Life On Assignment: Midwives

Jennifer Craig: Good evening everyone and welcome to tonight's webinar, Life on Assignment, Midwives. I would like to begin by acknowledging the traditional custodians of the various lands on which we are all joining from today and pay my respects to elders past, present and emerging and to any Aboriginal and Torres Strait Islander and Maori people joining us today. Tonight I'll be joined by three experienced MSF midwives and we'll be discussing the realities of midwifery within our overseas projects. As always, we'll also have a live Q&A at the end so please post any questions into the chat and we'll answer them at the end.

Now I'd like to start by introducing our panel this evening. We are joined tonight by Clémence Chbat. Clémence has completed several MSF placements as a midwife before she joined the Sydney-based Medical Unit as a women's health advisor supporting projects and midwives in the field as a member of the Paris Medical Department. Welcome, Clémence.

Clémence Chbat: Hello everyone.

Jennifer Craig: Next I'd like to introduce Shelley Harris-Studdart. Shelly has completed seven assignments with MSF as a midwife in contexts including Ethiopia, Palestine, Afghanistan and Yemen. Good evening, Shelley.

Shelley Harris-Studdart: Hi, lovely to be here, thank you.

Jennifer Craig: And finally I would like to introduce Lisa Peberdy. Lisa has recently returned from her first assignment as a midwife with MSF in Greece and she came to MSF with significant midwifery experience including in overseas settings such as PNG, Samoa, East Timor and Bhutan. Nice to have you with us tonight, Lisa.

Lisa Peberdy: Thanks Jen and hi everyone.

Jennifer Craig: Fantastic. So to get started, I'd like to talk a little bit about midwifery in MSF. So midwives play a vital role in all healthcare settings and even more so when providing care in conflict zones, natural disasters and areas with limited healthcare access. Educated and regulated midwives can deliver 90 per cent of essential sexual reproductive, maternal newborn and adolescent health services. Achieving universal coverage of care provided by midwives can help avert almost two-thirds of maternal and newborn deaths and stillbirths and this translates to over 4.3 million lives saved per year by 2035.

The role of midwives may vary from a small rural health centre in the mountains to a comprehensive emergency obstetric and newborn care facility in a large city. These activities are often combined with community-based approaches. In some projects, our midwives work in hospitals, mobile clinics and outreach programs.

Clémence, maybe you could give us an example of a rural area and a large city where we currently have projects. Understanding of course that our projects change regularly according to our needs. 

Clémence Chbat: Yes, thank you very much, Jen.

Yes, for example, I can give you Afghanistan. It's a very, very remote area, remote project where we have eight little health centres where you have just one midwife. The midwife is the only woman working in the full area to care to patients. She's seeing all the women, the children, women and girls. Her responsibilities are very wide. This is why, for example, we trained her on psychological first aid, on psychotherapy, on physiotherapy. These kind of settings are very, very remote. It takes four hours to reach a healthcare system that is functioning, So, to do C-section, for example, or to have a referral for a very small neonate. You have this kind of project, but you can have also another project, for example, in Yemen, where you have this big city, large city, where you have a lot of doctors specialised, 15 midwives working day and night in a hospital. It can really vary. This is what makes it super interesting and very important as well for women and girls to access the care.

Jennifer Craig: Fantastic. It certainly sounds like the sort of role that can change a lot depending on which project you're placed in. You can learn so much, I imagine. Definitely, definitely.

Let's talk a little bit in more detail about a few clinical scenarios that you faced while on assignment with MSF. So, Shelley, I'd like to start with you. Would you be able to talk to us about managing obstetric emergencies in resource limited areas? 

Shelley Harris-Studdart: Thank you, Jen. Yes. Hi, everybody.

So, it's a real asset to have experience in managing obstetric emergencies before you start with MSF. You'll be responding to emergencies far more frequently than you would in Australian and New Zealand settings, especially if you're working in a project that has the labour and birth component. Many of MSF's maternity projects have the reduction of maternal and neonatal mortality as a main objective. Because there are barriers preventing women coming into an MSF unit early, women often arrive in very compromised conditions like severe haemorrhagic or septic shock. A woman experiencing a postpartum haemorrhage may have received no antenatal care and be severely anaemic. And so, she's at much higher risk during a postpartum haemorrhage. A woman with high blood pressure may not have sought treatment until after she's had her first or even a second seizure.

