Twinning Up North

A journey between midwives from Iceland and the Netherlands

“The meeting of two personalities is like the contact of two chemical substances: if there is any reaction, both are transformed.” -Carl Gustav Jung

“For relationships to build trust, a fair amount of friction experienced as a shared problem is necessary to get to know each other and bond.” Franka Cadée

“We, as midwives can change the way we see ourselves as women and how we can empower ourselves through the strength of other women being together.” Edythe Mangindin

“When the twins become friends, their relationship carries on for a lifetime even after the project ends.” Liselotte Kweekel

Open the magazine

Foreword

“This magazine tells the story of a journey of a three-year twinning collaboration between twenty eight midwives, fourteen from Iceland and fourteen from the Netherlands. These midwife ‘twins’ worked together to generate positive change in maternity care in their respective countries. They did this by strengthening and profiling midwives and midwifery as key to humanising and optimising pregnancy and birth for women and their babies and families.

The evidence shows convincingly that midwives play a key role in providing women and their families the right care, in the right place and at the right time. Midwives, when trained to international standards, provide high quality and respectful evidence based care before, during and after pregnancy and birth, as well as advocate for the rights of all women to sexual and reproductive healthcare, leaving no one behind. Midwives are instrumental in reducing both unnecessary over- and under medicalisation. As an example, midwives can positively impact the prevalence of over medicalisation, such as the high caesarean section rates that we see in many high income countries. Indicators of under medicalisation, such as high maternal mortality rates, more common in middle and low income countries, is reduced by employing and supporting continuity of care by midwives.

Twinning is defined as ‘a cross-cultural, reciprocal process where two groups of people work together to achieve joint goals’ (Cadee et al. 2016). Using the twinning method with reciprocity and equity at its core, participating midwives committed to achieving common goals by collaborating on the projects described in the pages that follow. In addition, they took part in exchanges and joint workshops aimed at developing their transformative leadership skills.

All midwives were matched one to one based on their interests and expertise, such as students to students, researchers to researchers, teachers to teachers and practising midwives to practising midwives. As ‘twins’ they shared skills, experiences and inspiration with the aim to generate positive change in each other as well as for birthing women in their communities.

We share our results with pride. Enjoy!”

Franka Cadée, Project Manager, Twinning Up North

Cover →

Foreword →

Introduction →

The Twinning Up North Project Personnel →

Hannah and Asta: Don’t Cut the Cord! →

Edda, Loa and Jolene: Improving Communication among Midwives →

Merel and Harpa: Inspiring Visibility of Midwives on Social Media →

Vala, Margretha, Hildur and Lianne: Understanding the Motivation for Elective Induction →

Gulla and Nathalie: Embrace the Pain →

Carola, Bjork, Sigrun, Esther: Strong Women Make Strong Midwives →

Berglind, Elke, Olof, Leonnie: Empowering Midwives to Become Leaders →

Inga and Rodante: Connecting the Personal with Political →

Erna and Steina: Normalising Births →

Conclusion →

Colophon →

Twinning up

north

A cultural exchange between Dutch and Icelandic midwives

Eliza Reid, First Lady of Iceland, congratulates the Dutch and Icelandic midwives on the completion of the Twinning Up North project

A personal, reciprocal relationship with any like-minded person can give us life lessons like no other. When this person arrives from a different culture and context, she is then not just a person, but a human door to a foreign world full of surprises, in the form of new knowledge, learnings and practices. Every conversation brings us one step closer to each other, and every meet-up builds new inspiration.

The Twinning Up North project is a cultural exchange that brought together midwives from two northern countries- Iceland and the Netherlands. According to a research by Franka Cadée, the Project Manager, “Twinning is a cross-cultural reciprocal process where two groups of people work together to achieve joint goals.” The midwives from the two countries were paired with each other to work on a joint project in a three-year long journey. Each of the twins’ journeys had their own smooth and rough moments; filled with experiences that were both sweet and sour.

The project team was brought together by: Áslaug Í. P. Valsdóttir, LMFI President; Franka Cadée, Project Manager; Edythe L. Mangindin, Project Coordinator, Iceland; Liselotte Kweekel, Project Coordinator, The Netherlands.

