For several years, Kitty Ernst, Mary Breckinridge Chair of Midwifery at FSMFN has been telling me that we need to go to Scotland and follow the path that Mary Breckinridge took when she studied the Highlands Nursing and Medical Service (Wide Neighborhoods, Chapter 15). She modeled the Frontier Nursing Service largely based on this service.
In February, Kitty called me and said, “This is the year. We have to do it this Spring.” Her idea was to investigate the route and the trip with future plans to offer the “Mary Breckinridge Tour of Scotland” to alumni and others who are interested. Kitty, Susan Stapleton, CNM (CNEP Preceptor and former Antepartum faculty), Douglas Shedden, and I spent April 19th through the 26th touring Scotland by following Mary Breckinridge’s path.
I have so much to say. It was the trip of a lifetime. This is the story of our trip to Scotland.
We flew into Glascow on an all night flight. We left Newark at 8PM and landed in Glascow at 8AM (a 5 hour time difference). We went to a hotel, cleaned up and were in Edinburgh to meet with the Director of the Royal College of Midwives by noon. We met with Patricia Purton, the Director of the Royal College of Midwives – Scottish Branch, and her assistant Sharon Allison. They had lunch for us and told us about midwifery and nursing in Scotland.
By 2:30 we were at the Simpson Center for Reproductive Health. They have 6,000 births per year. Over 300 midwives are employed there (227 FTEs). All women have a midwife with them during labor although only 60% are actually attended by the midwife for birth. There is a large focus on high risk care at this site. All maternity care is provided by midwives. Nurses work in the neonatal nursery, not caring for pregnant women. A separate LDRP unit is reserved for normal birth, and no woman with any high risk factors will labor there. In this unit there are no epidurals. There was a tub in every room plus birthing balls and bean bags. I saw evidence that a lot of good midwifery strategies were in use. They do about 10 water births each month in the LDRP unit. They also use Nitrous Oxide for pain relief. It was interesting to see the nitrous tanks next to the tubs. There is a midwife who is hired and designated as the normality specialist, and it is her job to maintain normal birth. This includes coaching and evaluating the midwives who work here. I could see evidence of a lot of good care going on here.
The next day we drove through stunning countryside up past Loch Lomond to a beautiful little seaside town called Oban. In Oban, we boarded a ferry and went on a 4.5 hour ride through the islands and across the sea to Castle Bay on the Isle of Barra. On the ferry, we met a woman with a baby in her arms. We stopped and talked to her and she asked why we were visiting. When Susan Stapleton told her that we were midwives tracing our roots, she started talking about her birth and how wonderful her midwife was. She said that she had so enjoyed her 10 day post partum visits and how disappointed she was when they ended. Susan told her that in the United States there weren’t as many midwives and most women did not have access to midwives. She was very shocked and said it was such a shame because she loved her midwife. She thought that midwives did a great job because they spent so much time with you and talked to you. She mentioned that she believed that pregnancy is not an illness.
As we drifted into Castle Bay we saw a real castle rising out of the water with a beautiful tiny town scattered on the hillside behind it. What a vision as we pulled into that bay! We checked into a tiny hotel (12 rooms) on the hillside. On the wall of this hotel was a picture of the Plover, the ferry that Mrs. Breckinridge rode when she came to Castle Bay. We went to dinner in the hotel where four midwives (three nurse-midwives and one direct entry) met us for dinner. Their names were Mairi Campbell, Frances MacNeil, Nellie MacArthur and Joyce Baverstock. On this island there were a total of 12 women who gave birth last year. Only three had home births on the island. The midwives do all the prenatal and post partum care for all pregnant women, but only the very lowest risk give birth there. The best case scenario for transfer is 4 hours by plane. Therefore, most women go to the mainland at 38 weeks to wait for the birth. It is a difficult scenario for the families, but due to the remoteness of the area they feel this is the safest way to provide care. All the midwives do other work because, of course, this number of pregnancies does not keep them busy all the time. Two of the midwives are also “Practice Nurses” and they provide primary care to women when they are not doing maternity care. Sound familiar to all you nurse practitioners? One midwife is also a public health nurse. The direct entry midwife works at the airport; she can’t do nursing so that is her option at this time.
