The journey to the birth center in Atiak, Uganda, takes the Yale School of Nursing (YSN) midwifery group nearly 24 hours on a plane from New York to Dubai to Kampala and then it takes a seven-hour drive to reach the constellation of birthing huts. But it gives so much more.
“This trip was an experience that will inform how I practice as a midwife for the rest of my career,” said nurse midwifery student Colleen Traub ’23 MSN, BSN, RN.
“I would strongly recommend this trip to students with any interest in global health, non-traditional birth settings, or innovative approaches to maternal care,” said nurse midwifery student Sam Duplantis ’23 MSN. “The experience was truly unique and offered total immersion in a completely different birth culture. It highlighted the importance of deeply understanding the community to which you are trying to offer care and working directly with community leaders.”
Assistant Professor of Nursing and Interim Nurse-Midwifery Specialty Co-Director Dr. Michelle Telfer, DNP, MPH, CNM, FACNM, led the four-week summer trip, bringing students to Uganda for the first time since the COVID-19 global pandemic began. She described partnering with the Uganda facility as an opportunity for YSN students to understand the full scope of midwifery care.
“Our students caught many babies, including several who didn’t breathe after they were born and were successfully resuscitated using Helping Babies Breathe, a resuscitation protocol used in low-resource settings. They provided primary care and gained experience with global health by treating malaria and typhoid, and provided full-scope midwifery care including prenatal, birth and postpartum care and care of the newborn,” Dr. Telfer said. “These students got to observe normal physiologic birth and they saw women birthing without unnecessary intervention. They also see excellent outcomes: the birth center has never lost a mother in 15,000 births over 15 years and has a lower mortality rate than the rest of Uganda.”
A Nontraditional Birth Setting
The Ot Nywal Me Kuc (“House of Birth and Peace”) birth center is a sustainable, solar-powered series of huts with private rooms and a communal space in the middle. It is run by the NGO Mother Health International, and Director and registered midwife Rachel Zaslow began the partnership with YSN about five years ago. Dr. Telfer is looking forward to deepening the relationship with future exchanges, including welcoming Ugandan students to YSN.
The center follows the Quality Maternal and Newborn Care (QMNC) framework. This approach is derived from a landmark Lancet journal series with YSN’s Helen Varney Burst Professor of Midwifery Dr. Holly Powell Kennedy, PhD, CNM, FACNM, FAAN as one of the key authors.
According to Mother Health International, a woman has a 1 in 25 lifetime chance of dying during a childbirth in Northern Uganda, and the infant mortality rate is 10 times higher than anywhere else in the Western hemisphere.
Mother Health International also notes that its model of care following the QMNC framework results in a 90% increase in prenatal care, a 92% increase in births with a skilled attendant, and 87% reduction in perinatal mortality, and a 76% increase in the survival of a child ages 0 to 5 years old.
“It doesn’t take money or fancy machines,” Dr. Telfer said. “It takes people being respectful and having good basic skills. It takes having a good network and a good system for transferring patients to the hospital when needed.”
Preparation and Student Experience
Dr. Telfer uses the full spring semester before their departure to prepare the students, who learn the principles of cultural humility, global health, global ethics and working in a low-resource setting. Students learn how to understand and embody their roles not as volunteers, but as pupils learning from the Ugandan traditional midwives and nurse midwives.
The difference between a typical birth in the United States and Uganda was particularly noticeable for Traub.
“There was no rushed timeline dictated by a provider’s work schedule. There were no elective inductions. The safest option available was usually the option with the least interventions, and so that was the option that was taken,” she said. “The experience of seeing so many physiologic births, a rarity in the United States now with the medicalization of uncomplicated birth, will impact my care as a midwife for the entirety of my career. I have seen what uncomplicated birth can look like when a birthing person’s body is trusted. I have seen what the support of midwives can look like, and how nurse midwives and traditional midwives can work together to provide quality, community-based care.”
The birth center utilizes the distinct – and distinctly valuable – skills of traditional midwives, who are trusted members of their communities, and nurse midwives, who have hospital training. Traditional midwives act a vital link to the birth center. They mobilize the women in the community for prenatal care provided by the nurse midwives, usually at the home of the traditional midwife. The convenience encourages women to receive care because they do not have to miss a day of work on family farms.
