local midwife, one Ugandan midwife had heard about us and she wanted to come and volunteer. She came, it was her choice that she volunteered. She came, she volunteered for about four months with us. She had been trained for a few years, but had been working as a nurse because there's very few jobs for midwives. The problem is, Melanie, we have two realms of training. Again, we've now got these private facilities. We've now got these midwives that have got money to go to university. We now have midwives that are going and doing degrees and masters. But the problem is the training they are doing is obstetric nursing training.
Diane:
[36:13] So what they're doing is these private facilities are being led by the obstetricians. Normal birth does not line the pocket of an obstetrician. Medicalized birth lines the problem. So these midwives are coming out trained to be obstetric nurses. They are being called midwives, but when they get into that field, they are obstetric nurses and the obstetricians are the ones with the final decision. So your better call if you want a normal birth is to be one of those women who can't afford to go to these big hospitals because the government facilities are being run by midwives who have the most incredible skill.
Diane:
[36:58] These midwives are the ones who are delivering twins and breaches. Of course, they shouldn't be doing complications. But when there are no doctors, they are the ones who are having to deal with complications. I have learned more about midwifery in this last 10 years than I've learned in my whole career in the UK. And I did a good midwifery training. But still, when those complications came in, when the baby was breached or when there was an unidentified twin, And the doctor, you pull the bell and the doctor comes in and takes over. But what is happening now is that midwives have lost all of those skills, even for suturing. I have some midwives will come to volunteer with me and they've never sutured.
Diane:
[37:41] They've never cannulated. They've never put a cannula in. I've had final year students that have come that have never passed a urinary catheter. Basic skills as a nurse, as an 18-year-old nurse on my first week of training. 36 years ago, I was taught how to do. I wasn't allowed to do anything else until I could do a manual blood pressure. I could put a catheter in. And unfortunately, this is what is being lost. So the training that these midwives are having, it's not evidence-based in a lot of cases. And it is all geared towards the medicalization of midwifery. Or they're going to these certificate colleges where they do two years. And they're being taught by very, very skilled midwives. but they're being taught by midwives who still do episiotomies for all first-time mothers. They still rupture membranes with all four centimeters. So that's why I'm saying when you have a newly trained midwife, I have two of my midwives, I now have three local midwives, two of my midwives when I was interviewing them and I asked them how many babies have you unsupervised delivered in your training. Now, I don't know about Australia, but in the UK, it's 40. You have to have your little book with 40 unsupervised hands-on deliveries.
Diane:
[39:02] They were lucky if they had done five, but their book was full of 40. The midwives do not want the students doing anything. So they learn by observation and they learn bad skills through observation. So they are going out as qualified midwives, all of a sudden going, my goodness, so my midwives at nighttime, they work on their own. Whoever is on duty, they work on their own with me a second on call or me me there they're all of a sudden being put in this position where they're they're looking after these women with no backup and no skills you know they're not recognizing the difference between normal low you know maybe there's a nuchal arm or something that's causing a little bit of vaginal bleeding and somebody that's having a major abruption they don't have those basic skills and unfortunately that's where lives are being lost What.
Mel:
[39:56] Are you doing there then? Because you've got such amazing statistics. For the center to be have gone, it's been going for 10 years, is that right?
Diane:
[40:04] The clinic has been going for nine years in April.
Mel:
[40:07] And you're saying under your care at the clinic, no woman or baby has died during childbirth?
Diane:
[40:14] Yes.
Mel:
[40:15] So what are your midwives doing there? Well, not your midwives, but the midwives who are staffing the Amani Birth Centre. What do you believe it is that you are doing there that's leading to these incredible outcomes in a place where that should not be happening?
Diane:
[40:34] They are being allowed to work as midwives, low-risk experts. They have come in with their basic training and we've trained them up to be observant. We don't have scans. We have a little portable scanner that was actually donated by somebody from Australia many years ago. So we can go on and if we think on palpation that we think a baby is maybe breech, Yes, we can put the scan on but we're not trained ultrasonographers Our hands, our eyes, our ears, our noses.
