From MIDWIFERY MATTERS, Issue No.102, Autumn 2004
Susan Stephenson
IN THE SAME WEEK that a less-than-5-second image of a baby breastfeeding in a European election promotion film has had to have the nipple edited out of it for the British public, my local paper sported a front page proudly proclaiming that women in the hospital here are being offered skin-to-skin contact with their babies at birth - Hoorah! The paper has made no big deal about the suspension of the homebirth service.
Where on earth are we going with midwifery? How does a midwife fit into a society that cannot look a bare breast in the eye, and does not seem to recognise that childbirth has anything to do with love and respect (let alone bodily contact - or sex!)? For me, midwifery is about supporting women in childbirth and being alert and aware, ready to act if anything should deviate from the normal.
During my training I worked hard to try and discover how this role fits into the systems of maternity services that I was experiencing. I came to the conclusion that it does not, and I chose to work independently.
Since I have been practising, there have been many occasions where I have reflected on my actions, or on what I have observed, acutely aware of what the Midwives Rules say I should be.
I am well aware that we are held over a barrel by defensive practice, protocols and guidelines, but I can't help feeling that some clarity about what our rules say we should be doing, would enable us to be confident about what we are doing, and to fight for the right to be midwives, if that is what we want to do.
I am taking this opportunity to have a closer look at our Rules…
Section A 33.2 : Programmes of education shall be designed to prepare the student to assume, on registration the responsibilities and accountability for her practice as a midwife.
OK so far.
Or is it? Many Trusts will not take on newly qualified midwives as community midwives, and many midwives are nervous about the prospect of working in the community. Is it the opinions of others that make us feel this way, or does our training not properly prepare us? In which case PLEASE will someone in education listen?
Many midwives have never held caseloads and will work on busy wards, often feeling thrown in at the deep end. When it comes to supporting women in childbirth and enabling or empowering them to make informed choices, getting women to consent to the procedures advised by the guidelines is probably the best a midwife can hope for if she is acutely aware of her accountability and terrified of getting it wrong! Maybe to the extent that she feels her sole responsibility is her accountability.
…Rule 40
1. A practising midwife is responsible for providing midwifery care to a mother and baby during the antenatal, intranatal and postnatal periods.
What is midwifery care? Continuity of care is not stipulated here, although we have recognised it to be good practice.
The WHO definition of a midwife is that she is "a person who has successfully completed the prescribed course of education and acquired the qualification".
…She must also (according to the WHO) "be able to give the necessary supervision, care and advice to women during pregnancy, labour and the postpartum period, to conduct deliveries on her own responsibility and to care for the newborn and the infant".
If we go by the Midwives Rules as to what we do, and the WHO definition of what we are, the midwife may find herself in someone's home, catching a baby without any of the back-up she has grown used to. Or she may be involved with women antenatally or postnatally who do not necessarily want any hospital involvement. So the training must prepare her for that.
Is it our nerves, or do our colleagues make us feel we are not capable? Do those who employ us not believe us to be adequately qualified?
Everyone is new to a job once and it is bound to be nerve-racking but, if we are well-supported, we should have the ability. Where is the support? Does midwifery have a system that allows midwives to develop their practice, or to increase their confidence or ability in certain aspects of it where they may be unsure? Surely supervision should provide this support?
Theoretically then, to support women in childbirth, midwives need to be supportive and supported. Midwives will be able to support women in childbirth when they themselves have a network of helpful resources and contacts, and colleagues who share their philosophy.
The problem arises, possibly, with being "responsible for providing …" (Midwives Rules) "…the necessary supervision, care and advice to women…" (WHO Definition of a Midwife).
Or more precisely, 'the necessary'.
I do not think anyone actually defines 'the necessary' so, as a midwife with the philosophy I have described, I take it to be what a woman herself deems 'necessary'.
In order to understand what 'supervision, care and advice' is 'necessary' for each individual woman, we need to know the women we are supporting. We need to know them quite well. And they need to know and trust us, so that any decisions that are made (and as a labour progresses, the mother:midwife balance in the here-and-now decisions will change) are ones that midwife and mother will quite probably agree on and trust each other on as being necessary for that woman in that labour.
Women have asked for choice, continuity of carer and not to be interfered with without their consent. Research shows women to be more satisfied and happy with their experience when they get that, and to be dissatisfied and more likely to complain when they do not.
Purely by telling women that they can choose, and that we need their consent before we carry out procedures on them does not solve the problem.
But I think we know that.
IK updated 1 December 2004