So, women face things like an absence of antenatal care or antenatal care provided by untrained healthcare providers. Women often don't recognise the danger signs in pregnancy and we know this happens especially for first time mamas.

Sometimes there's a lack of transport or the rural roads are impassable as Clémence talked about, this four-hour journey. Now, that means that sometimes women will walk to a unit and that could take several hours or days. Security checkpoints, predatory males or armed assailants in conflict zones are just some of the reasons why women don't and can't present early for care.

In my experience obstructed labour, unidentified placenta praevia and postpartum haemorrhage happen frequently. We know that haemorrhage is the leading cause of maternal mortality and that happens predominantly in the context where MSF works. The early recognition of obstetric emergencies like these, and teams that respond effectively and swiftly, is the key.

We base our practices in MSF guidelines. The obstetric and neonatal guidelines particularly apply to maternity services and also our midwives are supported in training with the ALSO (advanced life support in obstetrics) training and that is modified for the MSF context. So yeah, we work with midwives from all ages and stages and really support their learning so that they can respond swiftly and effectively to obstetric emergencies.

Jennifer Craig: That sounds quite significantly different to the experience that women have in countries like Australia and New Zealand. I'm not a midwife but I have children and I understand that the process that I experienced, it sounds very, very different to that. So how do you find dealing with an obstetric emergency in an MSF setting is different to dealing with an obstetric emergency in a large hospital in Australia or New Zealand?  

Shelley Harris-Studdart: Thanks Jen. So a big difference is that you may have an obstetrician on site. In some projects there's no obstetrician at all. Sometimes an obstetrician might be on call but off site and the way that the need for the obstetrician to come in is by cell phone, and often the cell phone coverage is really sparse. So under these circumstances, MSF midwifery teams need to recognise emergencies and deliver treatment in that instance.

Just bear in mind that we always do have the basic essential medications and equipment needed to respond to the emergencies, but it's about everybody knowing what to do with the drugs and equipment and acting effectively. I think that a big difference you know is that when that emergency, like in Australia and New Zealand, we would push an emergency bell and so that's just not going to happen. An obstetric team or a neo-resuscitation team just isn't going to come to your assistance.

Another difference that I think it's really important to mention is the rates of neonatal mortality that you would see in MSF settings. It can be really, really confronting. We know that the three greatest causes of neonatal mortality are infection, intrapartum complications and prematurity. Now with those great basic medications we can speak to infection. The intrapartum complications, we work with midwifery teams to really strengthen them. Something that's quite different is the prematurity. If these babies were born in Australia or New Zealand, they may have the benefit of paediatric and expert SCBU nurses, special care baby unit nurses. Maybe even if they're born in a remote area, they would have the benefit of a helicopter or a fixed-wing retrieval system to take them to the specialists. But with the MSF context usually that doesn't happen and so the absence of those can land really heavily.

At the same time, I think that's just something really worth keeping in mind. There are incredible success stories. I recall working in Khost maternity in Afghanistan and this is a small maternity hospital that, now, I think their birth rate is about 1,800 babies per month. So it's quite a service that's provided there. We see many multiple births. I recall a woman having her first pregnancy and she gave birth vaginally to triplets. They were a little bit premature but with the combination we do use kangaroo mother care quite frequently—that’s really supported by MSF, and that can make a big difference to those premature babies. Although, it was quite a day when she was transferred home breastfeeding her triplets. There's all kinds of events that we're working with.

Jennifer Craig: You mind if I just ask super quickly, you mentioned before about basic equipment. I imagine though that the equipment that is used in MSF projects is probably a bit different to the equipment that people commonly have access to in a hospital setting in Australia or New Zealand. Is that right?  

