Are midwives justified in beating women in labour?

In a 2007 study, mothers mentioned unfriendly, rude and abusive midwives as a factor influencing their choice to not deliver at health centres

By Carol Natukunda

THERE was no sign the baby was coming out soon. Its head peeked out, then disappeared again.

“Push!” a midwife coaxed. “Didn’t I tell you not to kneel? Lie on your back… your leg here…push! Okay? Push!” the mid-wife went on, despite pleas from the mother that she felt more comfortable kneeling down. “Push!” the frantic midwife shouted with full force, until the baby finally popped out from the birth canal.

Seven years later, Doreen Sanyu has neither forgotten nor forgiven that midwife who delivered her first child.

“Those women don’t understand,” she mutters sitting on a little mat at her home in Nateete in Kampala. “My mother always told me kneeling was the best position. Can you imagine giving birth with legs spread and everybody is looking at you? I can never go back to hospital, never!” Sanyu swears.

In her heart of hearts, Sanyu knows she is risking her life. She has seen some mothers bleed to death shortly after birth. She has also seen some new borns die, just hours after they are born. But the fear, the feeling that a midwife would mistreat her, keeps her glued home.

Next to Sanyu’s one-room house, is Esther Nakanwagi, who is quick to defend her.

The 37-year-old mother of one says a midwife slapped her as she delivered her baby. She remembers wailing and “trying to do as the midwife instructed.” unfortunately, that did not save her from the “wrath” of the midwife.

“She was telling me ‘Push! Push... (Two slaps) Do you want to kill your baby? Push! (another slap),” Nakanwagi recalls. “I was thinking….‘does she understand my pain?’ Before I knew it, more slaps had followed!”

“At one point I even thought she was laughing at me; when she said ‘just be like you are pooing!’ I wondered if she was mocking me.”

The stories speak volumes about the conflict between the midwives and mothers. While mothers accuse the midwives of being rough, the midwives and maternal health experts argue that they are only helping the mothers.

“I would not say it is slapping as such. Some women are naïve and don’t know what to do. Others simply don’t want to cooperate yet if they don’t, they could lose their baby or lead to unnecessary operations, which may be costly,” says Dr. Alfred Driwale, the Koboko district health officer.

He explains that ordinarily, the uterus should push out the baby without help, but often women need extra force to get babies out.

“The maternity service is a highly emotional environment, with two people at the extremes. All the mother wants is to get a healthy baby. The midwife wants you to follow her instructions, because technically, she knows you could harm the baby. So misunderstandings arise when the mother responds negatively due to pain, fear or anxiety,” Driwale explains.

On the rude remarks, he says society has shaped people’s mindset in a way that the private body parts should not be mentioned in public. “Things like “spread your legs” could offend the mothers, because their society forbids that.”

He, however, acknowledges that some hospitals are many times understaffed, so midwives lose patience because they are stressed due to work overload. The issue greatly poses the challenge of convincing mothers to deliver from the health centres.

According to the 2006 National Demographic Health Survey, attendance of antenatal care had improved to over 90% but skilled deliveries remained at 42%.

Statistics further showed that only 5% of births are delivered with the assistance of a doctor, 37% by a nurse/midwife and less than 1% by a medical/clinical officer. While 23% of births are assisted by a traditional birth attendant, 25% are by relatives or friends, while another 10% of mothers did not receive any assistance.

While there are different reasons, research further shows that midwives’ behaviours greatly discouraged women from going to deliver at hospitals and health centres. They would rather do it the risky way at home.

In a 2007 study, “Midwifery behaviours and practices that affect utilisation of maternal health care services in Buikwe West, Mukono district,” 35.3% mothers mentioned unfriendly, rude and abusive midwives as one of the factors influencing their choice to not deliver at health centres. The research, done by Edith Mwebaza, the principal nursing officer of Mulago Hospital, also shows that 42% do not want to lie on their backs and spread their legs as the midwives insist. Also, 36.7% argued that they were afraid of C-sections.

Consequently, the majority deliver at home, where they face serious dangers. Out of every 100,000 deliveries in Uganda, 435 women die as a result of delivery-related complications. Most complications arise from delivering in the absence of medical workers. Driwale says more women will die, unless they are encouraged to visit health centres.

He feels the way forward is to empower women, especially at the grassroot level, with basic antenatal information, to prepare for labour and childbirth.

“Once they have the information, someone will know that it is far safer to deliver at a health centre than at home. Even if someone slapped you or sounded rude, it is usually done in good faith to save the baby’s life. Everybody, including the medical personnel, looks forward to a baby being born alive,” Driwale says.

But a 40-year-old mother feels it is sometimes too much. “I was looking forward to my first prenatal visit and was disappointed how it turned out. My midwife was quick. She checked my breasts, allowed me to hear the baby’s heart beat and asked whether I was taking some vitamins. Within minutes the visit was over,” the woman says. “I felt she did not take the time to give me information.”

The health ministry is aware that there are some negligent midwives and warns that if caught, they will be punished.

Dr. Anthony Mbonye, the assistant commissioner for reproductive health, urges women to speak out. “If you go for antenatal care and the midwife does not measure your blood pressure or does not explain to you why your feet are swelling, why you have headaches and faint, that is a case to report. We are auditing maternal deaths and have punitive action where there was negligence. This was a presidential directive in 2005.”

Prof. Medi Kauma of the Makerere University medical school, says some health workers have poor communication skills. “We introduced the concept in health training schools about four years ago. Most of the senior midwives, nurses and doctors have not benefited from it.”