Developing a Short-Term Study Abroad Experience
Cindy L. Farley, CNM, PhD, FACNM, is an Associate Professor in the Nurse-Midwifery and Women’s Health Nurse Practitioner programs of the School of Nursing and Health Studies at Georgetown University. She was awarded a Campion Hall Residency in Oxford, England for Fall 2019. This Georgetown program gives faculty the opportunity to live in residence at Campion Hall, the Jesuit hall of the University of Oxford, while conducting research in England.
Dr. Farley explored the structure and delivery of midwifery care in the United Kingdom (UK) for the lessons that can be gleaned for the United States (US). The US is unique as the only developed country in which maternal mortality and morbidity rates are well below those of peer countries. Racial and ethnic disparities in these rates are 3-4 times that of white women. Despite higher per capita spending on health care, the US performs at the level of low-income countries on a number of perinatal indices. Growing the midwifery workforce and integrating midwifery care into the US health care system, as the UK has done with its midwifery work force and midwifery-led units, can contribute to improvement in maternal and infant health outcomes. Dr. Farley developed a short-term study abroad (STSA) experience to expose Georgetown midwifery students to other systems and models of maternity care, supporting a transformative approach to tackle some of the social, political, and economic issues that constrain midwifery in some US communities. The following is a brief description by some of the traveling students on the learning they had from this experience.
Royal College of Midwives
The STSA began with a visit to the Royal College of Midwives (RCM). Michelle Lyne, the RCM Professional Educational Advisor, provided tea, biscuits (in US English, cookies!), and midwifery materials as she gave an overview of midwifery in the UK. The RCM represents the interests of midwives in all four UK countries – England, Wales, Scotland, and Northern Ireland – individually and collectively. The RCM strives to promote excellence, innovation, and leadership in the care of childbearing women, newborns and their families, nationally and internationally. Their mission is to enhance the confidence, professional practice, and influence of midwives for the benefit of childbearing women and their families. The RCM is both a trade union and a professional organization; this differs from the structure of the ACNM, which is a professional organization only. As a trade union, the RCM offers assistance in a number of areas, from professional advice, disciplinary hearings, and leave of absence reviews, to collective employment relations support and representation. Most UK midwives are members of the RCM, while about 2/3 of US midwives are members of ACNM. Behind the Blue Door by Betty Cowell and David Wainwright presents a fascinating history describing the establishment of the RCM and the professionalization of midwifery in the UK. Please note the blue door in our photo at the RCM.
Student to Student Connections
The midwifery students from Georgetown University, US, and Oxford Brookes University, UK, were connected by email prior to the STSA. Called “Inter-Pals”, short for International Internet Pen Pals, this introduction via email began conversations and relationships that set the stage for a successful in-person exchange. Once US students were welcomed at Oxford Brookes University, the Interpals were placed together with other midwifery students in small groups and given time to share US and UK midwifery practices. Each small group then summarized their comparisons to the whole class. Reflections were collected on post-it notes and formed a collage; overall feedback from both US and UK students was extremely positive.
One US student offers the following reflection: “For me, the discussions we had with the UK midwifery students regarding the similarities and differences between our education, details surrounding our workplaces, and the care we provide brought the entire experience full circle. The UK midwifery students were enthusiastic about asking questions and genuinely interested in learning about midwifery care in the US. Overall, it was a great discussion of both UK and US midwifery, recognizing where each country falls short, and then starting the conversation of what we can do to change it. It was very empowering on a global level as to how we can work on solutions together to improve the care of women and infants around the world”
Another student shared this: “An area of high interest for the UK students was our US political involvement. Leaving the experience, it seemed we had inspired the class to contact their own parliamentary representatives. Even though the world of American politics can be messy and hard to discuss, I was proud to share my advocacy experiences on Capitol Hill.” It was interesting to visit the UK in the midst of Brexit negotiations; it gave us the opportunity to reflect on US-UK similarities regarding the controversies of politics and the importance of midwives engaging in policy.
Some differences in practice came to the forefront throughout our visits. The integration among home, birth center, and hospital birth settings, both as a choice for women and as a workplace for midwives was supported and seamless. In the UK about 90% of vaginal births are attended by midwives, while in the US that rate is about 10%. Care by a midwife is normal in the UK; for the US, it is not typical for most women. Group prenatal care and breastfeeding are more established practices in the US, while midwifery care is seen at all levels of care for pregnant women and hydrotherapy is available at almost all sites with water birth as a supported option. One US student chose postpartum care as her comparison project and found this: “I was especially moved by the community outreach and involvement of midwives in the UK. When asking about their postpartum follow up and concerns about women being lost to care, the UK students responded, ‘We knock on their doors. They can’t get away from us.’”