Diane:
[41:11] Are our tools of our trade. Because any midwife with any experience should be able to tell the difference between a head and a bottom. Now, granted, it's not always easy. And we do use that scanner as a backup to say yes. So we put the scanner on very quickly. And yes, we confirm that the baby is head or bummed down. I think part of because of how we started, we had almost a full year without having mothers coming delivering babies. It was very, very much preventative. It was very much antenatal. Even before I got the clinic, the teaching I was doing with the mothers down in the slum was teaching. It was preventative. What do you do if you've got lower abdominal pain? What do you do if you've got malaria? What do you do if you see a little bit of blood? And it was about empowering them with the knowledge. Okay, Masao Diane said that a little bit of bleeding can sometimes be normal in labor but I'm only 24 weeks so I need to go to the facility and I need to get checked so it was it was teaching the women what is normal and what is not normal when we then started to build on the antenatal clinics a huge part of our work is antenatal I would say out of the mothers that come to us for antenatal there's maybe only a third of them will deliver with us.
Diane:
[42:35] We have a very transient community. A lot of the women, they come in for a few months, then they go back to the village. We are just like that stepping stone. So we average about 30 deliveries a month. So I would say in a week, we maybe have 200, 300 women come for antenatal. So only about a third of the women actually come to us to deliver, So a huge part of what we do is that antenatal and it's that basic talking to a mother. Did the midwife listen to the heartbeat when you were in labor? These women are not monitored in labor. They go into the hospital, somebody sticks their fingers in, they say you're four centimeters, go outside, walk around, come back when you want to push.
Mel:
[43:20] So they're not in labor care.
Diane:
[43:24] No, they're not. They're not. And that's the frustrating thing for us, because when we have to refer somebody with a complication, we know that that's what they're going to. We could send somebody at nine centimeters. One occasion I sent a mother and she was a grab at eight. I mean, this was not her first baby. She had all normal deliveries before. She obstructed at eight centimeters. She was for four hours at eight centimeters at nine o'clock at night. And it was in the days when there was only you know when we didn't have the same staff that we have so, at night time we had to transfer her because we didn't have the safe environment for her to be in to monitor to put up oxytocin or whatever so we sent her she pushed that baby at nine o'clock the next morning and, 12 hours later from eight centimeters and it was stillborn. So legally we have to refer at a certain point, but that's what we're having to refer to unless we pay for them to go to one of these private facilities, which we can't do all the time.
Mel:
[44:31] Right. So you're offering care free at the point that they come to you and you
Mel:
[44:37] don't charge them anything. No, no. And I mean, I'm a home birth midwife and about 90% of my clients will quite happily be fine give birth at home and we transfer about 10 percent of women so that sounds like the same thing as what you're doing if everything's fine no drummers they give birth there and then if they need to you transfer them out yes um so how do you fund this i mean i there's obviously bare minimum equipment yes which you know and even as a home birth midwife the equipment is not the expensive part really yes yes but how are you supporting the whole center and the staff and you must need some sort of supplies yes
Diane:
[45:20] Yeah so our our biggest cost is um i mean it is a midwife led unit so we you know as you say we we don't need a lot of equipment we don't promote ourselves as a high-risk clinic so we continue to do the antenatal even for the high-risk mothers but this is where we try and build those relationships with the hospitals so that, If we pick up a mother that has borderline high blood pressure, we'll refer, we'll get the obstetrician to prescribe the medicines. Then she comes back to us and we provide her with those medicines. But instead of her going back, having to pay money to go back to the hospital every week or every two weeks, they don't follow them up. Somebody with a diastolic of 100, they start them on medication and then they send them home and they say, come back in two weeks. But what we then do is we pick it up and we say right there's your medication come back tomorrow come back tomorrow when that's when that has stabilized then we get them to come back come back in three days then we start seeing as soon as it goes up again then we send them back to the hospital so the the the actual running of the facility the biggest costs are our rent our salaries for our staff and the basic monthly routine medicines. So a small range of antibiotics for when they come with UTIs. We do have a laboratory, which is probably our biggest cost.
