Food for Thought from an Australian Midwife.

I happily stumpled upon the musings below on the website of an Australian midwife from Victoria called Joy Johnston. For the record I think that if I lived in her neck of the woods then she'd be a midwife I'd ask to catch my babies. I like her perspective. It helps me feel better about obstetricians.

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