Meaning of ‘Midwife’ in Dutch and Icelandic

In English, ‘midwife’ means ‘with woman’. However, in Dutch and Icelandic, the word has different denotations. The word for ‘midwife’ in Icelandic is ‘ljósmóðir’, which means ‘mother of light’. In Dutch, the original word is ‘vroedvrouw’, which means ‘wise woman’.

Amidst multiple cultures, traditions, languages, characters and personalities, there was one thing in this project that united everyone, and that is midwifery. Midwives love their job, and when midwives come together, they feel excited to talk about midwifery and their passion for this profession. For them, midwifery is not just work, but a big part of themselves.

Fun Fact

The Dutch word ‘vroedvrouw’, being a word associated with women, excludes the minority of men who also work as midwives. Therefore, this word was gradually replaced by ‘verloskundige’, which means ‘the ability of freeing someone’ (from a baby). According to Franka, this word is void of any deep feeling and emotions, and she personally prefers to use 'vroedvrouw'.

Other Twinning Projects

In the past, two more twinning projects took place. The first one was between the Netherlands and Sierra Leone, and the second one between the Netherlands and Morocco. Recently another twinning project between Ghana and Sierra Leone was stopped, after agreement of all involved.

What are the challenges?

Franka describes that twinning between the high and low income countries brought forward a couple of ‘brilliant failures’.

“I call these failures ‘brilliant’ because what we saw happen were gems! At the time when those projects were happening, there was global religious tension prevalent which was seeping into all sectors of society, giving rise to institutional bias including racism. The Dutch midwives at times portrayed a feeling of superiority, and had discussions questioning the lifestyle and attitude of the midwives from Morocco and Sierra Leone. On the other hand, as a result of hundreds and hundreds of years of colonialism and its after effects, the midwives of Morocco and Sierra Leone had a very humble and submissive attitude. So it was very difficult for us to maintain equity, which is core to twinning. Through this project, we deeply faced the reality of what we have done to humanity.” -Franka Cadée

Liselotte says, “The idea of twinning is a two way process. Both the twins learn and gain from each other.” On a brighter side of the project, there were twins who developed a deep relationship, especially when they got to know each other as an individual human being.

The Sustainable Development Goals in the Western World

Two extreme situations take place in maternal health care in different parts of the world: Too Much Too Soon and Too Little Too Late. ‘Too Little Too Late’ refers to situations that can take place in low income countries, where necessary care is inadequate, until too late to help, leading to high rates of maternal mortality and morbidity.

‘Too Much Too Soon’ is a situation that is ascribed to high and some middle income countries. According to The Lancet, ‘it includes unnecessary use of non-evidence-based interventions, as well as use of interventions that can be life saving when used appropriately, but harmful when applied routinely or overused.’

“It is true that we need more and advanced medical interventions to be healthy. We need more midwives, doctors, nurses, hospitals, as well as procedures like Caesarian sections and induced labour when needed. But in the Western world, in countries like Iceland and the Netherlands, health is over medicalised. For example, a woman who is 41 weeks pregnant may be advised to have an induction even if it is not absolutely necessary. In the same way, she can also be offered a Caesarian section. When applied to a healthy woman, these medical procedures do more harm than good. There is a lot of evidence to prove that keeping birth normal is the best and safest for women who have good health.” - Liselotte Kweekel

Twinning between Iceland and the Netherlands

Based on the learnings from the previous projects, it was decided that in order to receive the best outcome from the twinning philosophy, twinning must take place between people who are contextually (geographically and culturally) closer to each other. Some of the priorities were to select a country where people understood and spoke English, and which was located closer so as to be more ecologically friendly. After shortlisting some European countries, Iceland was selected through a scoring system.

The Netherlands is known as a country where many of the normal births take place at home. The atmosphere in hospitals can feel over medicalised. In Iceland, there is little homebirth, yet the hospitals have a more homely atmosphere which does not feel too ‘medical’. This difference is one of the things, among many others that midwives from these two countries wanted to explore together through this project.