Shelley Harris-Studdart: I think that we have the basic equipment. So instead of a big fancy resuscitataire, that you have your heat and your oxygen flowing and a mixer for the oxygen and air concentration, that kind of thing we don't have. We don't have that high-tech equipment. Also, like in a special care baby unit, you don't have CPAP or the complex respiratory support systems, but we have a good basic neonatal resuscitation bag and mask and with the skills we can use that really really effectively. So yes, it is a big difference. So a bit of creativity, flexibility, resilience, those are all really good attributes that you would apply in those kind of areas, in those kind of contexts.

Jennifer Craig: Thank you so much, that's so interesting. Lisa would you mind speaking to us about your experience of providing care in a refugee camp setting?

Lisa Peberdy: Thanks Jen, no problem. It's very different to the situations that Shelley has spoken about. Look, I found working in the refugee camp life-changing. It was an amazing experience. So I was lucky enough to be placed in a refugee camp on a Greek island. The women I worked with came from multiple different countries. So the women were coming from places like Congo and Palestine and Syria, Somalia, Sierra Leone, Afghanistan, Sudan, Cameroon, Eritrea, Guinea, Yemen, Nigeria and Iran. So it was just a melting pot of all these different nationalities and cultures and they spoke very little or no English at all. So Google Translate really was my second-best friend and I say it was my second best friend because it often got very confused and that could be a little bit frustrating at times.

There was an enormous amount of women of all refugees in the camp. The camp on average had about 4,000 people and 50 per cent of the population were women and children. I was the sole midwife in the camp for the majority of my assignment there, so it was very busy to say the least. The role had very much a primary healthcare focus. So really the midwife space was a safe space for all women across their lifespan.

So I did all the antenatal care and that included doing the ultrasounds, the obstetric ultrasounds. I did the postnatal care: so, newborn care, child health, immunisations, breastfeeding support. The resources at the camp, you know we didn't have the resources or the equipment for any other form of infant feeding so it was all breastfeeding. And then there was the complication of the majority of the mothers [being] malnourished, so that caused quite a bit of concern to make sure those little babies got the best nutrition they possibly could get for the best start in life.

I had to work very closely and liaise very closely with the obstetric department at the local hospital because this is where our women went to give birth. So once they began to labour we would transfer them to the hospital and then after birth they would be transferred back to the camp and into my care. I worked very closely with our multidisciplinary team so our medical officer, our social workers, our psychologists, our legal officer, just so that we could give the women the most holistic care possible. The midwifery donger [cabin] because we all sort of had our own little dongers in the camp, it was very much known as a safe space for the women to come and it was a place they could come and share their stories and seek support, comfort and reassurance. And for the majority of these women it was the first time they'd ever been shown any kindness, compassion, respect or emotional support in their life. So it was very sad from that aspect.

Also a large part of my role was dealing with sexual and gender-based violence and sexual health and safe abortion care, and that is because a lot of our young girls had actually escaped from sex slavery or they had been raped and tortured while they were trying to seek asylum. So that could be quite traumatic. A lot of the young girls were actually raped by the people smuggling themselves or because the cost of passage across the Mediterranean was so expensive—it was about 4,000 euros per person—a lot of these young girls actually paid for their passage through sex. So then we had all the ramifications of that once they reached the camp on Samos.

Not only from a sexual violence point of view, the passage across to the camp was really quite dangerous as well because the Mediterranean can be quite rough but not only that, the boats they were coming across in were not seaworthy, and most of these people were coming from landlocked countries so they didn't know how to swim and we had multiple, we called them shipwrecks, multiple shipwrecks a week of people trying to come across the Mediterranean, and they always had to do it under the cover of darkness so that they wouldn't be captured by the coast guard. So those that actually made it alive were actually quite traumatised and a lot of the women that I cared for had travelled with their families but their families hadn't survived the passage so that was quite traumatic.

And I remember looking after one young couple, and it stays with me because their ship sunk, they survived, they managed to make it to shore but they lost their three children who drowned and their youngest being a fully breastfed baby. So I spent a lot of time with that couple, with the mother I had to help with suppressing the lactation, but then there was all the emotional and grief counselling that went with that. But despite how busy and intense it was, it was just the most amazing experience and I will do it again in a heartbeat. Jen, you're hearing that?