Water Birth in the UK
Dr. Ethel Burns, a senior lecturer in midwifery at Oxford Brookes University with a research focus on waterbirth, was our host for the Oxford portion of the UK experience. One student was fascinated by this topic and focused her international comparison project around water birth. She has yet to see a water birth in the US, despite her labor and delivery nursing background and her clinical rotations as a midwifery student, while a show of hands among the UK midwifery students indicated that almost all of them have had experience with water birth.
Both the UK and the US have guidelines outlining management of water immersion for labor and birth. However, there is agreement in practice between the RCM and the Royal College of Obstetricians and Gynecologist (RCOG); their joint statement supports water immersion during labor and the informed choice of a woman who desires to give birth in the water. In the US, the ACNM and the American College of Obstetricians (ACOG) have separate statements and they do not agree. ACNM guidelines are comparable to those of RCM and RCOG, while ACOG considers water birth experimental, in spite of a global body of evidence supporting its safety for selected women. Every UK birth facility we visited had birthing tubs available for any woman choosing hydrotherapy or water birth. These tubs, not the beds, were the center of attention when entering a birthing room. This environmental emphasis has a powerful effect on the interactions and expectations of the laboring woman and her care providers.
UK Vaginal Breech Birth Teams
A moment of insight and inspiration for one student was her visit to the John Radcliffe Hospital in Oxford, England, and seeing the midwifery-led unit there. Particularly notable to her was a team of five midwives who started a breech clinic that provides services for women with a breech-presenting fetus. Most UK midwifery students had either assisted or attended vaginal breech births during their rotations. The only vaginal breech births seen by one of the US midwifery students were a precipitous vaginal breech birth and birth of a breech presenting second twin. After ultrasound confirmation of breech presentation at 36 weeks’ gestation, UK women are given the option of having an external cephalic version (ECV), a vaginal breech birth, or a cesarean birth. A specialized breech team approach allows concentration of vaginal breech birth skills within these members who can then teach others. Vaginal breech births in the US were almost eliminated from practice due to the Term Breech Trial study in 2000, which claimed that vaginal breech birth was dangerous, although most of the morbidity and mortality found in the study was not attributable to mode of birth. However, after that study was published, US physicians stopped training in vaginal breech births, preventing US midwives from learning vaginal breech birth skills. Cesarean birth for all types of breech presentations became the standard of care. The work that the UK midwives are doing shows that with proper training, team development, and evidence-based care, vaginal breech births can be a safe alternative to cesarean birth for selected women. It also shows that skills thought to be lost can be reclaimed.
Call the Midwife
The British television show “Call the Midwife” has enjoyed great popularity in the UK, the US, and around the world. We reflected on how media attention, both positive and negative, affects midwifery practice. As part of our STSA, we visited the “Call the Midwife” official location at The Historic Dockyard Chatham. We walked in the footsteps of Midwife Trixie Franklin, Sister Julienne, and Dr. Turner and explored the history of the location on a tour led by a costumed midwife. The cobbled streets and buildings of ‘Poplar,’ plus iconic locations such as the Grosvenor Hotel and ‘Chummy’s Hill,’ where Midwife Chummy famously learned to ride her bike, were featured. The 400-year old Chatham dockyard was transformed into to 1950s East London. We did visit the modern-day East End of London with a trip to the Barkantine Birth Centre, however, the area is very different now than it was back then. Our tour culminated with an exhibition containing set, props, and costumes. One student was a super-fan of this show and was able to identify props and photos by episode, calling this the best day of her life. Our group posed for a photo at the Nonnatus House dining table. Afterwards, we enjoyed a traditional British cream tea, complete with scones, jam, and clotted cream.
Importing the Learning to the US
Although we speak the same language in the US and UK, some words are used differently or have varied meanings. This was notable in discussions around midwifery care. UK midwives avoided the terms “low-risk” or “high-risk” and instead use “straightforward” or “complexities” to indicate a woman’s health status in pregnancy and in labor. They also preferred the term “recommendations” for care, rather than “management” of care. We appreciated the subtle differences in these language choices that support rather than exclude midwifery care and put the woman at the center of that care. One student shares this lesson she will take back to the US: “The message of choice was one I already planned on conveying in my future practice, however, in my STSA experience, the concept really hit deep. Making a difference for the women and infants in the United States may be as simple as supporting the choices of how to labor and give birth that women desire.”
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