After dinner the midwives took us to the community center where a group of local women gather on Friday nights for Scottish dancing. They gave us dance lessons and at the end we had them circle up as we sang some Frontier songs for them. Later Mairi Campbell took us back to her house (the house she was born in) and told stories into the wee hours. The roads were very narrow, only one lane with designated “Passing Places”. When we came around the curves there were sheep and little lambs sleeping in the road.
The next morning we took a Ferry to the Isle of Eriskay and again saw beautiful scenery. We went to a hospital in Deliburgh. This is the town that Mrs. Breckinridge reported dropping off the two children who she was asked to transport (Chapter 15, Page 143, Wide Neighborhoods). Then we went to Benbecula in South Uist and met the two midwives who work on this Island. Their names are Margaret Morrison and Joanne Morray. They shared that they had seven births on their island last year. Again, they cared for more women than that but most went to the mainland for birth. Transport is difficult and long, so risk assessment is critical. They do many more visits for both prenatal care and post partum care. Every woman in Scotland has 10 days of home visits after the birth. They do have a tiny hospital; they attend some births there and some in the homes. Before we left, Joanne sang to us beautifully in Gaelic. She has produced a CD that has raised over 10,000 pounds for cancer prevention. We only had time to have a brief lunch with these midwives and then we were off to catch another ferry. The wind was blowing quite hard, a very blustery day. The midwives called ahead and asked the ferry to wait for us…and they did. J
We took the ferry to the Isle of Harris. When we got off the Ferry there was another nurse-midwife, Jane Hamilton and her partner John McAuley, waiting to greet us. It was a chain reaction, word of mouth that we were there. They were so welcoming. She and John took us to see the St. Clements Church at Rodil which is believed to have been built in the early 14th century. This is a beautiful old church full of history. John has actually written a fascinating book about the church (he later gave each of us a signed copy). The book is named Silent Tower (published in 1993 by the Pentland Press Limited) and provides some interesting history of this area of Scotland. Jane and John invited us to their house for a visit for the next night.
From there we traveled to Tarbet on the Isle of Lewis where we checked into a charming and comfortable Bed and Breakfast and then went out for dinner. Two women approached us in the restaurant and asked if we were the American midwives. We said yes and they replied that they were midwives too and wanted to come meet us. In the end, we found out that Mairi Campbell had called them. The midwives were Mary McElligott, who is Director of Professional Development for Nursing and Midwifery on the Highland Islands and Catherine MacDonald, a nurse-midwife who is working now as a public health nurse for the schools of Lewis and Harris. They shared with us a little bit about the politics of midwifery in Scotland.
The next day we again drove through fantastic mountains and ocean views and then went to visit the maternity unit at Stornaway. We met with the Director of Western Isle Midwifery, Catherine MacDonald, and about 10 other midwives. I remember there was Joan Munro who toured me around the unit, Margaret Smith who told me about the Scottish NHS, Kathryn Kearney, and Todag MacKenzie, one of the midwives who took us to church. Here was the first place on the islands that had cesarean section capability. The midwifery service did about 180 births last year. The unit was staffed entirely with midwives. Two midwives on at all times and one maternity assistant (similar to a CNA trained in maternity care). One midwife is assigned to the community every day, she goes out and does the home visits. They had a separate kitchen for the mothers where they could make their own breakfast whenever they woke up. They also had a utility room where the mothers could bathe their babies with the midwives assistance. They had two large tubs on the PP unit and a separate labor unit with two huge labor rooms. They did have a nice tub in the labor unit that was used frequently for labor and I was told they do some water births. I saw birthing balls and gymnastic mats. They had turned one of their rooms into a living space where a pregnant woman from the further islands could come and stay at 38 weeks to await labor.
Two of the midwives (Catherine and Todag) took us to church and then back to the unit where they served us lunch. The reason we had lunch on the unit is that everything is closed on this island on Sundays including restaurants, ferries, and stores. It turned out to be the best as we were able to visit with many of the midwives who worked there. It was a wonderful experience to spend time with this group of midwives.
After leaving Stornaway, we drove out to the very end of the Isle of Lewis and Harris. We stood at the tip of the island where there was a very tall lighthouse, huge rocks and the waves were crashing against the rocks. The sun was shining and the wind was blowing. It was just awesome.
