New Zealand is uniquely fitted to create such an inclusive system, because our nation has put in place everything all natural birth/midwifery advocates wanted, and before that, in the 1950s and 1960s there existed a pervasive societal message to become skilled, with studies confirming the positive benefits to everyone. The current problems we are observing seem to threaten the amazing accomplishment that is our national midwifery system, yet simply connecting the previously prevalent emphasis on skills with the current system will remove the threat and expand the “magic circle” to include the broadest possible population of birthing families – something the founders of the current system always wanted.
Philosophy, System and Structure of the Midwifery Model of Care
Tenets of the Midwifery Model of Care:
*pregnancy and birth are natural life events
*primary care should be woman-centred
*continuity of care
*partnership
*choice/Birth Plan/informed consent
*autonomous practice/full scope of practice
This is the philosophy; the system and structure to support this philosophy were put in place in 1990.
Goals of Midwifery Model of Care:
*lower c-section rate
*increase physiological birth
*reduce interventions
*empower women by giving them choices and right to exercise informed consent.
Is the broadest group of families achieving these goals?
Juxtapose these goals with the goals of the Common Knowledge Trust:
*To grow a skilled birthing population for all families.
*Families to feel competent about how they work through their baby’s birth journey no matter what.
*To become empowered by one’s own skilled capability no matter the circumstances.
Can these two models work together in order to strengthen the Partnership Model, and improve the birth experience for the broadest group of families?
Revisiting the Midwifery Tenets: What is continuity of care? There are two definitions: the same person throughout your pregnancy, birth, and post-partum; and 24/7 care.
“Midwifery takes place in a partnership with women. Continuity of care enhances and protects the normal process of childbirth…” Women’s Business, p.88. Does this mean women not having a “normal” birth should not be entitled to continuity of care? NZ midwives offer continuity of care to most NZ women. “In 1993 the focus for midwifery accountability was primary, low risk births. In 2010, midwives are LMCs (Lead Maternity Carers) for about 88% of women.” WB, p.404
“Our terms of reference were originally to identify a risk list, that is women who would not qualify for midwifery care but who would require medical supervision. Such a list, however, was to be elusive since there was little evidence to support many of the old risk assumptions. We finally developed decision points in pregnancy where we identified options available to both women and their care providers.” WB, p. 92. This is what makes New Zealand so unique. But what are midwives and women going to do together that supports continuity of care for all women?
“The employed LMC offering continuity of care did not and could not meet the requirements of the nursing employment contract. One example was that a nurse could not provide 24-hour care or contract out of the eight-hour day or days-off allocation. For midwives to do so required variations to the nurses’ employment contracts so that the midwives would be able to provide continuity of care.” WB, p. 458. This was a way to distinguish between “nurse” and “midwife” and for midwives to remain “outside/autonomous” from the system.
For a woman to have the same care provider is one thing. For that individual care provider to offer 24/7 care is something else. Independent midwives around the world who basically offer 24/7 care sacrifice their family, health, and often burn out unless they have a very small client base, no more than 20 births per year or less. 24/7 care deepens the bond of love and trust between midwife and mother, but it can also breed dependency. 24/7 care, if abused, can conflict with the message that pregnancy/birth are normal life events that infrequently need medical care. There need to be guidelines about when a midwife is called, with 24/7 care really only being necessary at the birth and immediately post-partum, when possible emergencies are most likely to arise.
“For instance doctors gave evidence that they undertook 4-6 antenatal visits in an hour while midwives’ evidence showed that they provided 1-2 visits in an hour. The same was true for postnatal care. Doctors visited in the hospital and often visited several women at once, while midwives visited women at home and their visits ranged from one to three hours depending on the need of the woman.” WB, p.256.
Questions: Should the government pay you for that increased time? Has increased time increased “normal” births? Or less interventions? Or less use of medical pain relief? How does continuity of care fit into a tiered maternity system?
Primary Care
“The other issue for midwives then and now was the lack of understanding that pregnancy and childbirth was not necessarily a medically led service. It was a life event, not a medical one, and like many life events, sometimes there would be the need for intervention. For most women, the full maternity cycle is a normal one, which can be assisted by a midwife without the need for full ‘team’ presence.” WB, p. 422.
Is this accurate? How many maternity clients come into pregnancy with health issues: asthma, endometriosis, diabetes, obesity, or other medical conditions? Because midwives are direct entry, how are health issues dealt with “without the need for full ‘team’ presence?” How many women develop health issues in pregnancy/birth or their baby does? (Including the inability to cope with the naturally occurring pains of labour contractions)? When a midwife practices “without the need for a full ‘team’ presence” how does she and the woman integrate into the teams that are the broad health profession, when the birth is perceived as not a “normal” process? What happens to continuity of care and primary care? How do midwives choose to remain in continuity of care when emotionally they want to attend physiological births that their profession promotes and protects, and how do they stay in primary care when that word is often associated with low risk and normal?
