Lawton (1975) wrote that curriculum is a selection from culture. Any midwifery curriculum should be a selection from the local midwifery professional culture, so when we ask whether the content of a midwifery course in sub-Saharan Africa is the same as in the UK, the USA, Europe and other countries, the answer must be no. The experience of childbirth is different between countries and the health services are also very diverse. Having worked in Malawi, a resource-poor country; Seychelles, a middle income country; and the UK, a high-income country; the content of the curriculum is very different depending on the culture (both political and social) and the context of the midwifery care that is given. This article will give an insight into midwifery care in these countries and how it may differ from the standard midwifery texts that are used.
All midwifery courses use the International Confederation of Midwives (2013) midwifery competencies as a foundation, and curriculum developers map the midwifery course content against them. In addition, each country prepares the midwife to work in their own context and this requires different practices to those that may be seen in midwifery textbooks. The textbook that most midwifery courses use (especially ex-colonies) is Marshall and Raynor's Myles Textbook for Midwives, which is based on midwifery in the UK. Although there is an African edition, it is based in South Africa and appears to be an ‘add-on’ to the main content.
Midwifery education must also equip the midwife of the future. There must be some degree of ‘future-proofing’ in midwifery texts to ensure that the profession develops in ways that are not simply an emulation of a western, UK-based model.
Resources
One aspect that may drive the curriculum as well as the care given is the resources that are available. In some countries there is a cost for maternity services and this affects uptake and accessibility. As such, cost is seen as a significant influence on maternal mortality and morbidity.
Numbers are also an issue. In Malawi, the main referral hospitals care for more than 1000 women per month, whereas in Seychelles it is 1500 births per year.
Some countries may depend on donations for their medical stores of basic equipment such as sterile gloves, gauze and suturing equipment. This can certainly delay treatments such as caesarean section. In Malawi one day, the local newspaper headlines highlighted the fact that midwives were using plastic bags instead of gloves for births, to protect from HIV. When teaching about the superiority of certain suture materials, some of these may not be available in the country. Other essential items such as running water and soap may also not be available.
Some clinics in Malawi, which may give labour care to more than 2000 women, are remote, with limited access to obstetric advice. Although mobile phone coverage may be good, the midwife may not be able to phone a referral hospital due to lack of phone credit—this is not provided by the Ministry of Health and the midwife may not have been paid for months. Transport to the hospital may also be dangerous, especially in the rainy season. In Seychelles, all woman on the main island deliver in the central hospital.
Antenatal care
Following a systematic review (Carroli et al, 2001) the World Health Organization (WHO) recognised the importance of antenatal care and advised at least four visits, each focused on an aspect of education. Some countries still adopt a traditional approach to the timing of antenatal visits (monthly until 28 weeks, every two weeks until 36 weeks and then weekly, in the case of Seychelles); whereas in the UK, the National Institute for Health and Care Excellence (NICE) has reduced the number of visits to 10 for nulliparous women and 7 for multiparous women (NICE, 2017). Seychelles is also looking at reducing the number of visits, based on NICE guidelines.
Antenatal care should be standard in all countries, but again this is not true. In Malawi, a woman may have travelled for many hours to get to the clinic for what may be her only appointment; therefore the midwife will examine her for hepatomegaly and splenomegaly, provide treatment for malaria and worm infestation (common causes of anaemia), as well as examining the uterus. Any advice will also need to be emphasised due to the possibility of future non-attendance.
There needs to be a way of tailoring antenatal care to countries. In more developed settings, this should take into account the preferences, as well as the needs, of women accessing the service.
Nutrition
Nutritional advice in sub-Saharan Africa will concentrate on cheap, iron-rich foods (in Malawi this will include roasted locusts, a cheap source of protein), as well as advice on a well-balanced diet, which may be difficult to follow, due to poverty. In more developed countries, it may be necessary to ensure that women are not eating for two, due to the high level of obesity. Although anaemia may be linked to poverty, it is seen in 40% of women in Seychelles, compared to 17.4% in industrialised nations (Khalafalla and Dennis, 2012). This high incidence may be due to lack of, or non-compliance with, nutritional advice. Many Seychellois women stated that they never eat vegetables, although they are plentiful; whereas in Malawi, vegetables and maize may be the only foods available, so the women have very little protein. Lifestyle changes may also be needed to prevent malaria and other mosquito-borne infections. Mosquito nets are provided to all pregnant women in Malawi.