That night after dinner at the Bed and Breakfast, we went to Jane’s house (the midwife who met us on the ferry.) She lives on the edge of the ocean where her partner, John MacAuley, builds boats. I have never, ever been on such a curvy, narrow road with high drop offs that go down to the sea and the rocks. The road to her house was more narrow than Wendover Road with straight drop offs on either side. And…..sheep and lambs lying in the road when you came around a turn! When we got to Jane’s house, we asked her was there another way to get here? She said “No, the road is really fine. You get used to it.” She has a little girl named Ella who is 11 years old. I asked Ella how she got to school. She said the school bus comes down that road to pick her up. I couldn’t believe that a school bus drove that road. Ella is learning to speak Gaelic at School. There is a big push in the islands to return to Gaelic as the primary language. Residents can choose to have their children taught in Gaelic with English being taught as a second language or in English with Gaelic being taught as the second language. In either case, the children learn both Gaelic and English. We had a pleasant evening at their house sharing stories about the similarities and differences between midwifery and nursing in America and Great Britain. Jane is from Yorkshire, England. She visited the Highland Islands “while on holiday”, fell in love with the place, and moved there. She is working as a Diabetic Specialist and loves the work. She is hoping to do some midwifery part-time soon.
While we were there, John played the violin/fiddle for us and Ella sang us two Gaelic songs. We had a wonderful time.
The next morning we got up bright and early and caught the 7:00AM ferry to Uig on the Isle of Skye. Here we again drove through beautiful views. We went to the town of Portree where we met with Rona Scott, lead midwife on Isle of Skye, for mid-morning tea. Rona leads a team of 10 midwives who do mostly home care on the island. They provide pre-natal care and post natal care to most of the women on the island. Again, the very low risk mothers can choose to stay on the island for their birth, the rest are transferred inland to Inverness. Those that stay on the island can choose to give birth at home or in the local hospital at Broadford. At Broadford, one room is reserved for maternity. If a woman is in labor, two midwives go with her to the hospital and provide care from beginning to end. When the birth is over and the woman is feeling well, the family and the midwives go home. It is very similar to our free standing birth center model.
Last year the midwives attended 24 births on the Island; this compared to 12 births the year before. While we were there, an article on the front page of the local paper highlighted this increase. The title in the West Highland Free Press was “Maternity Service Changes Send Local Births Soaring”. In the past year, the nurse- midwives changed the way that they deliver care. Previously all the nurse-midwives did both general care home visits and maternity visits. The result was fragmented care with no clear focus on the mothers. Late last year, they changed to having a cadre of 10 midwives who provide only maternity care. “The changes have given the midwifery team an opportunity to focus on pregnancy as a normal event, and to provide a service that gives local women a choice in their care.” West Highland Free Press April 21, 2006.
That afternoon, we drove through a very mountainous region. These mountains actually made our mountains in Kentucky look rather small (although I believe that the Appalachian Mountains are prettier than the Scottish mountainsJ). These mountains were towering and quite brown with snow covering the peaks. Our very patient, acting tour guide, Douglas, told us that people do come to ski on those mountains. We stopped to take pictures along the way.
We arrived at the town of Fort William at just about 4:30PM. We went directly to the local hospital, Bedford, where midwife Allison Cook was waiting to greet us and tell us about their service. Allison is an RN and RM, a graduate of Lester School of Nursing in England. She moved to Scotland to do “real midwifery” as opposed to the extremely busy practice she worked in London where “you hardly ever got to know the women.”
The Bedford unit is a midwife led unit with12 midwives caring for up to 150 clients of which 40-60 will give birth in midwife unit and a few will deliver at home. The rest will travel 2.5 hours to Inverness to give birth in the hospital there. Midwives work in both the hospital and the community. They do all of antepartum care and postpartum care, much of the care is delivered via home visits. Women can choose to have their prenatal visits at home or go to the hospital to have visits. Each midwife carries a case load of about 20 clients at any one time. This includes both high risk and low risk. As on the islands, the low risk women can choose to deliver at home or in the Bedford hospital. Allison stated that there is not much demand for home births; they did about 5 last year. The unit operates as a birth center. It is staffed when there is someone in labor, but if no one is in labor the unit remains empty.
