10 things I want to tell you about midwives.

Aaah…listicles. The favourite friend of the blogger.  I’ve got some thoughts to share about midwives. Thought you oughta know.

1. Midwives are trained to care for the “normal” in pregnancy and childbirth.

“Normal”, however, is a setting on the washing machine.  Midwives actually have the skills to provide care for ALL women during pregnancy and childbirth. Sometimes this care is in collaboration with a qualified or trainee obstetrician, and sometimes other medical specialists too. Midwives can stay focused on the woman’s transition to motherhood – psychologically and emotionally, while others provide their expertise.

2. Midwives like looking after “normal” pregnancy and birth.

Often the midwife’s work is to keep pregnancy and birth normal or even take steps to bring it back to normal when things go astray. Sometimes this can be bloody hard work, especially when other forces seem to be pulling in different directions.

3. Midwives take postnatal care seriously.

It’s neither “dramatic nor technologic” but it matters. To mothers, to families and to our world. And midwives do it. No other group of professionals have the expertise or passion that midwives have to provide this care. But women have low levels of satisfaction with their postnatal care, compared to other episodes of maternity care. We don’t know why…is it the care or is it something else – like the questions we are asking…or comparing it with other episodes of maternity care?

4. Wherever midwives are recognised care providers in the world, normal birth is advocated for.

http://midwives4all.org promotes the evidence that proves midwifery care assists in reducing maternal mortality and morbidity rates and neonatal mortality rates. All women deserve midwifery care.

5. The world needs more midwives doing research into midwifery.

There is very little encouragement for midwives to do postgraduate study and learn how to do research. Consequently the research focus in many maternity hospitals is determined by medical staff.  Midwives need to be equipped to do their own research – that way they can investigate the issues that matter to them as a profession and find solutions to clinical problems that matter. Dollars and pathways are needed.

6. Midwives are revolutionary by nature.

Even when they work in institutions, midwives know they do their best work when then follow the needs of the women they care for. This means they often have to defy the needs of the institution in which they work. When midwives work outside of institutions, they are criticised for doing ‘risky’ work.

7. Midwives are often oppressed by the structures they work in.

This can be especially problematic when the policies of that institution prevent them from providing the care for women that is needed and wanted. This makes them seem rebellious at times, and difficult to manage. Sometimes they go “underground” in order to do their job.

8. Midwives gain immense satisfaction from the work they do.

This means they often put up with a lot of criticism and confrontation to keep doing their job.

9. The work of midwives has consistently been undermined by others with vested interests in their sphere of care.

These interests are invariably about the amount of money to be made by providing alternative care to that of midwives, not in providing safer or better care for women. When history is read from the point of view of hospitals and the public health service they have provided, it may appear that they were trying to protect the interests of women. Complication rates were initially very high in these institutions, however, and were patronised by women who were too poor to even give birth at home.

10. Midwives have a significant role to play in public health.

Midwives provide primary health care at a significant time in a woman’s life. They have the potential (often realised) to encourage significant health behaviour change in a woman and her family during this time (think: smoking, nutritional choices, illicit drug use, general exercise and activity levels). Midwives primarily enact these changes through their care relationships with women.

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The issue of skin-to-skin.

photo (3)Atul Gawande  is a general surgeon and researcher from North America. And he writes. And thinks.

I “discovered” him a couple of years ago when I read an article of his in The New Yorker on how medicine takes up new ideas into practice (see links below).

In part of the article he described the efforts of public health workers in India trying to instil the practice of immediate skin-to-skin contact for mothers and babies after birth. The proven power of skin-to-skin contact in reducing infant mortality means it should be a natural activity for birth workers to encourage. And it’s an easy thing to facilitate and encourage in the clinical setting. But still it took time for widespread taking-up of the practice.

Gawande’s conclusion was that people are key in creating change in clinical practice.

Health workers with some clinical skills were employed to visit health care facilities to educate on the importance of the practice and also to make connections with practitioners. Practice is a complicated thing. Clinicians go through many processes in order to change their practice. It is one thing to know what the “evidence” is. It’s another thing to incorporate that into what you do. There may be particular factors which prevent the practice from being carried out, and perhaps most importantly, there may be colleagues who don’t share your priorities.

In the case of skin-to-skin contact, I thought of a few obstructions that might occur in a typical Australian maternity setting:

– the need or expectation that other activities will occur following the birth, such as checking the woman’s perineum, delivering the placenta or checking the baby, which skin-to-skin contact may delay or prevent being carried out.

– the desire of family, friends or health workers to give the mother “a rest” from her baby after what may have been a long and difficult labour.

– the belief that the operating theatre environment is too cold for a newborn baby to be unwrapped.

– the belief that a mother having skin-to-skin contact with her baby on an operating table will interfere with the rest of the caesarean procedure.

– the pressure on labour rooms necessitating the transfer of women who have given birth to postnatal wards as soon as possible.  This might mean that administrative tasks take precedence in the activities following birth.

In fact, many of these obstructions were issues in Indian healthcare facilities too!

Gawande’s conclusion in the Indian situation was that this ongoing person- to- person contact was the most effective means of creating change in practice.  Why?

-It meant that the activity was perceived as a priority (why else have someone dedicated to the task of changing practice?)

-It allowed for the clinician to understand all the reasons for the new activity by discussing it with the health worker.

-It gave local clinicians the opportunity to “own” the activity because they could discuss the particularities of their place of workplace with someone else and adapt their practice in a way that suited their context.

-When the practice was increasingly adopted the results could also be observed by the clinician which then had a positive feedback effect…and so skin-to-skin would become a “standard” feature of post-birth care.

And we haven’t even started to talk about breastfeeding…

 

The New Yorker article: http://www.newyorker.com/magazine/2013/07/29/slow-ideas

Atul Gawande’s website: http://atulgawande.com