Diane:
[46:46] All of our mothers, being in the slum, we have a lot of HIV and we have a lot of syphilis. And those are unfortunately, especially the syphilis is a very, very high risk for mothers, obviously, in pregnancy. So mothers are tested every three months for HIV. and they're tested once in their pregnancy for syphilis. We do their blood group. So the lab is probably the highest cost to actually buy those kits. In terms of the medicines, we have very, very few medicines. Not because we don't need them, but because we don't use them. Once they become out of the low-risk category, then they go to the hospitals and then we provide what we can. Yeah.
Diane:
[47:27] We have one main charity called Mama Emara, and that's a Canadian charity. And that was based with Courtney, who was the student midwife who at the time was around when the clinic started. And she and her mum set up a foundation way, way back at the beginning to help us build up on that. So they cover a few of our salaries they cover the rent and they cover probably about half of our medicines now it used to be the complete medicines but now that we've we've almost trebled in numbers so we are now getting other funding having to get other funding coming in um we have also doubled in our staff we now have a full team of eight staff so we um if we employ a new member of staff we have to find them a sponsor But our biggest need is to be able to support those women who we feel are genuinely at high risk. The 14-year-old mothers who we know physically are not going to be able to push. Sometimes they come, they push beautifully. But that's where the midwives have got their skill of being able to look at a particular 14-year-old and say.
Diane:
[48:38] I don't think that it's fair to put this young 14-year-old who's been raped through a normal birth. It's psychologically more beneficial for this child to go to a nice hospital where we can do a controlled C-section and it's actually going to be safer. So we do have cases like that where we make that judgment. But to do that, we have to fund that. We have to pay for that. So we're paying private health care facility costs.
Diane:
[49:09] And the rest of that funding it just comes in from individual donations, I have a just over the years I've built up a couple of partnerships where once a year we'll maybe get a big donation but we have to then budget that so what what we would love to have are more people giving monthly so to cover salaries and things like that just so that we know that every month we have at least this much extra for those emergencies. People have been amazing. People have been very, very good. I do have students come. I do have volunteers come. When volunteers come, I make it very clear that they will not be catching babies.
Diane:
[49:50] I don't need midwives to come and catch babies. I have midwives there to do that. What I need is midwives that want to come. They want to learn about normal birth. They are happy to adapt to what they see. We are very safe, but they will see things very, very differently to what they're being taught, especially in countries where it's very medicalized. And a lot of those midwives they stress they can't cope with it and we never see them again.
Diane:
[50:18] Because they come with this elitism that they have trained in this wonderful hospital with all this equipment but actually those midwives that have trained in the home birth system are the ones that do really well because they have that calm they calmly adapt to what they're seeing and they say okay this is what how we can solve this problem without the equipment without being able to pull the bell and the obstetric team come running in. So it's a very difficult community that there's a lot of social needs as well. So it's not just the midwifery side of things. As you know, that if you look at a woman who's being abused in the home, or she's been raped, or she's got syphilis, or she's got HIV, or she has no food, or she's sleeping on a street corner, those are all going to impact her pregnancy. So as a facility, we try and we manage the needs of all of those things as well as part of their as part of their package so it's all individual funding from all over um and sponsorship I love to have the sponsorship for the staff so that that person who's sponsoring can somehow build up a relationship with that member of staff yeah um so like sponsor a midwife.
Mel:
[51:31] And I mean, you live over there. You live in the slum.
Diane:
[51:34] I live outside the slum. It wouldn't be safe for me to live in the slum, but I live within five minutes. Yeah.
Mel:
[51:41] I mean, you don't take a weight. So this is, I mean, you are bootstrapping this entire thing.
Diane:
[51:48] Well, as I say, I go back to what I said about, I've learned more about midwifery in the last 10 years. And I did, I had done a few home births at home with a team of midwives where I worked. And their Kampala, the city, has a lot of expats in it. They have a lot of missionaries come in. They have a lot of NGO workers come in and those NGO workers come in with their families and they get pregnant and they don't want to go into the hospitals. So that started a little bit of a ball rolling in terms of me being the known home birth midwife. So I do go around with my little basket and I do do some homework at my home births. Still about a tenth of the cost that they would be paying in America, but I absolutely love it. And I would usually have about two home births a month maybe, and that just gets me enough to pay my rent, to keep me there, to run the car. So I do okay.