Jennifer Craig: I am, I absolutely am and I'm glad to hear it. I know that a lot of the contexts that we work in can be incredibly challenging, and as I know Lisa and Clémence and Shelley are all very aware we do offer significant psychosocial support for people while they are on projects and after they return, so that if any of these events do cause ongoing, or even if you just want to debrief and speak to somebody, we do provide that care at MSF as well. And there is absolutely no barriers to accessing it, so that is available for all of our staff as well, and I can imagine how these stories stay with you.

Clémence, following on from what Lisa spoke about, we understand that we do a lot of work with sexual and gender-based violence but we also do a lot of work with providing access to safe abortion. Would you be able to speak to us a little bit about that and why MSF is so, feels it's so important to service to offer? 

Clémence Chbat: Yes, that's a very good question and thank you very much for sharing all these stories, because it's very important as well for midwife to understand what are the all the components [of care].

So, safe abortion care is one of the components of women's health. We can do antenatal consultation, contraception, sexually transmitted infection consultation, SGBV—sexual and gender-based violence—care as well as deliveries, but while we are talking usually with women and girls sometimes we can see that there is a need for safe abortion care. It's been since the beginning that we had this need, and we addressed it slowly, slowly, through a lot of women helping other women: midwife mainly. And maybe it's important to know that it's one of the components of women's health. We have worked on it a lot because it's something very particular, but also we know that it's one of the main causes of maternal death. In the projects where we are working it's up to 30 per cent of maternal death, so it's a huge number that we need to take into consideration, and also we know that it's almost entirely preventable. It's just few tabs under the tongue, so it's not something that we can completely remove from our head and from our projects.

It's there every day. We are seeing post-abortion complications: women putting sticks, perforating their uterus, their bowels; drinking potions, teas and antibiotics, just to get rid of their unwanted pregnancy. So it's something that we need to know, because in other countries usually it's not something that we [come across] very often, but it's really part of the emergency rooms as well as mental health, as well as women's health activities, so it's really something that we need to take into consideration. And we are committed to reduce maternal death and suffering for all women and girls, especially from unwanted pregnancy and unsafe abortions.

I know that it can be difficult. I'm a midwife coming from Lebanon, so I know that it's not something that I was trained on, or it was in my context as well to speak about it, and with my experience I know that it can be hard for some healthcare professionals. I can tell you that we have a full support from all the operations; the teams are very engaged as well. I am providing support on a daily basis to midwives all around the world about this subject. We have a full toolbox, we really improved also the way we are training people and discussing about abortion, so I will always be available for midwives and [obstetrician-gynaecologists] even during weekend for this subject, because I know that it's difficult.

So you will feel supported on these aspects I hope, and we are providing a lot of information but you will see it directly when you're in a project, all these post-abortion complications and all these women asking for it. It will very much be obvious, the needs will be very obvious for women, and for midwives going into projects, that's what I would say.

Jennifer Craig: I see Shelley nodding at the support side of this, you felt supported in these sorts of situations, Shelley? 

Shelley Harris-Studdart: Yes I've really I've received support within the project from the medical coordinator, and then if it's outside of a med-co’s kind of scope of practice, then people like Clémence are really easy to access. And I think what I've seen over the years is that everything has become really honed to be able to deliver safe abortion care in a really safe way, and you know it's something that makes such a big difference to women's lives. Because women will become, you know, pregnant through so many circumstances that are not of their own volition, and so that service, and when we see someone that comes in with the consequences of an unsafe abortion, it's such an important service to provide, thanks.

Jennifer Craig: And just to make it clear that this is actually something that we ask all of our profiles to support so it's something that is really central to the way that we consider it part of the healthcare that we provide at MSF, and it is something that we ask across every profile that we recruit.

Fantastic, so look we've spoken a little bit about this, but of course midwifery in MSF projects isn't just about clinical skills. it requires adaptability cultural sensitivity and resilience. As we discussed earlier, managing obstetric emergencies with limited resources brings a lot of challenges and they're not always challenges that you can plan for before you experience them. So in light of that Shelley, could you speak to me a little bit about what it was like working with multicultural teams on projects?  

Shelley Harris-Studdart: So this is something that it makes the job fascinating. There is such diversity.