The twinning process began with a Call for Applications from midwives who were looking forward to enhancing their leadership skills and exchanging learning about their profession from other countries and cultures. Due to their large population, there was a fair number of applicants from the Netherlands, as they have 3,550 midwives in their country. In Iceland, it was rather more challenging to find a fair number of midwife applicants due to their small population. They have only 290 midwives in their country.

After the midwives were selected, they were matched and paired with each other- one midwife from Iceland and one midwife from the Netherlands formed a pair of twins. These midwife twins began their journey in 2018. Their journey officially ends in December 2020, but for many, this project created a relationship that will last a lifetime.

In this journey, the midwife twins learnt from each other’s culture and profession. They also learnt from each other as an individual. Together, they created products to spread knowledge about midwifery, motherhood and pregnancy. They were in touch regularly, and met twice a year- once in Iceland, and once in the Netherlands. When they visited each other’s countries, they stayed in their twin sisters’ home, met their families and went to their workplaces. For some, this experience was outside their comfort zone, yet everyone enjoyed the challenges and excitement that came along. The products that were created range from animations, testimonial videos, teaching modules and research; all with the aim of reaching out to women, expecting parents and midwives.

“After becoming a midwife I realised how political the profession is and how much power we as midwives can have. It's like the power of women they have within. We can change the way people look at women, we can change the way people treat women, we can change the way we see ourselves as women and how we can empower ourselves through the strength of other women being together. I think this collaboration has really shown me the strength of what happens when women come together, and especially midwives because we actually work with women. We see what we and other women go through everyday and see what we can do when we come together and support, learn from and respect each other. I have seen this beautiful collaboration and respect, and strength that comes from within when we come together, and it is really wonderful witnessing that.” says Edythe L. Mangindin

The Twinning Up North
Project Personnel

Franka Cadée, Project Manager

Franka has managed four twinning projects over the last ten years, the most current one being ‘Twinning up North’. While managing these projects she researched the processes and outcomes of twinning and defended her Doctoral thesis named ‘Twinning, a promising dynamic process to strengthen the agency of midwives’ in October 2020. With her anthropological and midwifery background, plus personal experience of living and working across a range of differently resourced countries, she is well aware of the realities of the field and a strong proponent of a human rights based approach to healthcare. Using her expertise in sexual and reproductive healthcare in general and midwifery in particular, with over 30 years of strategy and policy development, advocacy, leadership, research and project management experience, Franka is serving her second term as the President of the International Confederation of Midwives (ICM) (2017-2023). Currently she is a member of the Executive Board of the Partnership for Maternal and Newborn Health (PMNCH) representing the Health Care Professional Associations, a Board member of the ICM WithWomen charity, and a member of the High-Level Commission on the Nairobi Summit on ICPD25 Follow-up as well as a consultant on international collaboration to the Royal Dutch Association of Midwives (KNOV).

Liselotte Kweekel, Project Coordinator

Liselotte has been a midwife in independent practise in the Netherlands since 2009. She is a medical anthropologist, an advocate for Sexual and Reproductive Health and Rights (SRHR) and combines her skills in her work as the international policy advisor for the Royal Dutch Organisation of Midwives (KNOV). Liselotte is the project coordinator for KNOV in the Twinning up North Project.

Edythe Mangindin, Project Coordinator

Edythe earned a Bachelor’s of Science in Nursing, a Candidata Obstetriciorum degree in Midwifery, and a Master’s degree in Midwifery from the University of Iceland. Currently, she is a Doctoral student in Midwifery at the same university, and her thesis focuses on immigrant women’s experiences of respect, autonomy and mistreatment in Icelandic maternity care services and culturally competent maternity care. She works as a Registered Midwife at Landspitali University Hospital, Childbirth Educator and Project Coordinator for the Icelandic Midwifery Association in the Twinning Up North Project.

"Don't cut the cord!"

Ásta

Hannah

Don’t cut the cord!