We know these are struggling issues. Skills bridge all of this. Attending births with skilled families, regardless of the need for medical care, is just plain inspirational. No amount of medical care and no medical birth provider has ever stopped a woman from using her skills or father/other from helping her stay on top and in control.
Women’s Business, p. 21:
Dr. Rushmur (1993) “Much of the time that a midwife spends with a laboring mother is time spent in support and encouragement, as opposed to being spent in obstetrics-difficulty time.”
Dr. Heather Thompson “Where a midwife is involved I find the major attribute she brings to bear is additional psychological emotional support. Occasionally during labour, the midwife may be the patient’s companion along with the patient’s own family support for up to 12-18 hours continuously.”
The response to these quotes was “many doctors did not recognize the monitoring, diagnosing and decision making that takes place as part of all midwifery care.”
“The view of a midwife as only a risk identifier and monitor, however, is not the model of midwifery promoted by ICM, the professional association that represents the voices of midwives worldwide. Many argue that the true concept of midwifery sees the midwife assisting and some would say empowering the woman in pregnancy, before, during and after labour and birth in such a way that the woman feels she is in control of the birthing process. The midwife provides moral, physical and sometimes spiritual support, as well as information, education and care to the woman, her family, her supporters and community members.” WB, p.227.
On the one hand, midwives do and don’t want to see themselves as just support for the woman by spending hours and hours with her and do and don’t want to see themselves as merely “monitoring, diagnosing and decision making.” For a normal life event, when any health care provider spends that much time, it implies to the woman there are constant potential and imminent risks. Is government paying for the time spent, or the “monitoring, diagnosing and decision making”?
Partnership
“The partnership model is identified as a relationship of ‘sharing’ between the woman and the midwife involving trust, shared control and responsibility, and shared meaning through mutual understanding.” WB, p. 95. The supporting structure for this partnership is a set of underlying philosophical beliefs:
- Pregnancy and childbirth are normal life events.
- Midwifery is independent.
- Midwifery offers continuity of care.
- Midwifery is woman-centred.
What is the responsibility of the women? What is “shared control” when one of the partners is a highly trained professional and the other is a consumer? What is “mutual understanding”? Here are suggestions for the women’s side of the partnership:
1.Birth naturally follows pregnancy…100%.
- Only you do the activity of giving birth…how are you going to do it?
- You can choose the birth you want, but not the birth you have. How will you do the birth you have?
4.Birth and coaching skills work in all births.
“The partnership between a childbearing woman and her midwife is the foundation relationship for the midwifery profession in NZ. Every contact a midwife has with a woman she attends in childbirth builds her understanding of the childbirth process and influences the way women respond to what is a very profound and demanding process.” WB, p. 173.
Sharon Cole: “For midwives to not set boundaries and for women to abuse the partnership will inevitably lead to burn-out but it can also lead to a co-dependency between midwife and the woman, rather than a healthy partnership.” WB, p. 192.
Is it reasonable to give 24/7 care and spend hours and hours with every client in pregnancy, birth and afterwards and be able to live your life? Are midwives requiring their partners (birthing women) to take personal responsibility, besides “choosing what you want” and “what do you expect of me?”
Midwifery is a service to the populace. Is it reasonable to ask women to help strengthen the partnership, to take responsibility for their ability to cope, manage, deal with, and work through the normal/natural pain of contractions? Without skills they will use more medical pain relief and often end up with assisted births. Can we expect women to develop their capacity to skillfully birth their baby, no matter the circumstances? Finally, midwifery being a service, paid for by the government, do women have any responsibility to help prevent exhaustion in midwives who are giving so much of themselves in 24/7 care? Are women/men capable of becoming skilled families and to provide inspiration to skilled midwives?
“NZ manages a one on one woman-centred maternity service with great outcomes on considerably fewer midwives and doctors than most countries, and at a markedly lower cost.” WB, p. 256
Is this an accurate statement? Are our outcomes “great”? Considerably fewer midwives are offering 24/7 care at lower cost. There’s a lawsuit for higher pay for midwives. According to Midwife Andrea Vincent’s statistics * over 15 years of insisting her clients learn birthing skills, the results clearly show lower cost, in fewer interventions and surgeries, and better outcomes. Can we do better, and can we support our marvelous midwives before they burn out with overwhelm caused by unpaid 24/7 care of every patient? Of course we can. The solution is right in front of us.