And so if you imagine in your home country there are multiple layers of cultural customs, traditions, religions and behaviours, and this can vary from a city to a town, it can vary from one city to another, and then if you imagine working within a maternity unit and you could, for example, if you were in New Zealand—we’re all working from a similar set of guidelines—however a birth, labour and birth in Whangarei, could be very very different to a labour and birth in Wellington for example.

So in MSF contexts we have all those layers of cultural diversity and we're moving into a completely unknown country, to perhaps a town or a city, to groups of people, and then we have midwifery cultures that vary from unit to unit, so it's huge to take it on board, and I think if we come really back to basics, curiosity is the key, to have the quality of curiosity. To go into a project with an open mind and an open heart, the ability to watch and listen in these unfamiliar environments is really important, and to really engage with the midwives with respectful engagement because they're experts in their setting, and so that's where all the expertise and the knowledge is, with the locally hired staff. 
Going in and looking at the differences, or looking at what you're going to change because it's not like that at home, you know, some of the things that happen outside are not applicable in these environments, and I think sometimes your truths are challenged.

So another thing is the ability, to observe a new environment with fresh eyes is really important too, and so that's a component when you're going into an MSF project, coming with fresh eyes you're going to notice things that challenge, you notice things that interest you. And it's really worthwhile making notes about what your observations are, but taking a step back and employing that observation and engagement with the midwives, because language can be a big challenge. Many locally hired staff speak English and some speak none at all and so good communication skills are key. The ability to notice when something hasn't quite landed or something needs further discussion is really important. Translators are a critical bridge. Translators will give you insight and awareness to place you squarely in these new and unfamiliar environments if many of the staff don't speak English.

Now if you speak French or Arabic or another language that's a very strong skill that would be recognised by MSF. I've always heard it said that MSF midwives know how to say “push” in about five or six different languages. It's true, it's true you pick up these few key phrases in the language of the country you're in.

Now the locally hired staff, I think it's really important to recognise that they and their families can be beneficiaries of the service as well, and I think Clémence is going to talk about community engagement. So they're a critical part of that local picture and a huge source of cultural knowing. They're key to understanding the complexities of the very human experiences and environments that you'll find yourself in, and that's to do with midwifery practice as well as the cultural setting. They're absolute gold.

I do think that […] what you're gaining is friendships for life really. It's about making long-lasting, the silver lining is making long-lasting, global friendships. Yeah everything about MSF and every project is really different: every country, every scenario, every person, it's never dull. It's never dull.

Jennifer Craig: I can hear how much you have enjoyed the time that you've spent with MSF so far and I know you've spent a reasonable amount of time with us. Lisa, would you be able to follow on from this and speak a little bit about how you found collaborating with an interdisciplinary team?  

Lisa Peberdy: Oh thanks Jen. Yeah and definitely following on from you Shelley that I've had sort of very similar experience.

So in my experience I was working as part of a team that included intercultural mediators, nurses, doctors, pharmacists, social worker, psychologist, legal officer and logistics team. And I think with MSF, everyone who's worked with MSF will say that the logistics team really are key to keeping us all together.

In addition, also the intercultural mediators [ICM] or translators and in my situation the intercultural mediators were actually people who had come through the camp themselves as refugees and had English as a second language, so that they could be, you know, the translators for the refugees and for the MSF staff. I could not have done my job without them. They were like my third arm. Every consultation was a three-way conversation. It was me, the ICM, the woman, the woman, the ICM and myself. So, and we all hope that nothing got lost in translation, and I'm sure it did a couple of times, but you know everyone survived and the buildings didn't collapse so it must have been okay.

In regards to working with a multi-disciplinary team in a MSF situation, I just think everyone knows their role, everyone has their own professional expertise but everyone just chips in and they all support each other. We don't work in silos definitely, and Jen you'd probably say that as well, and none of us are an island. We just always work together in a team and just always constantly, constantly supporting each other, and I think it's because we all have the same ethos and goal, and that is to ensure you know that we provide unbiased support so that the refugees are provided with the best possible sense of safety and security when they are with us.