Screening
All three countries have very different populations and scanning procedures. Ultrasound scans are available in the UK, Seychelles and Malawi. Routine scans are performed three times in Seychelles, but only with an indication in Malawi. Some diseases are not seen in certain countries: for example, in Seychelles women are not screened for rubella, as this is not seen on the islands.
Student midwives in UK will be taught serum and ultrasound screening for a multitude of conditions that, if present in the fetus, may then lead to the woman requesting a termination of pregnancy, and midwifery texts feature whole chapters devoted to this. In countries with stricter laws, or where termination of pregnancy is illegal, prenatal screening for fetal abnormality is not undertaken. Even where termination of pregnancy is legal, there may be no laboratory to carry out serum testing. Where there are the facilities, there may not be the reagents, which may be dependent on charitable donation in resource-poor areas. Even screening for anaemia in some countries may be dependent on clinical examination and not routine blood testing.
Women in the UK can go through their whole pregnancy without a vaginal examination, but in the Seychelles a vaginal swab is taken at booking and at 34 weeks', due to the prevalence of sexually transmitted diseases. In Malawi, due to the lack of resources, women who present with a sexually transmitted infection are treated on the basis of their symptoms, and therefore this aspect of the curriculum needs to be taught in detail, as midwives cannot rely on laboratory investigations.
All three countries screen for HIV, but the treatments may be very different. Malawi has an HIV incidence of 11%, whereas the incidence in Seychelles is small. This has a bearing on how the woman is treated in labour. It is now policy in Malawi to treat all women who are HIV-positive, and T-cell tests are not performed. The woman then begins treatment, which she will continue for the rest of her life. It is also vital to ensure that neonatal prophylaxis takes place to reduce mother-to-baby transmission, and also reduce the high rate of HIV.
The autonomy of women and their ability to negotiate safe sex are seriously reduced in some countries. Advice to women in Malawi is to not engage in sexual intercourse in pregnancy and for 6 months after birth, which may see husbands seeking sexual gratification from prostitutes. The belief that there are useful vitamins in the semen, furthered by local, unqualified ‘doctors’ in Malawi, may also cause women to have unprotected sex. This is therefore one area where midwives can play a large part in changing practice.
Labour
Both Seychellois and Malawian women give birth with minimal pain relief. Higher parity is more common in Malawi, where children may die in infancy. This is in spite of sometimes high attendance at family planning clinics. In Seychelles, women tend to have just one or two babies.
Place of birth
In the UK and many developed countries, homebirth is an option when there is the ability to provide skilled care. In resource-poor countries, homebirth is not advocated due to the inability to provide skilled care at the point of birth, plus the lack of sanitation, electricity or running water. Some major hospitals and clinics may also lack running water, electricity, or even basic resources, so women may be asked to bring candles, razor blades and plastic sheets to lie on. As a result, some women may actively risk giving birth at home with no skilled birth attendant.
In a study that looked at barriers to women giving birth in hospitals in Malawi (Chanza et al, 2012), 78% stated the long walking distance to the health facility and 52% stated the lack of financial support while in hospital. One very upsetting aspect is that 40% cited the hostile behaviour of health professionals to women in labour.
Companionship
Companionship in labour has been seen to increase normality in birth. In major hospitals in Malawi, companions are advocated, and when new hospitals are built, individual rooms make up the delivery suite (Banda et al, 2010). In clinics with less privacy, companionship is not the norm, but in certain circumstances (such as pregnancy loss, or an extremely young mother), it is not refused. In Seychelles it is strictly limited to one companion, a rule that is rigidly enforced.
