Peer-reviewed articles, grey literature and website links, if you want further information.
Covid-19 and Global Reproductive and Child Health
The Covid-19 pandemic has reduced skilled birth attendance and health facility deliveries in low- and middle-income countries: in Uganda health facility delivery rates dropped from 63% to 59%. It is predicted that a 10% reduction in safe pregnancy and newborn care could result in 28,000 additional maternal deaths and 168,000 additional newborn deaths worldwide (Riley et al. 2020).
A report from UNICEF, the WHO, the UN and the World Bank, published in October 2020, estimates that there are 1.9 million stillbirths globally per year. These occur disproportionately highly in low- and middle-income countries. A commentary in the Lancet (Homer et al. 2020) predicts that this inequity will be exacerbated by the global pandemic, and describes the direct and indirect effects the pandemic is having on reproductive healthcare and outcomes.
Covid-19 has negatively impacted both supply and uptake of contraceptives in low and middle income countries. It has been estimated that a 10% reduction in the use of contraceptives could result in 48.5 million additional women without adequate family planning, leading to 15.5 million additional unintended pregnancies (Riley et al. 2020).
The importance of continuing routine childhood immunisations in the setting of the current global pandemic has been emphasised: modelled data from Gavi (The Vaccine Alliance) and the Bill and Melinda Gates Foundation suggest that ‘the deaths prevented by sustaining routine childhood immunisation in Africa outweigh the excess risk of COVID-19 deaths associated with vaccination clinic visits, especially for the vaccinated children’ (Abbas et al. 2020).
Cultural safety is a term first used in the 1980s. It refers to respecting a person’s differing cultural beliefs in a clinical setting. Given that we are practising and teaching midwifery in a global context, cultural safety is fundamental for the safe practice of midwifery and for improving maternal health outcomes:
“Cultural safety stipulates that care providers should not just focus on learning cultural customs of different ethnic groups, but asks the care provider to be aware of those differences, their potential bias’s and consider the power balance in their relationship with the woman, implement reflective practice, and allow the woman to determine whether a clinical encounter is culturally safe. Unsafe cultural practice comprises any action that diminishes, demeans or disempowers the cultural identity and wellbeing of an individual or does not recognise the cultural identities of individuals.”
Fleming T. et al. (2020). “The influence of yarning circles: A cultural safety professional development program for midwives.” Women Birth 33(2): 175-185.
This peer-reviewed article addresses the importance of awareness of cultural safety for midwives. Yarning circles were used as safe spaces to discuss issues of cultural differences and racism in Australian midwifery, with specific reference to equality and respect between indigenous and non-indigenous midwives, students and care receivers.
Decolonising Midwifery, Sexual Healthcare and Global Health
‘Decolonising’ is a term used in multiple different contexts, so we should understand how it is being used in relation to midwifery. Fundamentally, it can be understood as an ongoing process by which we work to undo the harmful legacies and ongoing practices of colonialism.
The history of colonialism and the development of medical practices – including midwifery – are very closely related to each other. In terms of medicine and health care, decolonisation therefore usually refers to the following principles:
- Acknowledging the colonial and racist origins of healthcare research and practices, especially in formerly colonised countries;
- Combatting racism directed towards medical practitioners, students, and patients;
- Addressing racial inequalities that can lead to poor patient outcomes.
Espinoza-Reyes E. et al. (2020). Decolonizing the Womb: Agency against Obstetric Violence in Tijuana, Mexico. J Int Womens Studies 21(7):189-206.
This peer-reviewed article approaches the question of decolonising maternal health from a sociological perspective. Examining the experiences of women who suffered from obstetric violence, it found that women were discriminated against because of their cultural identity.
Affun-Adegbulu, C. et al. (2020). “Decolonising Global (Public) Health: from Western universalism to Global pluriversalities.” BMJ Glob Health 5(8).
A peer-reviewed article tracking the growing consensus about the need to decolonise Global Health. This is difficult because Global Health in many ways is a field that emerges from colonialism. They conclude that it is important for medical practitioners in Global Health and its adjacent fields to move away from a ‘one-size fits all approach’, which actually tends to exclude world-views outside of Europe/North America.
Lokugamage, A.U. et al. (2020). “Decolonising ideas of healing in medical education.” J Med Ethics 46(4): 265-272.
This peer-reviewed article demonstrates that “there is guidance from professional regulatory bodies to improve equality, diversity and inclusion as well as legal imperatives to improve person centred care” as part of a ‘decolonising attitude within healthcare.
Global Sexual and Reproductive Healthcare
Gavi (The Vaccine Alliance) https://www.gavi.org
International Federation of Gynecology and Obstetrics (FIGO) https://www.figo.org
Royal College of Obstetricians and Gynaecologists (RCOG) https://www.rcog.org.uk
Royal College of Midwives (RCM) https://www.rcm.org.uk/login/
United Nations (UN) https://www.globalgoals.org/3-good-health-and-well-being
World Health Organization (WHO) https://www.who.int
MATERNAL MORTALITY DATA:
Kassebaum, N. J. et al. (2014). “A comparison of maternal mortality estimates from GBD 2013 and WHO.” Lancet 384(9961): 2209-2210.