I think also how to blend in with a multi-disciplinary team is that when you first get there it's watching and learning, it's not coming in like a new broom and just sweeping the place clean. It's about respecting the people on the ground and respecting every single staff member in the team, that you know everyone has their professional expertise and we're all thrown together in this big melting pot.

When I was on Samos I was the only staff member who had English as the first language, and English really was our common language, so I was often being called on just for clarification around pronunciation and meanings for the English written and spoken word by all staff, so by the time I left I had them all speaking Australian. And at the beginning I told them that I spoke two languages, English and Australian, and they believed me, but not for very long, so there's a lot of people out there using Australian slang at the moment.

Another common language I found working in such a diverse multi-disciplinary team was laughter, honestly. Because like some days you had the choice of laughing and crying and laughter won out every single time. Yeah so that's just my experience of working with such a multi-disciplinary team, but I think the most important thing is leave your ego at home. That really is the most important thing and because you'll find it's a very humbling experience.

Jennifer Craig: Fantastic, thank you so much and I absolutely wholeheartedly agree with what you said. Clémence, could you also just let us know a little bit about the intersection between our midwives and community engagement and health promotion?  

Clémence Chbat: Yes more and more our project are having this community engagement specialty. It's very very important for women to access to care.

It's not just women and midwives explaining to them when they need to come, for example if they are bleeding etc., it's much more than that. We need to discuss with for example the religious leader, the political leaders of the area, teachers, women's network, mother-in-laws, husbands. All these people are part of the community where the woman lives, and they are the ones as well to help. For example, for transfusion or a referral, we need to have the community really engaged with us to decrease maternal mortality and morbidity.

I will give you an example. I was called once, I was in a hospital in Iraq, and I was called in a refugee camp. So it was the mayor, let's say, of the little village where the refugees arrived, who called the director of the hospital to tell him that there is a woman who is not well—that was it. So okay [it was decided the] midwife [should] just go and see what is happening, but just to cross and to go there we had the governor to give us the security check, we had all the people on the road who were telling us where to go, what [way]. When we arrived it was women all over trying to help a woman to deliver. She was a nurse [it turned out]. She had a premature labour and she was really like traumatised from what was happening, so she was arriving very distressed. And all these people were really helping her, telling her that she will be fine, praying for her etc. When I took her back to the hospital, for me it was really like bam, bam, bam, I need to give this and that drug etc., and the hygienist came with like a little cake, and she started to feed her, and then it was the waiting area with the women, they were trying to find a clothes for the baby because we knew that the baby was coming and she was not prepared. So it was really,

I want to say that it's not only us providing some medication, it's really the full community helping, and it stays, these stories, because you feel that “Oh, I'm a midwife, I'm in MSF, I can do everything”, but at the end it's really much more than this. And for example, for natural disaster or any crisis in the world, it's usually women helping others as first responders. We are arriving after two, three days after a flood or something. It's midwife who are going saying, “Ah, I remember this one, she was she was starting to have contractions, let me let me see if she's okay”. It will not be only us, it's really a shared the shared responsibility, and I think it's how it works the best, when we are really working with the community and for the community.

I can give you plenty of examples like this where teachers are bringing young girls having herpes on their lip, or you cannot imagine the number of  patients that are coming because of the community, and because the community also saw that there is a problem in this family, maybe you need to check. So it's really important. And it helps as well for even for the babies, to get a baby vaccinated we need a community to accept the vaccinator to come in the community and start to knock on all the doors etc. So it was just to give you an example. I can go for hours on this subject, so I will stop here.

Jennifer Craig: It's also incredibly interesting though, and we all love hearing these stories, it really brings alive some of the things that you've seen and experienced. Just before we go to the Q&A, and a quick reminder of it to everybody if they have any questions, pop them in the chat, and we'll be getting to that in a minute. I've got a couple of last quick questions for you all. Shelley, what would you say are the top three skills that you've gained working with MSF that you found helpful in your practice in New Zealand? 

Shelley Harris-Studdart: I'm glad you limited it to three, because I have a very long list.

