International Day of the Midwife: Q&A With Sally Pairman

Sally Pairman, Chief Executive for the International Confederation of Midwives, knew nothing about midwifery until the very end of her nursing education. It was then that she was taught by a midwife who came to New Zealand (where Sally lived) from the United Kingdom and who “inspired me with her stories of midwifery” and the joy of bringing new life to the world. Attracted to the autonomy that midwives had—because they were “very much in charge of themselves and what went on in the maternity ward”—Sally decided to move to London to become a midwife herself.

Every Woman Every Child caught up with Sally to talk about the role of midwives now and after the COVID-19 crisis. This interview has been lightly edited for clarity.

The work of midwives has always been essential. How is the situation different during the pandemic now?
Women—who of course continue to give birth—are often very frightened about going into a hospital or facility for birth because they’re worried that they’re going to catch COVID-19, and of course some of them do. In many parts of the world, maternity facilities that were originally just for childbirth and the care of pregnant women have closed down and turned into hospitals specifically for the care of patients with COVID-19, leaving childbearing women with nowhere to go. There has been more and more demand from women for community-based services and home birth, including in countries where these services are not part of the usual services offered to women, and therefore with no infrastructure to support this demand.

It is midwives who are stepping up to meet this demand from women, often without support or resources from their health systems. Even women who are having babies in the hospital, including even those who have had Caesarean sections, are being discharged within hours of giving birth. And it falls to the midwives to provide their postnatal care and follow-up, so workload has increased. No matter whether midwives are providing midwifery care in the usual maternity services, or in provision of new community-based services, it’s been incredibly challenging for them to figure out how to manage provision of midwifery care in the context of the coronavirus, and often without evidence because this is a new disease.

Do the physical distancing rules provide new challenges too?
Midwifery care usually takes place in close contact with women and their families and so midwives are having to work out how to continue this support and care when physical distance needs to be maintained. Obviously, midwives must not become infected themselves, or spread COVID-19 to women. So they are learning to do virtual visits with women and working out when they must still have hands-on assessment and how to do this safely.

Midwives are finding answers to important questions: When do I need to be hands-on? When do I feel that woman’s abdomen and feel the baby and when do I not? It’s the same postnatally: What can I do by calling her up on the phone or Skype or Facetime, when do I actually need to see her and see the baby? And how can I keep myself safe?

And no matter how resourced the country is, midwives are suffering from a lack of personal protective equipment. They seem to be almost at the bottom of the list in some countries, so they have to make do, and tragically some midwives have died because they’ve contracted COVID-19 during their work. Many midwives don’t have the right equipment or the right support to help them provide care in facilities or in the community.

This is a real risk to midwives and it has been exacerbated in places where midwives have been re-deployed to work as nurses caring for general patients with COVID-19. The conflation of midwifery with nursing is impacting the health of pregnant women and new mothers. Midwifery and nursing are separate but complementary professions. Even if midwives also hold a nursing qualification, they practise as midwives in caring for pregnant women—and if they are taken away from this essential work it is pregnant women, new mothers, newborns and families who are paying the price.

What does that mean for the women who are giving birth?
On top of significant changes to maternity services, many women have seen their rights being eradicated when their support people are denied access during birth and when babies are taken away after birth or breastfeeding is denied. Services like family planning, contraception, abortion services and well child services have closed down and women are looking to midwives to try to fill these gaps, again without resources.

It is unacceptable that women’s rights are being denied through actions that are ostensibly to manage COVID-19, but for which there is no evidence and that go against all we know about what women and new mothers and their babies need to thrive. We know that babies need to be with new mothers, we know that babies are better off when they’re breastfed, and midwives are advocating to support those normal processes to carry on as much as possible.

What will that mean for the future?
What’s going to happen in the future, beyond this pandemic, is most likely a lot of unplanned pregnancies and women in dire straits, including an increase in unsafe abortion. On the positive side, many women have experienced community-based midwifery care and homebirth and I hope that we will look carefully at how to keep community-based services going for women experiencing normal healthy pregnancies and physiological births and for better postpartum care. We have seen that centralised health systems can fall over in times of health crises and that it is midwives in the communities that have very often stepped up to maintain the care of pregnant women and their newborns. That is essential and doesn’t change because of a pandemic.

What is the most important action we should be taking now to support midwives?
The big lesson is almost beyond COVID-19. What can we learn of this? I would say we must learn that midwives need to be at the table when decisions are being made around maternity care and around midwifery care. They’re the ones who actually know what’s going on and they have important contributions to make. And they need to be resourced. They can’t just be invisible or treated as though they don’t matter when they are bringing new life into the world. If we want to continue this world, we have to have life. We need to protect it, and protect the people who help women give birth and create new families. If this pandemic has shown us anything, it is that families matter—our communities matter, and if we want to keep our countries strong we need to protect our people—and this starts with birth and midwives!

Please visit the International Confederation of Midwives’ COVID-19 resource page for more information.