Mel:
[52:44] Incredible. Okay, so you're living just outside the slum, making money. People are paying you private fees to attend their home births, the ones who can afford it.
Diane:
[52:54] Again, it's more seen as a donation because some of that, any residual then goes to the clinic. So it's not seen as a, I'm not working as such. But yes, they pay me like a donation. And then part of that goes to the slum once my costs are covered.
Mel:
[53:10] And this whole, the birth center is legal. It's not as if you're operating illegally. No, it's very legal. Yeah, so it's all above board. I guess my question is, what's next? You know, if the centre closed down for those women, they would just go back to, you know, the the situation at the hospitals or giving birth at home how I mean for the people listening what can we do to help you keep this going
Diane:
[53:44] I think what what we've come to the stage now Mel is um we have to grow as I say when I came when I went out to Uganda I didn't go out to build a birth center.
Diane:
[53:56] It was the last thing on my mind. And every year I say, what am I doing? This was not meant to happen, but it's just happened. And now there we are 10 years almost. And we are doing an amazing job at the level that we're at, but we could be doing a lot more now. What you also have to understand is that culturally, there's a very, very different work ethic. And a huge part of my job there is managing the clinic, is managing the staff, is keeping everything going.
Diane:
[54:39] There is a culture where if there's no mothers there, then there's no work to be done.
Diane:
[54:45] Whereas you and I will be looking at the cupboards and we'll be going the cupboards need tidied or we've no medicines we need to do a stock check or we're in this community with 40,000 people let's go for a walk through the slum and go and follow up some of our mothers postnatally so unless there's somebody there all the time cracking the whip so to speak and saying okay I want you to go down and see that mother who delivered last week who had a problem I want you to go and do this. I want you to call in a few of the mothers and do a teaching session with them. It's not done. And as one person, I'm sort of at that burnout level where I want to be a midwife. I want to be involved in the clinical. I still want to be there as a clinical person. But more and more, my time is being taken out. we've now registered as a CBO which is a very very big step a CBO is a community-based organization not quite an NGO I'm not quite ready for that stress yet but this takes us to more of a level within Uganda where we can now legally have a bank account and save money so people can now in Uganda can now give us money and we have a bank account and so on that's been a huge, challenge this year anything to do with the authorities is always hard work, it doesn't happen even Ugandans will say things are done in Ugandan town.
Diane:
[56:11] There's very little urgency for things. So that's been a big stress. So in terms of people power, I would love to have people coming out, experienced midwives who could teach. As I say, the midwives I have are brilliant at their clinical practice, but it's teaching them about what's going on in the evidence-based world. It's teaching them new suturing techniques it's teaching them um it's supporting them um but that then means that it doesn't have to be midwives come it could be nurses it could be doulas it could be anybody that is willing to come in and fit in with us and not come in above us they don't need to come in above us yeah those midwives have been brought up to a level that you won't see in the rest of Uganda. And there is nowhere else that you will have a facility that can say that they've a hundred percent live birth rate. So they are, even in cases where there's big PPHs, those midwives are managing those midwives single-handedly sometimes.
Diane:
[57:19] And we very, very rarely have to transfer even PPHs. So we've got oxytocin and we've got misoprostol. We can't, unfortunately we don't have we don't have sintometrin I'm still trying to find ergometrin but the whole thing is we have very few PPHs, because our lack of intervention is meaning that the PPHs are not happening yeah so you're really prioritizing.
Mel:
[57:46] Physiology in order
Diane:
[57:48] To minimize the amount of yes they get their oxytocin but then they push their placentas their self We don't cut the cord until after the placenta's out.
Mel:
[58:01] Right. So little things like that. Active management for the third stage for every...
Diane:
[58:09] We sort of have to, because that's, if something was to happen and a mother was to have a PPH and she was to die, we would be shut down. So there are certain things that we have to be seen to be, and we follow, we follow everything that's done in guidelines by the Ministry of Health. We have to follow that. So the guidelines are that all women get their oxytocin. Now, in defense of that, we have never seen problems with mothers breastfeeding. We've never seen problems with a higher risk of postnatal depression. We never, ever have a baby that leaves that facility having not breastfed within the first 10, 15 minutes. So culturally, this is very different. And the mothers, they come in, they deliver, they go home within a few hours.