So I think yes some of the specific skills would be supporting women to give birth to breech-presenting babies. Because we know in Australasia that there's a high degree of fear that's associated with vaginal breech birth, whereas in the MSF settings it's really seen as a variation on normal. And what we aim is to have midwives that are really fluent with hands off the breech techniques, but also with to know to be familiar with the manoeuvres that are necessary when breech becomes complicated, and how to identify when to use those manoeuvres. In some contexts we do have recourse to emergency caesarean sections when that's necessary, but it's not about “It's a vaginal breech we go to caesarean section”. Not at all. So that's a skill that I've really developed since working with MSF, and that equips me so that when I come back home I really don't feel that same fear around vaginal breech birth, and if a woman wants to consider having a vaginal breech birth then I can advocate for her to achieve that.

I think that another skill is real fluidity and trust in neonatal resuscitation. I mentioned earlier, you know, you asked about the equipment that we have and it's all about using that equipment effectively. So within MSF, we have inflatable neonatal mannequins and a set of, a bag and mask set, and so we'll have that out in the environment, so it's when it's a quiet time the midwives will actually come and practise that bag and masking. Because that's the key: familiarity with the equipment, working in a team, working together to create that opportunity to practise those skills, and so when we implement it it's really effective, and rapid. and so I really see that accomplished in MSF settings, because there's not going to be that person to come, the paediatricians aren't coming to take over.

And then one last thing quickly is management and leadership skills. So this is a real asset to have before you go on an MSF assignment, and certainly there's a lot of support to hone the management skills but I think it's really valuable to know that the midwives actually are really experts in their practices, they know themselves what to do, and they know what they need to do the service better. I think there's, you know, implementing an SGBV project, a sexual violence response service, sometimes that the role of a midwife. Or implementing a safe abortion care service. And there's going to be resistance, there's going to be obstacles that you face introducing those services, so change management is a really good skill to have before you go. But there are ways with open communication, and I've learned a lot of techniques to engage with communities and service providers, the networking. I could go on for hours so I'll leave it there, thank you.

Jennifer Craig: Thank you Shelley, and I just want to actually add to what you said. Management is actually one of the key essential criteria that we look for across all of our positions, so it's worth having a look at the essential criteria. And the reason we include management is because almost every position with MSF internationally requires management experience and skill sets, so it's a really great one to mention.

Lisa, I'd like to ask you what was what was one of the highlights of your first assignment. What did you really, what did you love about it?

Lisa Peberdy: I'm going to do a Shelley and I'm going to try and condense it into three.

Look, the first one is, I had known about MSF for many years. I had worked with colleagues who had worked for MSF for many many years, and I always respected it. Once you're in the organisation, it is so much better than what you think it's going to be. So that's a big highlight for me, was actually working um for MSF and working with the amazing international and local staff that make up MSF. definitely a highlight. Because you know it's the culture, it's the ethos, it's the guiding values of neutrality and respect that we all have, and it's an amazing organisation. So that's number one.

Number two is the women that I met and I provided care for. They were just amazing. They had overcome, you know, just some horrific scenarios, but their absolute resilience after what they'd endured was just amazing to witness. And just their belief in, and their positivity that they would be moving on to a very peaceful and safe life. So that's what I learned about how to be resilient.

And then thirdly, it was the multi-disciplinary international team that I worked with. I mean, that was just wonderful getting to meet everyone, work with everyone, get to know everyone socially, learn so much about different cultures, different languages, different foods—very very important—and just the lifelong friendships that I have made as a result.

And a big shout-out to you Shelley, because you were my support midwife all the way from New Zealand when I was over there on project, and you were just so supportive. And as probably all of you can tell on the webinar tonight, Shelley is just a wealth of experience. She is the real deal, and I can't thank her enough. And that's about it for me.

Jennifer Craig: That's amazing, and I've already heard that you want to go back again, so we love to hear that.

Finally I have one question for Clémence which I actually think speaks a little bit to one of the questions that was asked in the chat as well. What advice would you give to somebody who's thinking about a career with MSF as a midwife? What skill sets or experiences would you encourage them to acquire, to prepare themselves for work in our projects, and give them the best chance of being recruited?  

Clémence Chbat: A very subjective thing, but I think the most important is the motivation. Motivation to be uncomfortable, to be in a context that you don't know. Sometimes I go to countries I don't know the capital of them, I'm like “Oh la la!”. You discover a lot of things. You are uncomfortable as well in a lot of things. So to be motivated to be uncomfortable.

