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Autonomous midwifery practice safeguards childbearing womens health

In 1902 The Midwives Act was introduced and the main reason was to protect women from those ‘birth attendants’ who were unqualified. The Midwives Institute (now the RCM), encouraged the Act as they wanted to raise the status of the profession and open it up to more middle class women. The Act established the Central Midwives Board, after much changing we know this now to be the NMC. The Central Midwives Board created rules and standards that Midwives had to follow and supervision was introduced. Although, Clarke (2004) agrees that women benefited by having a qualified midwife, she argues that the Act actually took away Midwives autonomy, and midwives had to accept having their practice defined and restricted by Doctors. The midwives institute it seems also happily agreed the division between midwives work and doctors work, again showing that midwives were subservient to the medicine (Clarke 2004).

The NMC’s main function is to protect the public by maintaining a register of practicing Midwives

Autonomy can be defined as :

“….. the right of self government, the ability of the Midwife to practice on her own responsibility for women in normal pregnancy and childbirth”. Winson & McDonald (2005) p22.

Thompson (2004)suggests that autonomy or self-determination is a key value to midwifery and one that should be expanded so that it includes both the midwives right to practice decisions and the mothers right to decide the care that she wants (p50).

The Nursing and Midwifery Council (NMC, 2008) also demands that “you [Nurses & Midwives] are personally accountable for actions and omissions in your practice and must always be able to justify your actions”. This is reaffirmed in the NMC (2004) Midwives Rules and Standards when it advises that practice should be based on best available evidence and we are accountable for our own practice – accountability cannot be taken from us from another practitioner and accountability cannot be given to us from another practitioner” p17.

Ledward (2004) reminds us that autonomy should not be limitless, midwives should work within their own personal competence. If a woman is low risk and uncomplicated then obstetrics should not interfere. Although Myles (p7 – ref properly) agrees, they go on to advise that autonomy is not about creating professional boundaries or exerting powers to protect what they see if their territory – does this mean that we shouldn’t be autonomous?????

Drivers for safeguarding

Changing Childbirth

Changing Childbirth was based on the principle of autonomy, it expanded the midwives professional autonomy and the main focus was that care should be woman centred (Ledward 2004). Deery & Kirkham (2006) try to advise why the teams that were set up after Changing Childbirth did not work. Caroline Flint’s team who were the focus of a know your midwife (KYM) scheme, had worked as a team for a while and each person had a strength so their dynamics were successful. When teams were created during the NHS – Deery & Kirkham suggest that no thought was given to the team environment and as such midwives were quite anxious and felt demotivated and demoralized. These midwives, who were meant to provide support to the women in their care, were not supported in their working environment. It was apparent that the focus was on finances and not on the women. This was echoed by Clarke (2004) who suggests that changing childbirth wasn’t accepted by midwives as they felt unprepared and unwilling to accept the new level of responsibility (p227)

Maternity Matters

As a driver to safeguard childbearing and women’s health, it seems appropriate to say what they advice autonomous to mean. ‘Autonomy means having the freedom to act on behalf of childbearing women and work in partnership, have knowledge and capability to provide continuous care for straightforward pregnancies as well as having a working relationship with other members of the healthcare team’. Do you agree???

The executive summary advised its aim was

“to develop a patient-led NHS that uses available resources as effectively and fairly as possible to promote health, reduce health inequalities and deliver the best and safest health care”.

It also advised that there should be National choice guarantees:-

1. Choice of how to access maternity care

2. Choice of type of antenatal care

3. Choice of place of birth

- homebirth

- birth in local facility , inc hospital, with MLC

- birth in hospital with maternity team

4. Choice of postnatal care.

Is it happening anywhere?

The Prime Ministers Commission on the future of Nursing and Midwifery in England

It drew on systematic reviews conducted in OECD countries with broadly comparable health systems and nursing/midwifery roles; 17 of the 32 reviews looked at studies from the UK. It only included studies where it could be ascertained what was being done and by whom, and to what other types of care nursing and midwifery was compared (no intervention, different models of nursing or midwifery care, or care from other

health professionals).Can easily be interpreted as a revision of Maternity Matters and NSF Children, Young People and Maternity Services and Changing Childbirth. The Commission was launched by the Prime Minister on 10 March 2009, and was asked to report by the end of March 2010. It was highlighted early on that there was room for improvement in maternity services; there were unnecessary medical interventions, limited choices & limited involvement in decision making for women. The commission called for views off people and in 4 months their independent website had had 14000 hits. They received 2500 views, but this was from organisations on behalf of their members and individuals. Most people understood the role of the midwife in relation to maternity, however, many worryingly, believed that the doctor input was necessary even in normal pregnancy.

They reviewed existing effectiveness (& cost effectiveness) drew on rapid systematic reviews and the findings for midwifery was positive! Midwife led care for low risk women compared to dr led care appears to improve a range of maternal outcomes. ↓no of procedures in labour and ↑ satisfaction with care. No evidence of any adverse outcomes associated with MLC.

They have proposed a pledge to be taken on under the NHS constitution, which they believe after interpreting the feedback, renew the sense of civic responsibility and provide guidance on handling the impact of economic pressures on health services. The guiding principles of the NHS are underpinned by core values derived from extensive discussions with staff, patients and public. These values are:

• respect and dignity

• commitment to quality of care

• compassion

• improving lives

• working together for patients

• everyone counts.

Evaluation of midwifery

Our commissioned review found evidence of the benefits of midwifery in three systematic reviews conducted in the UK, Switzerland and the USA that compared midwife-led care during pregnancy and after birth with doctor-led care (Caird et al. 2010). No evidence of a difference between providers was found for infant outcomes. Midwife-led care demonstrated better maternal outcomes than doctorled care with respect to pregnancy-induced hypertension, spontaneous vaginal birth and breastfeeding initiation, and less intervention, in terms of instrumental

deliveries, episiotomies, use of analgesia and anaesthesia. Women receiving midwife-led care were less likely to experience antenatal hospitalization and fetal monitoring in labour.

Midwife-led care was beneficial in terms of service users’ satisfaction and perception of care, and was more likely than doctor-led care to result in attendance at birth by a known midwife. There was no evidence of a difference between providers with respect to some other maternal outcomes and interventions, including Caesarean sections. The mean number of antenatal visits and duration of postnatal stay did

not differ between providers. Other studies support this evidence that midwife-led care for low-risk women, when compared to doctor-led care, appears to improve a range of maternal outcomes, reduce the number of procedures in labour, and increase satisfaction with care.

The narrower scope and more specific expected outcomes of midwifery make its socioeconomic case easier to construct. The challenge is not to analyse what midwives can contribute, but to ensure their resource is properly used. At present, for example, there is some wasteful duplication between midwife and GP, and midwife and obstetrician. The midwifery ‘offer’ has not changed and the midwife should work at all times in the way she is enabled to in statute and through education; otherwise society is not getting best value for money.

High Impact Actions for Nursing & Midwifery

A page advises that increasing “normal” birth and stop unnecessary caesarean sections through MW’s taking the lead role. Gould (2010) advises that this document defines the need to rebalance between medical focus and more emphasis on involving midwifery, however, Goldstein (2007) (In Gould 2010) suggests that more work should be done to stop “loss aversion phenomena”, whereby the public believe that an obstetric unit becoming a midwife led unit is a downgrade and not a positive. A sense of loss for not having Drs and Epidural available. However, it could also be that this time of budget cutting, could assist with the Prime Ministers commission as Gould (2007) suggests that medicalization will not be affordable. This would certainly help with a redistribution of power.

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