No woman forgets her midwife. She might not recall the name, or even the face, but she will probably remember how that healthcare professional made her feel.
"We're with people when they are most vulnerable and when they are at their strongest. It's an amazing balance," says Naomi O'Donovan a 40-year-old midwife at Cork University Maternity Hospital (CUMH), where about 7,500 babies are born a year.
The role of midwives has been amplified during the pandemic, as they have had to cope both with safeguards against coronavirus and the need to offer extra support to women coming in with heightened anxiety and without partners. Hospitals not allowing partners to attend until the later stages of labour and then only remain for a short time after birth has had repercussions for staff as well as the couples themselves.
"It has been quite fraught, I think, for everybody," says the chairwoman of the Association for Improvement in Maternity Services (AIMS) Ireland, Krysia Lynch. On International Day of the Midwife, we get a glimpse here of what it has been like.
“Amongst all the handwashing, the masks and the PPE you still feel so vulnerable and conscious of every act you do in terms of reducing the risk of infection,” says O’Donovan. “It’s been so much on our minds.”
Yet, when with a woman labouring, “you do close the door on that and carry on doing what you have to do. It’s so different but also very much the same.”
We were worrying about what we were bringing in from home and what we were bringing home with us
Fear is a big barrier and these have been more anxious times, not only for expectant women but also those caring for them. The threat of infection isn’t new to midwives, she points out, “but the level of it was really overwhelming”, particularly at the outset. “We were worrying about what we were bringing in from home and what we were bringing home with us. You’re worried about keeping the woman safe and you’re worried about when you go home and get into the car. ‘Did I clean my phone? Did I clean my glasses?’ It has taken up a lot of mental space for everybody.”
“Initially, there was a lot of fear around it,” agrees Ruth Larkin, a clinical midwife manager at the Rotunda Hospital in Dublin, where more than 8,000 babies are born each year. Now that staff are vaccinated “there is a much safer, confident vibe”.
Through 2020, things were changing all the time “and we were learning as we went”. Then they were only swabbing women with symptoms, and getting about one positive case a week.
Now they swab every admission, with those coming in for an elective section or induction tested 48 hours beforehand. The only exceptions are those who have already had Covid-19, unless they are showing symptoms, in which case they may have been infected with a new variant.
Midwives are, knowingly at least, seeing more “red” cases, as they are dubbed, than they were. There is concern about the impact of Covid-19 on women and their babies, although it’s too early to be definitive about any link to miscarriages, premature labour and stillbirths.
“It is scary for the woman, and I would say it is not the nicest time to be pregnant or having a baby,” says Larkin.
The Rotunda has allowed partners into the labour ward throughout the pandemic, with staff socially distancing. Postnatal midwives “felt the brunt”, she says, of a total ban on visitors to their wards but that has been relaxed and “there’s somebody else there now who can help with the baby”.
However, for women who come in testing positive, no partners are allowed at any time “because the risk is they are also positive”, she explains.
“If somebody goes for an emergency section who has just found out that they are positive, they might not see their partner for five or six days. It’s tough,” she agrees. “They are completely isolated and the baby is in the incubator beside them; it’s very lonely.”
They can be on video links with partners and family “but it’s all very digital and a bit colder”. Although the midwives do their best, they can’t spend hours with them.
Despite the challenges of pandemic birthing, Larkin says she has never been more glad to be a midwife as the relatively small number of staff Covid cases in the Rotunda, “were nothing compared to general nursing or to general medical”. The midwives have taken turns in handling Covid-positive births, to cut down on exposure.
When assigning a Covid-positive woman to a midwife, Larkin would always ask if they were okay to look after her because that midwife might be in early pregnancy and not have told anyone yet, for example, or have a high-risk partner at home.
Typically a midwife is thought of as a person delivering babies, but the Republic’s 10,000 registered midwives (not all of whom are practising) cover a range of roles, including antenatal care and education, postnatal and neonatal care, hospital management and academic research to support policymakers, as well as attending home births, within both HSE and private services.
O’Donovan has recently joined the midwifery-led Domino team at CUMH, after seven years working in other roles there. The continuity of care that this system offers women having a normal pregnancy gives both sides a chance to get to know each other and facilitates an early discharge from hospital, with follow-up care at home.
“It’s the absolute bones of being a midwife, so I love it,” enthuses O’Donovan. The value of building a trusted relationship is reflected, she believes, in statistics for the Domino caseload at the CUMH for 2020. They showed only 11 per cent of women ended up needing a Caesarean section and the breastfeeding initiation rate ranged between 80 and 90 per cent.
“That gave me a little sense of pride; through all this we have still helped women to maintain normality.”
Women can feel so indebted to their midwife, observes Lynch, they’ll say to her (or occasionally him): “I couldn’t have done it without you.” However, a midwife’s role is “supporting and enabling the woman to be her greatest self”, and when the relationship clicks, it’s joy all round.
But at such a vulnerable time, personalities don't always bond and AIMS Ireland hears negative stories too.
If a woman believes a midwife has not been supportive or she has felt coerced in some way, “the sense of betrayal is huge”, says Lynch, who is a practising doula. “It is almost as if they would expect it from a doctor but they have a much higher expectation from one-to-one care.
“We don’t often talk about the vulnerabilities of women in the birth process. That is why the restrictions have been so horrific, because of that vulnerability.”
We've seen women really struggling without the partner visits
She thinks the lack of investment in midwifery has been exposed in the pandemic, particularly in postnatal wards. “We’ve seen women really struggling without the partner visits, struggling with breastfeeding and coming to terms with being a new mother, and midwives not really having the time to support women in that huge transitional phase of their lives.”
In recent decades, Ireland has had a very medicalised, obstetric approach to birth. Whereas the other approach is the physiological model, where midwives lead the way. It recognises that most women go through pregnancy, labour and birth as a normal physiological function and, while they need healthcare support, only a minority need medical intervention.
The first National Maternity Strategy (2016-2026) highlighted the physiological model, says Lynch, “and here we are five years on still waiting for so many aspects of that strategy to be enacted”. There are only two midwifery-led units in the Republic, and the one in Cavan recently came close to being subsumed into the hospital’s consultant-led maternity services.
“We need people to see what we’re worth,” says O’Donovan. “I always get the sense that the women do appreciate our care; it’s the policymakers who need to open their eyes to our virtues.”
At her own hospital, at least, the CUH Charity is using International Day of the Midwife to thank midwives "for their strength during this very difficult time". One emerging positive has been the use of online consultations and education, both for parents and for staff in professional development. As a result, the charity is trying to raise €10,000 for a "soundproof pod" at the CUMH to improve this facility.
O’Donovan likes to think she and her colleagues meet women’s high expectations of them. But she’s not sure anybody can have a realistic expectation of giving birth, only hopes and aspirations, as there is no straight line when a baby is being born.
“It’s all little curves and bumps in the road. No matter how well everything goes,” she adds, “we still have a little hitch in our breath when we’re waiting for these babies to come out and start crying.”
Read: Professional and personal lives collide in pandemic pregnancy