Pregnancy/birth normal life events?
If you look at photographs of traditional women birthing, it often looks like a normal life event, because there are no doctors, there are no monitors, there is no technology. The woman is on her own, coping on a primal level with whatever is happening. This is what natural birth advocates want, and what midwives believe reflects pregnancy and birth as normal life events. But we don’t know if her baby was stillborn, if she tore through her rectum, if she had a severe post partum haemmorhage, or if she ended up with sepsis. Is this what the majority of traditional, rural women want? Do they refuse with disgust the option of a hospital birth with medical support?
If you look at a photograph of a modern woman in a hospital, hooked up to IV, monitor, etc., but obviously in command of herself, calm, focused, using skills, natural birth advocates might minimize her experience because of all the assessments, monitoring and procedures that are happening. Yet this image is symbolic of the broadest group of birthing women in our country. Because of her attitude and her use of skills, this woman would be an inspiration to be with. This woman is also pleased with her circumstances, given all she knows about her condition, whatever it is that has led to so much medical support. And her medical condition is a “normal life event” for her.
“It was the focus on pain relieving anaesthesia for laboring women that eventually saw doctors winning their campaign.” WB, p.15. Women around the world consider that the natural occurring pain of contractions is “suffering” if they feel out of control and overwhelmed.
Modern medical maternity care deals primarily with two aspects of the “normal life event” of birth:
reduction of normal, natural pain that is unmanageable by most women who lack birthing skills;
management of health issues that are part of many women’s lives.
*Appendix, pp. 31-33.
“Maureen Thompson, 1978, said: “The dying out of midwifery in NZ could change the face of obstetrics irrevocably. The rate of interventions in birth would soar. We, too, could have a 20% c/s. We too could have routine scans, episiotomies, foetal monitors and inductions.” TWW, p. 126.
Under midwifery care, all this has happened and more. Would any of this be improved with a skilled birthing population that strengthens the Partnership between midwives and women? WB chapter on Section 88 states “As more healthy women give birth at home and in primary maternity facilities, only those who actually require the costly secondary/tertiary services will need to use them.” Yet since 1990 the home birth rate has not particularly risen to reflect that.
“Birth at home used to be a choice that had to be fought for. Women were very aware and vigilant about the need for optimum nutrition, health, antenatal care and psychological readiness. Now for some people, home birth has become a trendy thing to do rather than an informed health choice. Women are less prepared and often have no history or philosophy around home birth. This is not necessarily a bad thing but it does impact on beliefs, practices and also safety and transfer statistics.” WB, p. 202. If birth is such a normal life event and infrequently needs medical care, then home birth shouldn’t require women doing anything special to prepare. Reality does not bear that out. The societal expectation that all birthing women learn skills will reduce transfer rates due to lack of progression in labour or inability to cope.
“…these women believed that women learn to know and trust their bodies through personal and positive accounts of this amazing natural process.” Promoting normal birth was a strategic priority for the College and involvement in this project contributed hugely to this strategy. Through publications such as this, the College hopes to spread the word that women’s bodies are well-designed for the natural process of childbirth and the ability to give birth naturally should be protected.” WB, p.205. The word “natural” implies easy, manageable, with a good outcome. Are women’s bodies well-designed to birth if so many women end up with a delay in first or second stage? Or if they tear?
“Child bearing for the vast majority of women is a normal, physiological process.” WB, p.10.
Unless a woman has a surgical birth, birth is always normal and physiological, even when there are many health issues and extensive care. And still her baby’s birth is” normally” following her pregnancy. She is just as capable of preparing her body for birth and using birthing skills as she is to birth her child “normally.”
More examples of “normal and natural”
Birth normally and naturally follows pregnancy, regardless of all sorts of circumstances, including death or injury.
The normal/natural pain of contractions can cause women to feel they are dying.
Medical assessments, monitoring, and procedures take place around the normal physiological process.
“Many midwives gradually lost their understanding of childbirth as a normal life event and of themselves as ‘guardians’ of the normal birth process.” The goal was to “rebuild the midwifery workforce to once again believe in and be able to provide a service that recognized birth as a normal life event.” WB, p. 11.
Most traditional cultures do not have midwives. It’s your aunt, mother, grandmother, or some other relative. They attend every type of birth and consider everything that happens at birth to be normal, even if infrequent, challenging, or disastrous.
There is a perpetual confusion of the words “normal,” “natural,” and even “physiological.” A bleed is normal, physiological. So is a tear. So is a dead baby or a dead mother.
