In February this year, I had the privilege of spending my final transition period as a third-year student midwife on a 3-week voluntary observational placement in a 104-year-old government-run hospital in the city of Arequipa, Peru. Experiencing how a maternity system works in a developing country compared to the UK was something I had wanted to do since I had started my training and now that I was almost at the end of my degree, it seemed the ideal time to push myself out of my comfort zone and experience a completely different birth setting.
Another soon-to-be-qualified midwife and I decided to travel together, and after booking through a specialist company we arrived in Arequipa and settled into our home, shared by a further eight medical students from around the world. This collaboration of different nationalities and disciplines allowed us to compare how the health-care system in Peru differed from our own respective corners of the world, as well as sharing the experience as a group.
The first week involved attending one-to-one conversational Spanish lessons, covering medical jargon, to boost our vocabulary and confidence—thus enabling us to have basic conversations with maternity staff and women. It was an intense week, which left us excited to start in the hospital.
First impressions
The hospital itself was run down; however, I was pleasantly surprised to discover that most of the equipment was very similar to that in the UK. The antenatal care is also comparable. However, ultrasound scans are undertaken monthly throughout pregnancy.
The maternity unit consisted of a number of rooms, including a fetal monitoring unit that was much the same as our fetal assessment unit in the UK, again with similar equipment. The postnatal and antenatal ward was large, with no curtains or cots; the beds were all close together and the babies slept with their mothers, and as no formula was allowed in the hospital all the babies were breastfed.
The labour room
The room for women in established labour contained three beds, again with no curtains to protect women's dignity. Vaginal examinations appeared to be undertaken with no consent and in full view of anyone who was in the room, which I found distressing. On the other hand, though, I found this room strangely relaxing and calm.
I noted that the midwifery care was good; however, the midwives did not actively support the women, who laboured alone as partners were not allowed to be present. Nevertheless, the labouring women appeared to gain strength from one another while staying mobile and focusing solely on themselves. Pain relief is not an option in this hospital and so, even if a woman is on an oxytocin infusion to augment labour, she has no choice but to cope with her pain. At times it was harrowing, and I witnessed one woman in excruciating pain, screaming for help. Shortly after this, her mother wheeled her out of the hospital, apparently taking her to a private clinic to have an elective caesarean section. This was something I found particularly hard to deal with; however, I managed to support and reassure a number of labouring women using my limited Spanish and basic supportive midwifery skills of being ‘with woman’, using massage and breathing techniques to encourage them through their contractions. This is something I gained a great sense of achievement from; however, due to the availability of pain relief in the UK and the high-risk setting in which I was placed, this was not the norm during my training.
One thing that struck me was how quickly the women progressed; within the space of a few hours, the majority of women had become fully dilated. They were then walked next door to the delivery room. This room consisted of two beds next to each other, both with lithotomy stirrups. Within half an hour or so, after lots of encouragement from the midwives and obstetricians, the babies were born and put straight to the breast. Delayed cord-clamping was practised.
As in any birth setting, not all births are straightforward. As this hospital does not undertake instrumental procedures, on average it has a 50% caesarean section rate. This figure is mainly due to elective caesareans, as they try to avoid emergency sections by having robust guidelines in place; for example, women are advised to have a caesarean section if they have had a previous section, twin pregnancy, the mother is under 140 cm tall or if she is measuring large for dates.
What I have learnt
One of the key things I learnt was that women are strong and resilient, and they will birth their babies no matter what kind of pain relief they receive. However, my experience in Peru also made me realise that while having a choice of analgesia is something to which all women should be entitled, I also feel that the way birth is portrayed in the media in the UK causes many women to doubt their bodies, assuming that they would not be able to birth their babies without some form of pain relief—thus unknowingly and adversely prolonging their labour.
As a newly qualified midwife, while I agree that everyone should have choices, I believe it is my responsibility to inform and educate women on the risks of analgesia to enable them to make a fully informed decision, which is right for them. I feel it is my duty to be really ‘with women’ in every sense of the word, supporting them mentally, emotionally and physically with whatever choices they make.