Second stage
The use of the partograph is advocated by WHO and is widespread in the UK, although its importance it is given less than a page in the Myles textbook (Jackson et al, 2014). However, the use of the partograph is a major problem in many countries—especially those that may benefit most from them (Nyamtema et al 2008; Fujita et al, 2015), and educational interventions are often needed in order to increase completion. In low-resource countries, cephalopelvic disproportion requires urgent transfer to a facility capable of performing caesarean section, and so there is the need to focus on identifying of signs such as increased moulding, increased caput and lack of descent of the presenting part, all recorded on the partograph. In Malawi, descent was plotted hourly on the partograph following abdominal assessment. In Seychelles, the priority appears to be the nursing notes, and students needed to be actively encouraged to complete the partograph, especially the fetal heart rate, which, in the absence of electronic monitoring, is not consistently completed.
Continuous electronic fetal monitoring is available in referral hospitals, but can only be used if electricity is working. Interpretation of the trace may be a problem in both countries.
Interestingly, Seychellois women tend to have very short second stages of labour: even when diagnosed by vaginal examination, I have not seen a second stage that lasted longer than 30 minutes. This is an area that needs further research.
Complications
In Malawi, students are taught breech and ventouse birth, and would be expected to undertake both on a regular basis; in the UK and Seychelles, breech birth would be undertaken in emergency situations.
In Malawian referral hospitals, midwives are used to dealing with eclampsia and act very quickly, using magnesium sulphate. In Seychelles, acute emergencies are very rare and therefore there is the need for continued practice in simulated settings. Sometimes, the demand for staff and theatre time is high, and cases that would have gone immediately to caesarean section may be delayed. In Malawi, it was surprising to see a confirmed cord presentation proceed to vaginal birth when there was no table for caesarean section available. The outcome in this case was a healthy baby. This demonstrates a high level of autonomy in low-resource settings, due to the absence of immediate medical aid. It appeares that autonomy is the rhetoric of middle- and high-income countries but the reality in resource-poor areas.
Third stage
Students in both countries are taught active management of the third stage, but this is conducted very differently. In Malawi, where routine ultrasound is not conducted, the uterus is palpated after the birth to rule out a second twin, before giving oxytocin. Students are taught manual removal of the placenta, which is also part of the UK curriculum, although not detailed in midwifery texts. In Seychelles, with routine ultrasound, active management follows procedures similar to the UK. These differences must be highlighted within texts and to overseas staff who may be working in low-resource settings, in order to avoid the situation that I experienced, having given oxytocin prior to the discovery of a twin. Happily, the second twin, which was breech, was safely delivered.
Both Malawi and Seychelles appear to use episiotomy sparingly, and midwives routinely suture. Suture material is readily available, although scissors to cut the thread may not be, meaning that the razor blades used to cut the cord may be used.
Birthweight
The average size of a term baby in the 50th centile in the UK is 3.5 kg. In Seychelles, the average weight was found to be 3.4-3.5 kg, while in Malawi, students' logbooks showed the average weight to be 2.9-3.1 kg. However, it must be acknowledged that the Malawian students worked in public, government hospitals and clinics, and that the birthweight is expected to be higher in private hospitals. If not, it may reflect a lack of appropriate food available locally, especially in times of drought.
This demonstrates the social determinants at work on fetal growth. In a study conducted in the USA (Buck Louis et al, 2015), birthweights were given for different ethnic groups. Babies born to white women were found to have the highest birthweights (50th centile=3.5 kg; 90th centile 4.4 kg); while babies born to black women had the lowest birthweights (50th centile=3.3 kg; 90th centile=4.1 kg).
This of course takes no account of different social standing: women in the Seychelles are seen as black, but in fact, the population is a mix of races and ethnicities. How this affects the birthweight may not be as great as women's social situation, and research should call for increases in social status, education and nutrition.
Many midwifery educations texts now provide centile charts, rather than average birthweights, which puts practitioners under a misapprehension when not tailored to a particular population. There is the need for centile charts for different populations to ensure that intrauterine growth restriction is not unnecessarily diagnosed.
Conclusion
This article has aimed to provide an insight into midwifery care in different contexts. There are many aspects that have not been discussed, such as care of the baby and postnatal care and the social circumstances of the women in both countries, which is so different. In both African countries, midwives are the main carers in labour and give care to the best of their ability, sometimes in very constrained circumstances.