I like the curiosity that Shelley mentioned, to be curious about what is happening in the environment. I would really advise midwives who want to go, and who have an assignment, to really read about the countries and geopolitic a little bit, the history. Not to be only like technically speaking about midwifery etc. So that would be an interesting one, like, to be motivated, adapting to the context and curious about it.

For the more technical side I would say don't put too much pressure on yourself. I've seen a lot of midwives reading a lot etc. I would say you will never arrive to knowing everything, because you will see things that are really written in very little [ways] and policy in in the obstetric book. So it's mostly, yes, to have a good basic of obstetric emergencies, that's yes. You need to have done many deliveries the past two years, the last two years before applying, that's yes.

But also to have this capacity to a little bit do more learning. For example, for sexual violence, that would be super interesting if you have French and or Arabic that would be perfect, because the more and more we have a project in Arabic-speaking countries. In this case I would really encourage you to have experience overseas or experience in remote areas, where you feel already uncomfortable. When you are too long in the same space it makes me a little bit worried, not that you will not be appropriate for the job, but you will be very uncomfortable for the first mission. So it's really this adapting mechanism that you need to already have and build.

But don't worry too much. I remember when I was 26, when I started with MSF, I was really worried about malaria, HIV, what can I do if this and that happen. It's not really that, it's more to have the basics and to be open to learn more. You have online trainings for SGBV I would really recommend you to do, and really to go to uncomfortable places. Voila. I think that would be already something, if you do all that! And in any case, we are here as well to help and to support you during your first mission and the other ones. You will always learn. I’m still learning a lot from all the midwives, all the context. So you cannot do everything before your assignment.

Jennifer Craig: It's one of the things that I've heard time and time again across webinars that one of the things that people love about working with MSF, and one of the things that I loved about working on projects with MSF, was the amount that you learned. and I think it's so important that you have that learning mindset and that desire to be challenged and to see new things, and to learn from them, and learn different ways of working rather than going in with very set expectations.

The one thing I want to add to what Clémence has said. I mentioned it earlier, we do have essential criteria on our website for midwives, and also the essential criteria that is relevant to all positions. So if you're thinking about a position with MSF have a look at those. They're a really good place to start to look at the sorts of skill sets that you might need to brush up on, or you might need to acquire to meet those essentials, because we do look for evidence of all of those essentials in your applications. and if you're a few years off applying, perhaps, and you haven't done it yet, get French, it would be a huge benefit.

Now there's another question that came through in the chat for Lisa, so Julia's asked, “In your situation, were you on call 24/7 with no back-up midwife, or did you have support from somebody like a healthcare worker?” 

Lisa Peberdy: Julia, no I suppose I was in quite a unique situation where I worked Monday to Friday. The official hours were nine to five. I lived outside of the camp. I lived in town and I would go to the camp for work, but officially it was nine to five. But the role of a midwife is never nine to five, so I tended to start work about seven in the morning and I often went through to about seven at night. But no, it wasn't on call 24 hours a day.

If there were any maternity emergencies overnight, the camp itself would organise an ambulance transfer for the women to go to the hospital.

Jennifer Craig: Fantastic, thank you. In all of our projects we really try to structure time off as well, because we know that everybody works better if they're not working 24 hours a day, seven days a week. And you may have restrictions on your movements depending on the context that we're in, but we do try to give everybody some downtime. It might be that you work, you know, five and a half days or six days a week, but we usually try to at least have one, and it's really important that people take that time because there's always going to be work to do, but you will not be effective as an individual if you're not also looking after yourself. So it's something we strongly encourage.

Look I think that's actually all of our questions at the moment. If people have any they can always contact the MSF Australia recruitment team, or pop in an application. We always love to hear from you. And otherwise, I just want to really thank everybody for joining me tonight. Clémence, Shelley and Lisa, it's been so interesting and so informative, and I'm sure that everybody online has appreciated your time as much as I have. So I think we'll say good night to everybody, and hopefully hear from you all soon.

Clémence Chbat: Thank you very much.