Traditional midwives call the Atiak facility for a motorcycle ambulance to transport a pregnant person when needed, and a traditional midwife is always on staff at the center to act as doula or additional support.
There are always two nurse midwives on staff and always one who sleeps at the birth center at night so when a patient arrives in need, they always are greeted by a skilled staff member.
On this trip, four YSN students were joined by 11 master’s midwifery students at Makerere University in Kampala, Uganda on their community health rotation with Dr. Scovia Nalugo Mbalinda. Drs. Zaslow, Telfer and Mbalinda provided workshops on the QMNC framework, community engagement and one of the YSN students who did her master’s thesis on group prenatal care in global health presented on that topic. The student’s from both universities were able to share experiences and knowledge from their different perspectives which was a unique opportunity.
Duplantis viewed the timing as significant; the group departed shortly after Roe v Wade was overturned.
“Upon arriving at the birth center, I was immersed in a community where women’s rights are legally and socially curtailed and motherhood is rarely a choice but the one and only expectation,” Duplantis said. “I was reminded that we enjoy so many privileges and rights in the United States, but people before me fought for those rights and it is incumbent upon us (perhaps now more than at any other time in my life) to continue that work.”
In addition to providing clinical care, students also contributed by bringing a suitcase of much-loved cloth diapers and newborn outfits for each baby. They also made a color-coded tool known as “HeartString beads” to help traditional midwives assess fetal heart tones (FHT).
As explained by Zaslow on the Maternova blog: “For every heartbeat, the midwife ticks off a bead and then after 15 seconds (we use sand timers), looks at what color bead they have landed on. White beads mean the FHT is too low. Green beads, FHT is in a range of normal. Red beads, the FHT is too high.”
This methodology was used accurately almost immediately, Zaslow reported, because it correlates well to the traditional systems of knowledge traditional midwives were already using. For examples, protocols at the Atiak birth center are communicated entirely through song and dance for the traditional midwives.
“Over the last several years, we have used the Heart Strings with traditional midwives in several countries and have been overwhelmed with their success,” Zaslow writes. “Midwives who previously could not tell the difference between a high-risk mother and a low-risk mother were able to make appropriate medical decisions prior to a bad outcome, thereby avoiding catastrophe and saving lives.”
Funding for Student Travel and Expenses
Both Traub and Duplantis emphasized the importance of a fully funded trip and expressed concern that the transformative experience would have been out of reach without the financial support provided by YSN. Funding sources included travel support from Dean’s Leadership Council Chair Jim Leitner ’75 to The Office of Global and Planetary Health and the Plank Fellowship.
“The financial support meant that we could spend class time learning about Ugandan history, practicing basic Acholi, and studying the treatment of malaria, rather than brainstorming ways to gather financial resources through sales and donation letters,” Traub said. “It meant we were more prepared when we landed in Uganda and could focus on learning from the beginning.”
Duplantis echoed the sentiment.
“YSN’s assistance in funding the trip was very significant. Even my recommendation that future students take advantage of this opportunity hinges on some funding from the school. Not only is the trip itself costly, but it requires students to sacrifice about a month of work during the trip. In addition, since students often have to make up clinical hours before and after the trip that could have been worked during the month we are abroad, your availability for paid work can be limited before and after the trip as well,” Duplantis said.
Telfer estimates that the total cost of next year’s trip will be $7,000 per student, a price tag that includes paying the midwives, room and board, and interpreters who can translate Acholi and English.
More on Midwifery
For more on the QMNC framework, check out YSN’s first-ever Coursera course: Global Quality Maternal and Newborn Care. More than 8,000 students have enrolled since Dr. Telfer and Dr. Joan Combellick ’91 MSN, PhD, MPH, CNM launched the course in 2020.
Applications for next year’s trip will be available later in the fall. Applicants should be prepared to commit to cultural preparation during the Spring 2023 semester and possibly contribute to the cost of the trip.
A collection drive for cloth diapers and newborn clothing will take place at YSN in Spring 2023.