Despite beliefs among midwives from Canada and other western nations that volunteering in developing countries can strengthen maternal care, little is known about what the experience of integrating these volunteers can look like to the health care workers who will actually practice with them. This article describes findings from a qualitative research project that investigated midwives¹ and other health care workers’ perceptions of western trained midwives who travel to Malawi to volunteer at the Embangweni Hospital for a three-month period.

Malawi is a small country in sub-Saharan Africa with a population of approximately 12,000,000 people. The Embangweni Hospital was founded in the early 1900s by the Free Church of Scotland and is now operated by the Central Church of Africa Presbyterian. The hospital has 1 30 beds, runs an operating theatre, serves a rural population of about 100,000 and manages four health centres and sixteen mobile clinics.¹

Demographic and Health Survey data identified that the incidence of maternal mortality in Malawi was 1,120 per 100,000 live births, one of the highest in the world.^2-3 There were 28.6 nurses (including midwives) per 100,000 people.^2-3 Skilled birth attendants, also known as accredited midwives, were available for 55% of births.² Although traditional birth attendants or non-accredited care providers are present at many village births, it is unclear whether their presence has significantly reduced maternal mortality.^4-5 Given that the presence of a skilled birth attendant at a birth can reduce the number of women who die in childbirth,^5-8 if foreign midwives volunteering in hospitals such as Embangweni are perceived as welcome guests, they may be able to contribute to an immediate and urgent need to reduce maternal mortality.

THE RESEARCH APPROACH

This project was framed from a constructivist theoretical perspective,⁹ where knowledge is believed to be constructed through an individual’s interactions with social processes and contexts. The design was descriptive and the findings a case study representation of one Malawian health care facility.

Robin Stott, an African-born British medical researcher, championed an investigative process of actively listening to the voices of the African people themselves. “The west is belatedly recognizing that much health research has little relevance to the world’s most unhealthy people. … We do not yet listen and learn from the people who suffer, even though they may have better solutions than we do.”¹⁰

The purpose of the research was to listen to and explore health care workers’ perceptions of western trained midwife volunteers. A secondary purpose of the study was to begin to consider strategies that would respond to these health care workers’ needs. The research was guided by the question: “What foreign midwife contributions do workers at the hospital believe are meaningfuf?

The participants in the study all worked at Embangweni Hospital in Malawi. They included each of the six staff midwives, the head nurse, a clinical officer, two patient attendants, and four American visitors (one of whom was a nurse, another was a midwife and two were physicians).

The data was collected during guided interviews with these fourteen health care workers over a three-month period. All of the participants invited the primary researcher to their homes to conduct the interviews. In keeping with Malawian customs, participants offered customary greetings and served nsima or traditional food during the research discussions. Typically, these in-home interviews were conducted in small brick houses across hand crafted wooden tables and with candles as the only source of light. Each interview was approximately two hours long and was initiated with the question: “How do you feel about western trained midwives coming to volunteer in the Embangweni Hospital?”

Participant responses were written down verbatim throughout the interviews.

Content from these data sources were analyzed first independently and then collaboratively by the researchers. The transcripts were thoroughly read and re-read and a systematic process of content analysis was developed to create a categorization and coding scheme leading to themes.¹¹ Trustworthiness was established through ongoing interaction and member checking with participants to ensure authenticity. To ensure anonymity, pseudonyms were used when participants’ comments were reported verbatim. Approval was granted from the Embangweni Hospital and all participants gave informed consent.

The following three overarching themes emerged from analyzing the data and are used to explain and describe significant features of Malawian staff members’ experiences with western trained midwife volunteers. The first theme was that western midwives offer important contributions to health care services. The second theme was that western midwives’ limited knowledge of Malawian culture was problematic. The third theme was that thoughtful preparation before arriving in Malawi was valued.