Allison took us on a tour of the unit. This is a very traditional looking, small hospital maternity unit. She told me “this is the labor room and when they are in active labor we take them to the delivery room.” I asked her why they take the women to a delivery room. She just said, “Because that’s how we do it.” I was a little confused. She then took me to the “delivery room.” It looked very much like a typical small hospital birthing room. It had a large, portable tub in it. She said, “We are hoping to get a plumbed one soon.” I asked her if they used it much and she told me that 75% of the women delivered in the tub. She stated, “That is one of the big reasons they want to come to the hospital.” There was the tub with the Nitrous Oxide tank sitting beside it, similar to the LDRP unit at Simpson. Nitrous Oxide is commonly used for pain relief all over Scotland.
Allison also told me that they didn’t think there were any nurse-midwives in America. She had seen the women being cared for in the ER on Thursday nights on the TV show and they all wondered what in the heck was happening in America. I reassured her that the women were not cared for in the ER, but did tell her that most women in America do not have a midwife with them during pregnancy, labor, and birth.
After our visit with Allison, we drove the 2.5 hours to Inverness. We had dinner along the way at a little Scottish pub in the town of Augustus and yes, we had fish and chips. J Later we went past Loch Ness and looked very hard for Nessie, the monster. We came back the next morning and looked again, but no sightings. J
That night we stayed at a Travel Lodge in Inverness. It was clean and decent and had very reasonable rates. The next day (after the Loch Ness tour) we went to visit a little town called Dingwall. We had breakfast and shopped. Then we drove down through Perthshire. We stopped at a beautiful place called Queen’s View. This is a mountainous area that overlooks the beautiful Loch Tummel. There are many Lochs in Scotland, and I soon learned that a Loch was a very long and beautiful lake.
Later in the day, we went to the city of Perth. We were determined to find 7 Barossa Place. Perth is the town where Mary Breckinridge reported in her book visiting Miss Williamson, the Superintendent of Nurses for Perthshire to learn more about the system of health care in Scotland. (See Wide Neighborhoods, Page 134). Sure enough, with the help of modern technology (a computerized navigation system in the car) we drove right to the house. There we met a lovely young couple who now lived in the bottom flat. When they learned why we were there, they were quite enthralled. They took us in and showed us their flat and the beautiful Scottish garden out back. I could picture Mary Breckinridge having tea with Miss Williamson in the garden. Then the upstairs neighbor located a history of the house for us and sure enough, the document stated that “In the 1920’s, Miss A.J. H. Williamson, Superintendent of the Perthshire Nursing Federation succeeded in occupancy.” (Know Your Perth, Barossa Place No. 7, Perthshire Advertiser, August 7, 1984) It was a highlight of a beautiful journey!
That night we returned to our original hotel where we had dinner and the next morning boarded our flight for Newark. As I said before, this was the trip of a lifetime.
“The time had come when I must leave the Hebrides. I have tried to tell what they meant to me. To the Frontier Nursing Service, in after years, all that I gathered from those islands was to mean more to me than I can put into words. As Sir Leslie MacKenzie said of his own wanderings through them, “No words of mine can match the subtleties of the reality … words are only symbols of an incommunicable experience.” Mary Breckinridge, Wide Neighborhoods, Page 145.
I am certain that we can take alumni, students and others who are interested on a tour of Scotland. We can all have the pleasure of walking in the steps of Mary Breckinridge. It would be a fabulous trip for anyone who wanted to go. The country is beautiful and the culture is so interesting. It was great to see a different way to do things. More news will be published as our plans continue to develop. In 2008, the International Confederation of Midwives will hold their meeting in Scotland and I think we need to have many Frontier alumni and students at this meeting.
I must express my very sincere appreciation to Mr. Douglas Shedden, a wonderful Scottish man who made our trip not only possible, but all that it was meant to be. He patiently drove us through Scotland arranging our travels and assuring that we were able to do all that we wanted to do. He was a gift to us in our travels and I will be forever grateful.
For pictures of our tour of Scotland, visit www.midwives.org, click on Members only and then Newsletter. |
