the midwife`s journal < contents

21. changing midwifery
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I was hunting through a file the other day when I came across some sign-up sheets. Page after page filled with names, addresses, and phone numbers, each entry written by the hand of the person named. The pages are headed "Do you want to be a part of ARM? - CHANGING CHILDBIRTH 18 March 1995". Those sign-up sheets became the database for the ARM - Australian Radical Midwives and Mothers - mailing list.

Today as I reflect on what has been happening in my profession I mark that day three years ago, when a large group of midwives attended a workshop with Caroline Flint, as a significant milestone in the journey. They came from Mildura, Mount Martha, and Malvern; Shepparton, Hamilton, Barwon Heads, and Kangaroo Ground; the suburbs, the regional centres and the bush, and even a few from Tasmania.   Many whose names appear on that list are today active in the struggle to bring about change in maternity care.

There were several other independent midwives, also members of MIPP (Midwives in Private Practice), present. Caroline Flint is an English midwife whose work and writing is widely admired. Caroline told the story of Changing Childbirth and the role played by ARM (Association of Radical Midwives) in the United Kingdom. Towards the end of the day, when many had spoken of the difficulties faced by midwives in this State, Caroline challenged us to do something about it. We divided into small groups, and were told to come up with a plan of action.

I was sitting with Patrice Hickey at the time, and we agreed together to form our own ARM. We knew that if something was to be done it had to be done quickly, and we agreed to work hard on ARM for the next year. We liked the irony of the title ARM, recognised instantly by midwives as the abbreviation for 'artificial rupture of the membranes', that common starting point in the cascade of intervention. We announced our plan to the group, and passed the sign-up sheet around.

Midwives were ready for radical change. A couple of years earlier the registration of midwives had been replaced by endorsement as a midwife on our certificate of registration as a nurse. Midwifery, under the Nurses Act of 1993 was being lost in nursing. That is what the powerful captains of the nursing profession wanted. Midwifery was to be considered a specialty of nursing.

At the same time our government had been persuaded, after an 'eleventh hour' intervention by obstetricians, to retain old Midwives' Regulations. The letter from the obstetricians' group to the Minister for Health stated "for our midwives to practice without medical supervision is not in the best interests of mothers and babies in this State."

'Our' midwives said "NO".

It is easy enough to disagree with the 'powers that be'; it is another matter to form an effective and unified voice in opposition, and to plan and effect a desired change. The movement that was started in March '95 had no money, no structure, no powerful allies - just a few committed midwives who were aware that we did not like the status quo.

ARM began meeting and sending out a news-sheet which we called ARM Radical Review. The pace-setters of ARM were also independent midwives. As members of the executive committee of the College of Midwives, Annie Sprague and I were able to bring the concerns of ARM to the more formally structured College. A meeting of ARM was scheduled to follow the College celebration on International Midwives Day, 5 May. A group of midwives and consumers were chosen at that meeting to work with the College in planning and lobbying the Nurses Board for the protection of midwifery. The group called itself the Sunset Working Group. As a direct result of the recommendations of the Sunset Working Group the Nurses Board appointed an expert committee to develop a Code of Practice for Midwives.

ARM continued meeting and working underground, and once there was a draft of the Code we met together and raved about how bad it was. Then we got to our computers and fax machines (no-one had e-mail then), reviewed the draft thoroughly and gave the Nurses Board the reasons why it should say what we said it should. The end product, the Code, still has vestiges of the medical model, but it was a good start.

ARM had done its job, and there was no-one with the energy to keep it going. It could be reactivated if needed. But that year of hard work has *empowered* a lot of midwives and a few consumers.

Looking back on that year has made me realise just how confident I and several other midwives have become in speaking about midwifery. We have a definition. We are 'with woman' (NOT with normal - whatever that is)!!! WOW!

The Code of Practice for Midwives in Victoria begins with the International Confederation of Midwives' definition of the Midwife, which has been ratified by World Health Organisation and the International Federation of Gynaecologists and Obstetricians. The Code emphasises the partnership between the woman and the midwife, a concept which was foreign to previous definitions and regulations of the profession in this State. The Code clearly acknowledges midwives as practitioners who can work 'with woman' as primary carer, or collaboratively in a team setting.

'Changing Childbirth' is the title of the 1993 Report of the Expert Maternity Group of the Department of Health in the United Kingdom. The major changes in the provision of maternity services in response to this report are all related to the fact that now the woman, not the care-provider, or the 'condition', is the focus of care. One of the many highly significant statements of this report, which midwives should read and re-read, learn and inwardly digest is:


"The Select Committee concluded that a 'medical model of care' should no longer drive the service and that women should be given unbiased information and an opportunity for choice in the type of maternity care they receive, including the option, previously largely denied to them, of having their babies at home, or in small maternity units."

Midwifery as it has been must change, or midwifery will disappear. Obstetric nurses who are assistants to the medical practitioners could replace midwives in mainstream maternity care. Many women do not know that maternity care could be different. Midwives have a responsibility to inform and educate the consumer. There are strategies which have been shown to reduce the need for medical forms of pain relief - these are powerful in the hands of a competent midwife. There are common practices which have been shown to be harmful or ineffective. Midwives who provide evidence-based care will seek to eliminate such practices. Through ongoing education, reading, critical reflection, and research midwives can take the lead in changing childbirth.

Change may come slowly, but we must make sure that it comes.

