Massachusetts General Hospital Vincent Program in Global OB/GYN
Welcome to the January newsletter! Our goal is to share with you stories from our work around the world, important new publications from academia and the media on global women’s health, a few fun facts, and tips on how to stay safe while traveling. We’d love your input, so if you have a story, or wish to share a tip, send them our way! firstname.lastname@example.org
From the Editors: AK Goodman, Adeline Boatin, Tom Randall
Warm wishes to you all for the new year! We wish prosperity and health equity for everyone!
Midwifery, a specialty health profession, is being prioritized by many low and middle countries to fill in the gaps in newborn, maternal and reproductive health. In this newsletter, we would like to share stories and literature on midwifery, on its training programs, certification, and its challenges.
Notes from the Field: Midwifery Education in Lira, Uganda Jennifer Lynn Neczypor, CNM
Pic: Jennifer Lynn Neczypor (in middle) with Lira University midwifery students, Uganda, 2019
Pic: Jennifer Lynn Neczypor and Julie Mann (on the left) with Lira University midwifery students, Uganda, 2019
The cheerfully-painted campus of Lira University and its sparkling new teaching hospital stand in sharp contrast to the flat, desolate surrounding terrain, where old clotheslines, rusted cans, and wandering goats, are the only remaining testament to what was once a sprawling camp for internally displaced people fleeing the violence wrought by the Lord’s Resistance Army. Once home to unspeakable tragedy, the grassy plains now resound with the scratch of pens on paper, the shouts of students playing soccer, and the wailing cries of newborns. As a MGH Global Nursing Fellow, I and fellow CNM Julie Mann were privileged to spend two weeks in June serving as clinical preceptors to third-year midwifery students attending Lira University, which currently boasts the only bachelor’s program for midwives in Uganda. The students and patients that I came to know during my time in the country left me with indelible impressions, not only of the lack of resources, medications, transportation, and transfer systems so familiar to those who work in global health, but also of eager students and resilient mothers whose daily lives exude quiet strength and dignity. While in the packed labor ward of the regional referral hospital, which routinely sees fifty to sixty laboring women jostling for three flimsy labor beds, and accompanying the students on postpartum home visits, I came to realize that what these learners require, far more than fancy simulation labs, new textbooks, and complicated, impractical technological solutions, consists of quality clinical education and mentorship.
The role of the clinical preceptor, working one-on-one with a student midwife, helping to guide her hands and imparting both the science and the art of midwifery care, is foreign to many parts of the Global South, including Uganda. In Lira, the two or three harried staff midwives who run the labor ward struggle to provide basic care for high-risk patients, obtain medications and blood, track down the elusive “on-call” physician when necessary, and perform non-nursing tasks such as inventory, sanitation, and maintenance, leaving them with little time to supervise students. As a result, the majority of babies born at the hospital are delivered by unsupervised nursing, midwifery, and medical students. I was initially surprised to find that Lira University faculty members do not accompany their students into the clinical setting. As a result I observed doubt, hesitancy, and quite a few shaking hands amongst the students in their initial practice. When a mother entered the sweaty fray with her dress held high above her knees, actively grunting and pushing, I was reminded of my own first delivery, a rapid multiparous birth that occurred in the hallway. I turned to the student nearest to me and told him to put his gloves on. “I want to watch you first,” he protested. This was a common refrain amongst the students, as much of their education consists of watching others, instead of actually performing skills themselves. I gently placed my hands over his instead and guided him through the motions of a beautiful vaginal birth. The look of pure pride on his face when he brought the screaming infant to her mother’s chest is not something I will forget.
Throughout our two weeks in Lira, Julie and I endeavored to demonstrate the art of preceptorship – giving students the space to practice skills, execute procedures, manage complications, and catch babies while serving as sounding boards, resources, and, occasionally, an extra pair of hands during surprise twin deliveries. The concept of precepting students in this way, providing real-time feedback, daily informal performance evaluation, and personalized support, is relatively new to midwifery training in Uganda. It is was greatly appreciated by the students, who grew in confidence with every baby they resuscitated and each laceration they repaired. Due to the well-documented lack of skilled birth attendants in developing nations, local providers, pulled in so many directions, are often not able to devote adequate time and energy to clinical education; it is this imperative gap that could be partially filled by volunteer providers from overseas hospitals and birth centers. Midwifery services in developed countries should collaborate with educational institutions such as Lira, sharing knowledge and precepting students, an endeavor that must be framed as a partnership rather than a one-sided “aid mission.” In our case, the Lira students, accustomed to sporadic lectures from Western male physicians, frequently mentioned how grateful they were to work with experienced female midwives, women who shared the calling to the same vocation and could identify with the struggles, joys, and heartbreaks of the profession. On the other hand, Julie and I made sure to emphasize how much we were simultaneously learning from our host country counterparts, including comfort measures to facilitate low-intervention birth, methods of reducing perineal tearing, and ways to safely deliver vaginal breech babies. On the surface, midwifery education may not appear as glamorous as opening a free clinic or dropping in for a week-long medical mission, but ultimately, it will prove more fruitful, as the students we teach today will become the providers and preceptors of tomorrow.
Jennifer Neczypor is a certified nurse-midwife and family nurse practitioner who currently provides full-scope midwifery care at the MGH main campus and at Chelsea Health Center as a member of the Vincent OB/GYN Service. She received her education at Vanderbilt University School of Nursing, where she also earned a Graduate Certificate in Global Health. Prior to becoming an advanced practice nurse, she served in the Peace Corps in Vanuatu. She is extremely passionate about global health, particularly improving maternal and neonatal morbidity and mortality in developing countries and underserved regions, and has worked as a midwife in Uganda, Nepal, and Vanuatu, as well as the United States. As a Global Nursing Fellow with MGH this year, she had the opportunity to precept midwifery students in Lira, Uganda, a site where she hopes to return next year to continue collaborating with the Lira University faculty and students.
The World Health Assembly has designated 2020 as the Year of the Nurse and the Midwife.
Travel Grant of $2000.00 is available to support residents, fellows, and faculty who would like to embark upon a global health trip. If interested, please contact Ak Goodman (email@example.com).
International Tumor Board ECHO Sessions: International Gynecologic Cancer Society holds monthly gynecologic oncology tumor board meetings including gynecologic oncologists and GYN-ONC trainees all over the globe. Interested fellows and residents, please email Thomas Randall (TRANDALL@mgh.harvard.edu) or Ak Goodman (AGOODMAN@mgh.harvard.edu).