Ásta Dan Ingibergsdóttir, Icelandic Twin
Hannah de Klerk, Dutch Twin

Project

Visualizing tricks of the trade: Empowering maternity care providers to support physiological birth

Animation Video by Ásta and Hannah. It shows the Somersault method to resolve a tight nuchal cord

Hannah and Ásta

Hannah has been a midwife for three years, and has done different jobs before she decided to begin her career in midwifery. Hannah initially studied Cultural Anthropology, but was never completely satisfied with her professional life. Later, her partner encouraged her to pursue midwifery as a profession. “We are going to make it somehow,” he said. Today, Hannah says that she is eternally grateful to her partner for pushing her, because she couldn’t have done it on her own. Hannah strongly believes in true autonomy and choice for pregnant women. She believes that it is not right to make statements like ‘You have to go to the hospital.’ Instead she believes in explaining the protocol and possibilities of birth, and enabling women to make an informed choice for themselves.

Ásta too, has been a midwife for three years. She has worked as a nurse in various departments for seven years before starting her midwifery programme. When Ásta was pregnant with her third child, she wanted to have a normal birth. Previously, her two children were born via Cesarean section. After learning that a normal birth won’t be possible this time too, she told her midwife, “I want to have my baby on my chest as soon as she is born, even if the surgery is still happening.” When my baby was born, she was with the paediatrician in a corner of the room. The doctor, who was inexperienced, felt that the baby needed to go to the Intensive Care Unit for an observation period. The midwife could see that the baby was fine, and would be fine with her mother. So she asserted to the doctor, “Now what the baby needs is her mother,” and handed the baby to Ásta. This precious little moment, and the midwife’s empathy and leadership encouraged Ásta to become a midwife so that she could be a positive force in the life of other women, the same way her midwife was a positive force in her life.

Ásta works at a hospital delivery ward with other midwives and healthcare professionals, while Hannah works at a small scale community practice and does home deliveries.

In Iceland, midwives carry scissors in their pockets all the time

Their Journey

When Hannah and Ásta met, they were both newly graduated midwives who were trying to find their fields in their professional lives. Hannah says,

"When we first met, I felt comfortable immediately. We were matched well as we had so much to talk about. We had wonderful conversations"

One of the most memorable moments for Hannah and Ásta was delivering two babies on the same day in Iceland at Ásta’s workplace.

Hannah always keeps a pair of scissors on her desk. This scissors was gifted to her by Ásta, and is a symbol of a workplace difference between the two countries. Ásta says, “We have very different practices in our professional lives. I have to wear scrubs and carry pens and scissors in my pocket all the time.”

Ásta (left) and Hannah (right) discuss about their project

What did they create together?

At their very first conversation, Hannah and Ásta discussed a method of delivering babies that had a cord around their neck, that did not involve cutting the cord before the baby is fully born. This method involved making the baby do a somersault in case the cord was too short. For Ásta, this method was not much of a big deal because according to her, “That’s just something that we do.” For Hannah, this method was revelation, and she desperately wanted to get this knowledge out to the whole world. This conversation further led to developing the idea of having a good visual, an animation to be able to learn this method without someone teaching you.

With this video, Hannah and Ásta intend to reach to midwives, midwifery students, family doctors, doulas, obstetricians and women themselves. The most important message that they strongly want to convey is “DON’T CUT THE CORD!”

Hannah and Ásta on a boat trip in Amsterdam during the first exchange

Ásta says, “People who don't know a lot about birth, they don't realise the importance of the cord. It is the most important thing in the first minute of a baby's life. It is its lifeline for oxygen and nutrition from the mother. If you cut the cord too soon the baby will have less haemoglobin and less blood in its bloodstream. It is very important and you have to keep it intact. The cord doesn't have to be cut unless the mother wants, or if the baby needs immediate help that is not available at the mother's bedside.”

Hannah says, “In Holland a lot of women ask to cut the cord once it is not pulsating anymore. In the beginning it is still pulsating, blood is still being transferred to the baby, that's when it's full and you can see the blue veins. At some point it just goes limp and it's white, there's no blood in there anymore. That can be an appropriate moment to cut it. Sometimes that's after a minute, sometimes it takes half an hour.”

Visit somersaultbirth.com to learn more about somersault births.