What's in a name? Midwife or nurse?

Phil, an obstetrician, has questioned my statements about midwifery and nursing, and in this brief response I hope to clarify my position. I value this opportunity for dialogue, and I hope that the readers will find it constructive. Isn't it interesting that we Aussies are carrying on a virtual debate mediated by Donna at her computer somewhere in the US, and that people scattered around the globe are listening.

Phil says "If you are not nursing a woman through labour what are you doing?"

I don't want to take an academic stand, and present definitions, but I did check the dictionary. Nursing relates to care of sick people. Pregnancy, birth and nurture of the infant are basic life events, wellness rather than illness. The midwife's focus is the woman, not the 'condition'.

I call myself an independent midwife because I am self-employed. The mode of entry (direct or nursing) is not important. Midwives who are employed in maternity units or birth centres and who have come through a 'direct entry' program are limited to maternity, whereas their colleagues who are registered nurses as well as midwives may be asked to work in non-maternity areas. As to Phil's question about midwifery training programs, "how long and what emphasis on physiology of pregnancy vs pathology &c" I am not involved in direct entry courses, so someone else will need to answer that.

One major phenomenon that has dominated maternity care in most of the developed world in this century is the removal of childbirth from the home to the hospital. The concurrent medicalisation of the event has occurred with little objection from either the consumer or the professionals. I would not like to turn the clock back to the day when women with obstructed labours called the barber-surgeon to extract the dead baby, only to then suffer the consequences of asepsis and excessive blood loss. I am confident in the fact that I can always access good hospital facilities and obstetric specialists who are skilled and able to perform life-saving surgery. When that time comes I continue with the woman as her midwife, and work in collaboration with the team which includes doctors, nurses, and others. That is appropriate care.

Phil has asked "… is your criticism that even nursing is too scientifically oriented today ie too much science and not enough art?"

No. Not at all.

In fact it has been the science of evidence-based practice that has convinced me on most of the points about which I am confident in midwifery today. The art of midwifery is an essential component, but the skill and knowledge, carefully tested and reported, are foundations of competent midwifery practice. 'A Guide to Effective Care in Pregnancy and Childbirth', first published in 1989, opened the discussion for me with statements such as: "As technical advances became more complex, care has come to be increasingly controlled by, if not carried out by, specialist obstetricians. The benefits of this trend can be seriously challenged. It is inherently unwise, and perhaps unsafe, for women with normal pregnancies to be cared for by obstetric specialists, even if the required personnel were available."

When I open my copy of the Cochrane Database I can thank the obstetrician Archie Cochrane for questioning care practices. Of particular interest to the midwife are topics such as 'Continuity of caregivers during pregnancy and childbirth', 'Amniotomy to shorten spontaneous labour', 'Early initiation of breastfeeding', 'Active versus expectant management of Third Stage', and 'Planned elective Caesarean section for term breech presentation'. The global Baby-Friendly initiative gives recognition to facilities that have done away with common care practices, such as separation of mother and baby, that have a negative impact on breastfeeding outcomes. World Health Organisation has recently published 'Care in Normal Birth - a practical guide', in which the unnecessary medicalisation of childbirth is discussed from the viewpoint of available evidence.

Phil says: "I think handing on a complicated case without any previous contact (which will happen at least 15-20% of the time) would not be a good experience for the mother.  This is the way trust is built up over the course of the antenatal care time and why the public system of unfamiliar medical attendants is such a poor model".

I agree that this is a poor model, and the Australian public health system leaves much to be desired. But I don't think the answer is to train lots of obstetricians so that every woman can receive personal specialist care. The "inverse care law" in which well women who pay for hospital insurance are more likely than women under public care to "need" operative birth has been reported in our society.

There are demonstrable benefits to the woman who is able to build up a relationship of trust with a midwife or a small team, and I believe maternity services should be making every effort to provide continuity of carer. That is the one reason likely to be given by a woman who employs an independent midwife. The woman who sets up a trust relationship with her obstetrician may be disappointed that (s)he has little involvement in care during labour, unless she gets what we often refer to as "the hamburger with the lot"(induction, immobilisation, continuous monitoring, narcotics, epidural, forceps, …).

I would like to suggest that rather than 15-20% being the rate at which the specialist meets the woman for the first time when she needs medical intervention, it should be over 80%. In this model the specialist would be the primary carer for those women who present prior to labour with pre-existing medical conditions or complications such as pre-eclampsia, insulin dependent diabetes, placenta previa and the like. These women still need midwifery care, from a known midwife if possible, as part of the 'team effort with everyone playing complementary roles".

I do not feel as though I am on the "other side" to the obstetricians or the hospital maternity units, even though most of my work is in the home, without a doctor being involved. In a better world there would be a place for each model of care, and the authority for choice and control would be securely in the hands of the consumer. A few years ago I had a senior midwifery position in a maternity hospital. Today I am unable to work in my capacity as a midwife in that or any other Melbourne public hospital, because visiting access is not granted to midwives. I could work there if employed by the hospital, or an agency, but not when employed by the woman.

Even as I write today I am conscious of a woman planning homebirth whose pregnancy has gone to 42 weeks by dates. Every observation available to me tells me that this woman and her child are well, but my advice to her is that we now need closer monitoring than I am able to provide. I need, as much as any other professional, to know my limits, and to be able to access further levels of care. I do not practice obstetrics, and most doctors do not practice midwifery.

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