WB, p.3. Joan Donley says, “Many challenges remain, but the College has ensured midwifery has a strong base to support the continued role of the midwife as the specialist in normal birth.” This is identifying midwives only with low risk pregnancy and birth, yet all women would love a continuity of care midwife, which thankfully is available here. The midwifery profession identifies so strongly with promoting and protecting normal, physiological birth that this is creating a conflict of interest by serving the whole population in continuity of care, within primary care. Whenever an agenda, of whatever kind, is adhered to in birth its proponents are setting themselves up for disappointment. The course of each birth is unpredictable. And the needs of each birthing woman are unique to her responses to the unfolding events of her birth. To “be with woman” a midwife must relinquish her “agenda” and go along with whatever the woman “chooses.” Skills can bridge these gaps, empowering a woman to successful self-management that may or may not decrease the use of assessments, monitoring, and procedures. Whether or not a “normal, physiological” birth eventuates, the empowered woman will have the lasting gift of a positive subjective experience, and her midwife will honor her courage and skill in navigating the unknown journey of birth, feeling grateful to have been present.
Glynette Rainforte, WB, p.192. “for the wonder of the home birth movement is that such a comparatively small group of busy parents managed to effect such major and fundamental changes in the maternity services in such a short space of time…first in the moderation of attitudes and practices of health professionals and eventually in the status of midwives.” In reality, a very small group of home-birthing women and a small group of midwives who served that population developed the midwifery model of care we have today. It’s quite remarkable.
Nevertheless, the majority of birthing women are fine with the medical model, just as they are with the rest of medical care. Why would anyone think that modern families would want this one-off dynamic experience to fall outside medical care? People may choose not to have medical care for themselves, but put a baby in the equation and people are much more cautious. Birthing skills can bridge these gaps.
Rea, WB, p. 201. “There are endless studies documenting the safety of home birth and/or the requirement for no intervention for 85-90% of women, and yet the rate of many interventions during pregnancy and birth continues to rise. It is hopeful that in the last few years the rate of intervention has slowed and normal birth rates show a slight increase.” When Birthing Better skills developed, the WHO gave 97% as the number of women requiring no interventions in birth. How are women supposed to know if they fall into that 10-15% group, particularly when cared for by a profession that basically sees pregnancy/birth as normal life events, infrequently needing medical care? Assessments, Monitoring, and Procedures (AMPs) identify the 10-15%. Andrea Vincent’s statistics clearly illustrate that skilled families are more likely to fall in the 85-90% group, yet have an empowered birth when they fall into the 10-15% group. Most interventions come from women not coping with contractions. Learning birthing skills changes this.
Sharon Cole, WB, p. 189. “We believe the Nurses Amendment Bill will give women the opportunity to reclaim control over their birth experience, especially as they are re-educated to view birth not as a highly dangerous, medical procedure, but as a joyful event within their life experience.” She then goes on to say, “We believe that midwives are the most experienced health professionals in the support and care of women in normal pregnancy and birth.” Once again the word “normal” is being used to correspond with low risk. Marjorie Tew’s research showed that there is no correspondence between “high risk” or “low risk” and a normal or natural birth.*
Choice/Birth Plan
Can we choose the birth we have? What happens if we don’t get what we want? Is there another element that can positively impact the birth experience in addition to “choosing”? Skills constitute the responsibility taken by each family to bring about their choices.
“…midwives are women’s advocates and conduits for women’s best interests and choices, someone who tries to orchestrate an environment of care in the best interest of women and newborns.” WB, p.227.
What is the best interest of “women and newborns” when a profession holds such a strong philosophical foundation? Are midwives willing to advocate for the “choice” of a non-labouring c-section with no health reason? What happens when choices change? What happens when women regret their choices six months later? What happens when women want to choose a clearly unrealistic option? What about when on a list of ten choices, nine happen, but the most important one didn’t? Learning birthing skills helps women to achieve their choices themselves, by their own efforts, thus empowering themselves within the birth environment. This helps to remove some of the burden of responsibility from midwives and makes the partnership more viable and fair.
Informed Consent/Thinking/Primal Brain
“…Both reports stress the rights of women to dignified care, informed choice and decision making.” WB, p. 231. Do women exist in their rational mind or primal brain during pregnancy and birth?
WB, p.192. Sharon Cole: “Birth is an incredibly emotional event with heightened feeling accompanied by decreased rational thinking, with a resultant lessening of the ability to look at matters objectively.”
Michel Odent wants women to get into their primal brain. Tummy Talk says that women should “trust” their body but that’s often in conflict with what Sharon Cole says. Woman cannot exist in the primal and rational brain at the same time or easily move back and forth between them. How can women make informed choices and give informed consent if they are in their “primal brain”? As reflected in the 1950s studies of skilled families, skills allow the mind/body to be yoked together, resulting in more rationality.