Diane:
[58:54] Unless they deliver in the night, there are no mothers that stay for more than six hours. So it gives us that little bit of extra assurance that when we send that mother home, she may have left five children at home unattended. It's not that we are throwing them out by six hours. It's they are wanting to leave two hours sometimes, three hours. I need to go home. I've left my children on a company down in the slum. So it gives us that little bit of reassurance that if something was to happen and come back on us then we have been seen to be doing everything that the ministry of health are telling us we have to be doing right um and it's we we have very very low numbers of pphs very low and actually the the majority of the pphs that we've had have ended up being um uh cervical tear because of very precipitate labour.
Mel:
[59:47] I mean, what are your, this is, I'm going to ask one of the few last questions. Firstly, the question I have would be what are your biggest challenges and then what are the solution to those challenges that I'm hoping listeners, people who are listening could help you guys?
Diane:
[1:00:05] I think it's probably now the growing. Ideally, we would love to get another building. We would love to grow the building that we have because we're now running out of space again. However, from my perspective as managing, I would love support in being that person to be working with the staff to build that initiative to set up more smaller projects within. So for example, I personally feel we're not doing nearly as much postnatal follow-up that we could do and antenatal teaching that we could do. Teaching the midwives about setting up their own little antenatal programmes giving them that initiative walking with them as we build up that service of going down into the slum and following up the postnatals giving them ideas.
Diane:
[1:00:57] Because that's not a normal thing that's done. They don't do postnatal follow-up. We do postnatal follow-up, but again, we might have only one or two midwives on duty at any shift. Because we've only got four midwives, including me. We don't have that staff always to be able to go down and leave the staff, the place unaccompanied, unattended. So people with an interest in teaching to come out and help us grow within what we have. And of course financially as I say in the next year or two I would love to either, buy our building and then we can extend on it we can build it up we had an opportunity about a year ago that somebody offered us another building.
Diane:
[1:01:40] And when I said to the staff, one of them actually started crying and they said, but Diane, we can't leave here. I said, but this is a lovely, lovely big new building. No, we can't leave here. We can't leave here. We're right there in the slum and we have mothers walking past the gate and we're looking out the gate and we see them and we're waving and they're coming in with their babies after months to say, just to say hello. And we're now well known in that community, that Amani is there. Mothers will run to us with babies that need resuscitated. People will come with injuries and so on. So I would love ideally to buy that building and to make it better is to extend on it and at least start on that. So anybody with an interest, especially in teaching and management and even HR.
Mel:
[1:02:32] Okay. So you need some people with organizational management and business skill. Fundraising. And fundraising. Some people are good at writing
Diane:
[1:02:41] Proposals for fundraising, all those sorts of things.
Mel:
[1:02:44] Can I ask the ballpark, if you say you were to buy that building in US or US dollars or Australian dollars or pounds or however, how much would that cost?
Diane:
[1:02:54] As a guess, I would say it wouldn't exceed maybe $1. $100,000. It's a small building and it's in a slum community. There's a lot of renovation would need done on it, but it has the potential to give us more space. But again, then we would need to have more money for more staff. At the moment we're managing, but for us to grow, we need more people coming in. And for me, I am badly in need of support in terms of that day to day working with the staff and keeping things going not from a clinical necessarily from what happens in the clinic but just boosting that motivation and that encouragement
Diane:
[1:03:37] sort of have a thought to to build other services that we could be providing yes.
Mel:
[1:03:42] Okay so how and I'm going to put all of these details in the show notes of this podcast and anyone who gets the emails will get details in their email we've got 17 000 people on our mailing list hopefully something out there has got some cash and we can help make this happen or an interest in putting your body on the line and taking yourself out to uganda and being both practical use as well have you got an account that we can transfer into is that all official now you said you're now a cbo
Diane:
[1:04:16] Yes so and it's literally this week we are literally signing for the bank account so we now have a we now have an account in Uganda that people can put money into we now have a full board so we now have a board of trustees that takes a huge pressure off me we have an emergency fund which is the one that I want to really try and build up because if we have a mother that we feel is is badly at risk or we think that if we send to one of the government facilities and there's a delay that we could lose either the mother or the baby, we want to be able to pay for them to go to one of these hospitals. If we were to grow the building, we could get our own theatre.