“Your encouragement is good. After the birth the congratulations is good.”
Asmaa, Malawian mother

Theme One: Western Midwives Offer Important Contributions to Health Care Services in Malawi

Without exception, all of the staff members who were eligible volunteered to participate in the study. And, participants’ comments all reflected an overwhelmingly positive attitude toward visiting midwives. However, as Jane, a visiting midwife from the United States explained: “Sometimes people don’t tell you that you may not be doing something right, Malawians are too polite. This is not a blame society.” Sara, a visiting physician from the United States added: “Even forthright educated Malawians may not criticize. After a long time people will tell you things, [there is a] fear of offending.”

During research discussions with the six Malawian midwives, comments such as the following emerged: “We ask Questions about your country, about how you manage patients. We can learn more.” “We share experiences.” “It is good, encouragement and assistance.” Marita, a Malawian midwife, believed the relationship with foreign trained midwives was “hand in hand.” Similarly, the patient attendants expressed that: “If hard workers come it is good.” “[It can] make the work lighter.”

The specific midwife contributions that Malawian health care workers believed were important included an exchange of knowledge and practices, ideas about patient care in other countries and assistance with a heavy workload. Khetase, a clinical officer trained in obstetrics commented: “Work wise, [western midwives are] strict on what you do, and [you offer] encouragement. We learn at school, for example, palpations, not always the way we are taught, but you do exactly as we were taught, no shortcuts.” Since little is said to new mothers immediately following birth in Malawi, Asmaa felt that: “Your encouragement is good. After the birth the congratulations is good.”

Theme Two: Western Midwives’ Limited knowledge of Culture was Problematic

By count, a lack of understanding the Malawian language and cultural practices was the most frequently identified problem in the present project. Visiting staff members urged volunteering midwives to “insist on interpreters” but cautioned “translation may not always be exact.” Through the eyes of the Malawian health care workers, volunteers’ limited command of their language resulted in difficulties communicating with patients and taking their histories. For Khetase, “[the] language [is a] problem, especially the first days. When you are just new I have to spare my time to teach.” When western trained midwives attempted to learn the language through strategies such as definition and lists of common phrases in English and Chitumbuka, they were perceived as interested and having “the heart” to learn.

Greetings in Malawi are important. Individuals routinely greet one another and have an elaborate system of words and phrases that are used at different times of the day. It was a mark of courtesy to be familiar with and to use these greetings.

Also, perceptions of time can be different in Malawi. Anne, a visiting nurse from the US explained: “Punctuality is not an issue for Malawians. The wheels go slowly. Forget western preoccupations. Relax, observe, and get to know people.” Khetase added: “Timing is a big difference. Our friends are strict on this.”

Visiting midwives perceived further differences in working conditions. Anne, discussed how .. chickens, lizards, insects and sometimes snakes are common. The food is different. Be prepared to eat what is put in front of you. [There are] transportation issues, isolation, be patient.” Mesi articulated: “The midwife from the West has a lot to learn to fit in here. Have to use your head here, improvise here. A lot of work is done by the midwives responsible for more areas of care — become a ‘small doctor¹.”

Patient approaches, such as nursing women while they sat on the hospital floor, using strips of chitenjis or sarongs for sanitary napkins and doing without medication because of shortages made adjusting to the experience challenging for visiting health care workers. Likewise, visitors expressed their observations of Malawian attitudes towards high risk cases with comments such as: “[It is] not like North American practices with well-nourished women. [Labour is a] lonely experience for women [here], the lack of labour support is different – not a bad thing – just different. People are calm around birth [there is] faith that the woman will give birth. I appreciate the attitude to life and death here. [There is] an acceptance that things happen. Death is more accepted.” Mphatso, a Malawian midwife, commented on her concern about “missing, if we are too busy postnatal checks and counselling . ..we have to concentrate on the labour ward forgetting about the postpartum mothers.”

Theme Three: Thoughtful Preparation Before Arriving in Malawi Was Valued

Procedural considerations such as communicating through postal rather than e-mail letters with hospital administrators, obtaining relevant vaccinations and malaria prevention medication and bringing all professional certification documents were identified as important. Visiting midwives advised: “If you have a medical condition.- consider not coming, bring all meds, [there are] no facilities here for major surgery. [This is a] dry station, a Christian mission: people who are employed on the station must be Christian, guests must respect Christianity.” In order to match volunteers with fitting work placements and accommodation, hospital administrators expressed interest in knowing volunteers’ reasons for coming – was it to travel, to serve as a missionary or in the role of student?