PERINATAL MORTALITY DATA:
CAUSES OF MATERNAL MORTALITY:
Kassebaum, N. J. et al. (2014). “Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.” Lancet 384(9947): 980-1004.
Khan, K. S. et al. (2006). “WHO analysis of causes of maternal death: a systematic review.” Lancet 367(9516): 1066-1074.
Say, L. et al. (2014). “Global causes of maternal death: a WHO systematic analysis.” Lancet Glob Health 2(6): e323-333.
CONTRIBUTORS TO MATERNAL MORTALITY:
Thaddeus, S. et al. (1994). “Too far to walk: maternal mortality in context.” Social Science and Medicine 38(8): 1091-1110.
Gabrysch, S. et al. (2009). “Still too far to walk: literature review of the determinants of delivery service use.” BMC Pregnancy and Childbirth 9: 34.
SKILLED BIRTH ATTENDANCE AND HEALTH FACILITY DELIVERY:
Robinson, J. J. et al. (2001). “The relationship between attendance at birth and maternal mortality rates: an exploration of United Nations’ data sets including the ratios of physicians and nurses to population, GNP per capita and female literacy.” Journal of Advanced Nursing 34(4): 445-455.
Doctor, H. V. et al. (2018). “Health facility delivery in sub-Saharan Africa: successes, challenges, and implications for the 2030 development agenda.” BMC Public Health 18(1): 765.
Midwifery in Uganda
Kemp, J. et al. (2018). “Developing a model of midwifery mentorship for Uganda: The MOMENTUM project 2015-2017.” Midwifery 59: 127-129.
This article studies MOMENTUM, which was a 20 month midwifery twinning project between the Royal College of Midwives UK and the Ugandan Private Midwives Association.
Wilson, M. et al. (2019). “Assessing the determinants of antenatal care adherence for Indigenous and non-Indigenous women in southwestern Uganda.” Midwifery 78: 16-24.
This article discusses the importance of health equity to ensure care has a high degree of utility for all women, regardless of socio-economic status and material resources.
Racism in Midwifery
Unfortunately, racism persists in midwifery and maternal healthcare both in the UK and abroad. Anti-racism is important for all clinical settings across the world. This has particularly been highlighted in US midwifery: especially for combating racism against black women.
Suarez, A. (2020). “Black midwifery in the United States: Past, present, and future.” Sociology Compass 14(11): e12829.
Gordon, W. M. (2016). “A Racial Equity Toolkit for Midwifery Organizations.” J Midwifery Womens Health 61(6): 768-772.
Likis, F. E. (2018). “Racism, Racial Bias, and Health Disparities: Midwifery’s Work Continues.” J Midwifery Womens Health 63(4): 393-394.
Moorley, C. et al. (2020). “Decolonizing care of Black, Asian and Minority Ethnic patients in the critical care environment: A practical guide.” Nurs Crit Care 25(5): 324-326.
This peer-reviewed article talks about racism in UK healthcare during Covid-19, and links to the next topic of ‘decolonising’ healthcare. For example, they discuss how it is important to listen to BAME when they express pain: “Often, when BAME patients express pain, the comment “it’s their culture to express pain in this manner” has been made, assuming that the level and intensity of pain is over-reported. This practice needs to stop, and the patient’s experience of pain should be acknowledged as non-exaggerated and a clinical need. Viewing the patient’s experience as cultural exaggeration is a form of micro-racism, and using an appropriate pain assessment tool, can change this practice.”
While many of these resources talk about decolonising medical practice and maternal health in the UK, US, or Australia, it is essential to implement decolonising attitudes in Uganda. Uganda is a former colony of the British Empire and so the links between colonialism in the recent past and racism today are very strong.
When white people from the Global North (Europe, North America, Australasia) come to Uganda to volunteer, this is often motivated through a will to do some good in the world because ‘they need help’, ‘we know best’. However, this practice is also known as ‘white saviorism’ and can end up doing more harm than good if conducted in an unregulated way within charities without proper safeguarding and anti-racist values.
There have been some high profile cases and campaigns recently which have brought worldwide attention to the issue of volunteerism in Uganda.
The Missionary Podcast: https://podcasts.apple.com/gb/podcast/the-missionary/id1494353780
“A young missionary named Renee Bach left her life in America to start a malnutrition program in rural Uganda. Folks back home and in Uganda praised her as a model missionary — an example of the healing power of God’s message. But a decade later she’s accused of masquerading as a doctor and rumored to have killed hundreds of children in her unlicensed clinic. How did Renee Bach end up here? Is she a case of good intentions gone wrong…or a predator posing as a saint? Hosted and reported by journalists Rajiv Golla, Halima Gikandi and Malcolm Burnley.
Lough, B. J. et al. (2015). ‘Confronting the white elephant: International volunteering and racial (dis)advantage’ Prog Dev Studies 15(3):207–220.
This peer-reviewed article tackles the question of white volunteerism from a sociological perspective. Analysing the attitudes of Black ‘recipients’ of aid in Kenya, it found that “Because white volunteers are often commended with high levels of resources, knowledge, skills, trust and compassion, their racial privilege tends to result in a comparative denigration of indigenous ideas and practices.” In other words, white international volunteers are valued because they are associated with power and resources, at the cost of Kenyan expertise which is consistently devalued and marginalised.