Pandora Hardtman left Bermuda in 2002, tired of fighting to have her skills as a midwife recognised by medical professionals here. It is a career move she has never regretted. In the years since, she has travelled the world as a midwifery specialist, leading the way in Syria, Nigeria, Rwanda and Bangladesh. Last month, she was elected to the board of the International Confederation of Midwives.“I returned home with a master’s degree in the early Nineties and there was almost a two-year battle to get admitted to the midwifery register despite the fact that I was licensed and board-certified,” said Dr Hardtman, who is also the clinical director for the Syrian American Medical Society. “It was horrible.” The bar was in place even though there were “no local midwives to fill the gap”. Those here were brought in “mostly by the Bermuda Hospitals Board” as nurses that could “catch a baby” if the physician could not make it.This, although to qualify as a midwife they had to be able to provide “the full range of basic primary healthcare”, everything from well woman gynaecology to menopausal care, Dr Hardtman said. “So when we look at the scope — all those other things you could do and, even in terms of fully supporting the antenatal process — you can’t do it.“Most midwives there under the BHB don’t do it because they’re brought in under contract. And in those limited contractual obligations who’s going to fight about it?“They’re not going to rock the boat — this is kind of a lucrative working holiday — but you can see where that would put a huge limit on [a midwife]. And if you don’t use your skills what happens? I had invested too much, educationally, practically, socially ... there were a lot of other things influencing that to just say, ‘OK I’m just gonna sit now’.”It worked to her advantage that the US was then “having a down surge” in the conditions required for a green card, which hastened her acceptance into the country to work.The Atlanta area is now her home base although, with “all her family here”, she keeps up with what is happening in Bermuda socially and also stays connected through professional associations she will now oversee in her role as a board member of ICM.“It’s wild,” said Dr Hardtman of her election to the global organisation, which manages more than 140 midwifery associations.“It sets the standards, the education regulations, competency, the regulatory duties. They are the overall governing body as regards to every school — all the accreditation, everything. “I have been elected now as the North America-Caribbean board member, representing the region from Canada straight through America and straight down through the Caribbean countries. “It’s based on a combination of not just experience and work, but experience in those areas. You also have to get endorsement from the associations in those countries and regions. It’s been an intense process to say the least, one that I never could have dreamt.” Most fulfilling is that she is able to put all of her skills to work.“State to state there may be some differences but we do everything — from contraceptives to basic kinds of healthcare to all the deliveries. I also function as a first assist in the operating theatre. “Many times my patient will never see a physician at all unless because there’s [a problem] with the labour. And if a patient needs to go to the theatre, we go with them so we’re not abandoning our patient; we’re the surgeon’s right hand in the operating theatre.”Her speciality, conflict and low-resource countries, has led to work outside the United States for years at a time. It has enabled her to see first-hand, the “huge” impact of midwives all over the world.“In many, many countries midwives are the mainstay of normal births, even more complicated births. That is not necessarily supported the same in Bermuda and when we talk about well woman here. “If we look at some of the countries with the best outcomes, the perinatal morality rates, the neonatal mortality rates; if we look at Sweden, Denmark, the UK, those countries’ midwives are the mainstay of normal women’s healthcare births. “You only go to the consultant if there’s an actual problem. That is more of the model that you find in many, many countries that I’ve lived and worked and visited.”Despite that, there are still not enough midwives based on a “per capita, per ratio” count. It is the ICM’s hope, that 2020 will bring more people into the field.Dr Hardtman said: “The numbers are not sufficient to the need. When we look at this being the Year of the Nurse and the Midwife, where they’re really trying to shine a light to develop more midwives, midwives who are well educated, who are well regulated, who are supported in the system ... if we tie all this back to Bermuda, even though I had succeeded in getting added to the register, without the support of the system I still could not function to my fullest capability.”Insurers put another hurdle before her by refusing to put her on their list, Dr Hardtman said. The end result was that women were “denied access to care”.“If you’re not added to the register the insured woman who might want midwifery care is not eligible because she would have to pay out of pocket.“It was an equity issue and still remains an equity issue. Someone’s got to pay $5,000 out of pocket. That’s quite a significant investment.“In other countries, many of them, the midwifery services are right there. They’re paid for under government support, the full gamut of resources. All midwives are supported to open their clinics, they can function independently which makes a complete difference in how this moves forward.”Dr Hardtman has served as clinical director for several “large-volume” practices. At one period she was responsible for nine midwives in four countries who handled 300 births a month in immigrant and low-resource communities. “I’m an immigrant myself. I’d always worked in immigrant communities and low-resource communities, particularly with the onset of what we call the ‘anchor babies’ in the US. “I became frustrated by the politics and policies in place because I would see so many upper-level decisions being made for immigrant women and poor women and marginalised women, by others who had no idea about their reality,” she said. “That is actually what sent me back to school. I went back to school and got a doctorate and, during the doctorate, focused on the international competency for midwifery practice. “The reality of it is midwife Pandora is one person, but Dr Hardtman is another.”