On the other hand, emotional preparation was equally important. Visitors described feeling “drained emotionally,” “unsure if people will tell you if you are messing up,” and “needing to chat but there may not be other people to connect with for debriefing.” Comments such as “[there is] more tragedy here, no matter what we do” and “feeling like a failure [at times]” reflect the intense nature of professional volunteer work. Knowing that self-care will be an ongoing consideration, participants in the present project encouraged volunteers to pay careful attention and to look after themselves as well as the patients they came to help. Suggestions such as not attending work when sick and “take time to enjoy the place” were offered.

However, the genuine support and willingness to nurture their guests were reflected in Malawian workers’ statements such as: “Teaching, we are ready to do that to anyone interested to come here. I will teach whoever comes as I have done with you.” And another worker commented: “[We value a] spirit of wanting to learn more things.” Further, one worker appreciated: “Being able to ask when you have a problem. Someone asking for something, it showed me the interest. If she asks, it means she has interest in that so, because of that we were encouraged to tell you more because you asked.”

Some donated equipment items were valued while others were not. Sara advised: “Bring equipment, things to share, doing continuing education. Bring something worth sharing, something to give back physical, equipment, books or information.” And, Mesi cautioned: “When we ask for things, please do not bring expired, they will not be used.”

DISCUSSION

The aforementioned three themes, developed from discussions with practitioners who were either employees or visitors at the Embangweni Hospital in Malawi, begins to illustrate how volunteering midwives can work towards becoming welcome guests in this small African country. Clearly, health professionals cannot simply travel to developing countries and assume they will be welcomed and readily integrated. Listening attentively as participants in this project shared their personal perceptions, suggestions and beliefs of local hospital staff revealed useful ways of looking at how culturally different professionals might work together on possibilities in order to reduce maternal mortality in this area.

Important contributions that volunteer midwives can make centre on exchanging knowledge and practices. A willingness to offer culturally competent professional services and to accept new and different ways of providing care were perceived as invaluable. Defining culturally competent care, nurse scholar Alaf Meleis articulated: “Ultimately, culturally competent care is about acknowledgment of differences, advocacy for the marginalized, and intolerance of inequity and stereotyping.”¹²

“Bring equipment, things to share, doing continuing education. Bring something worth sharing, something to give back…
Sara, Malawian midwife

Given that language barriers are well known to impact care that practitioners offer to their culturally different patients,^{13 14} findings from this project indicate that language issues in Malawi can be addressed in part by using interpreters and creating lists of English definitions or commonly used midwifery assessment questions translated to Chitumbuka. Similarly, understanding nuances associated with exchanging greetings, perceptions of time and a seemingly overwhelming workload can help manage this limitation.

Preparing for a volunteer experience includes thoughtful attention to bringing required documents, vaccinations and certification. Sharing educational materials, working equipment and non-expired supplies was appreciated. And, intentionally planning to attend to self-care must not be neglected. The needs of bereaved nurses and midwives in developed countries’ hospitals have not been studied extensively,^{15 16} and, with the high maternal mortality rate in Malawi, conditions are even more dispiriting. Anticipating that these conditions may trigger emotional responses is critical.

CONCLUSION

This article presented findings from a naturalistic descriptive research study that explored the perceptions of Malawian health care workers towards midwives who volunteer at the Embangweni Hospital. This project found that visiting midwives offer important contributions to health care services, that limited knowledge of the language can be problematic and that thoughtful preparation before arriving in Malawi is valued. The article calls for the creation of more opportunities to view the experience of serving as a visiting health care professional through the eyes of practitioners in the field and to construct culturally sensitive approaches that help us become welcome guests.

ACKNOWLEDGMENTS

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