Diane:
[1:04:57] Now that's a massive step in which I would need complete support of an obstetrician coming in and training up an obstetrician and knowing how to set up a theatre. I mean, a theatre in Uganda is very different from a theatre in Australia or UK or whatever. It's very, very simple. So that is a possibility in the future. Our main donors are Mama Imara this Canadian charity it's a fully set up foundation in Canada and they have a Canadian account that also accepts American I think they're they're now registered for tax you know for tax back in America as well so they're organized their trust is called Mama Imara so a lot of people can put into that and they are responsible as I say for paying a lot of our salaries and our rent so without them we're we have problems they're the our biggest donors, there's never anything residual i mean literally what they get is what they pay out each month so we'd love to build on that, Otherwise, if it's a small donation and you think that there's going to be, when I say a small donation, people will send me like $10 and they'll just go, Diane, I wish I could send you more. But actually, $10 will pay for two of our women to have a scan.
Mel:
[1:06:11] Wow.
Diane:
[1:06:12] So $10 in American dollars is two women having a 20-week scan. So the smallest amount, we have people that will give $10 a month. That's huge. A very small amount goes a long way. And also supplies if they want to pay a bill for somebody. If we have a mother that goes to one of the hospitals, they can even pay the hospital directly. So there's that way as well.
Mel:
[1:06:36] So there's lots of opportunities. Yes. And you've also got a beautiful YouTube video about your service. So what I'm going to put in the show notes is the YouTube video so everybody can watch and get a really visual understanding of what happens there. Yes. I'll put a way that they can be in contact with you. And if anybody's inspired to add to this work, you can get in contact with Diane and we will make sure we link all the ways that people can donate us.
Diane:
[1:07:06] Now that we're a CBO, we're now Amani Mama's Initiative. I have to even get it into my own head. Amani Mama's Initiative. We now have a webpage under Amani Mama's Initiative. It's not live yet. because we're still building on it, but that will also have a donate button on it. There's a couple of other Amani organizations. There's a baby's home. There's a couple of other things. So just be careful when you look up the website that there's a few similar things, but it's Amani Mama's Initiative.
Mel:
[1:07:38] Amazing, Diane.
Diane:
[1:07:39] Come, come. Uganda is the most beautiful country. The sun shines the whole year round. It has amazing people. It has amazing potential of these staff. There are some absolutely beautiful, beautiful staff and tremendous skills. They will learn a lot. You know, we don't just bring what we know. These are the women that are there at the coalface dealing, saving these lives without being able to pull the emergency buzzer. They are the ones with the skills. So come. It's a beautiful country to travel in. I have plenty of space. I rent out one of the rooms and just come have a holiday and come and volunteer with us just even for a couple of weeks. It's lovely.
Mel:
[1:08:24] It's an amazing opportunity for everybody listening. Now, this is true rebellious midwifery, I think, if it's nothing else. Amazing. Thank you so much, Diane.
Diane:
[1:08:36] Thank you for the opportunity. Oh, fantastic.
Mel:
[1:08:39] If you want to continue working in a woman-centred way to enhance your skills as a midwife, to not feel like the black sheep in every maternity care setting, join the Assembly of Rebellious Midwives. I'm in there. We meet almost every week to discuss research, cases. We've got vaginal club. I'm there. It's the way to connect directly with me. It's the inner circle of rebellious midwives, and I'd like to invite you to join the assembly. All the details are in the link. It's for any midwife all over the world. I'll see you in the assembly. That has been this week's episode of the Great Birth Rebellion Podcast. us. All of those details will be in the show notes and I will see you in the next episode of The Great Birth Rebellion.
Diane:
[1:09:24] Be midwives. Don't let anybody stop you being midwives.
Mel:
[1:09:28] To get access to the resources for each podcast episode, join the mailing list at melaniethemidwife.com. And to support the work of this podcast, wear the rebellion in the form of clothing and other merch at thegreatbirthrebellion.com. Follow me, Mel, @melaniethemidwife on socials and the show @thegreatbirthrebellion all the details are in the show notes
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