Saturday, August 23, 2008

Decision Points

Midwifery in Australia today can be one of the most satisfying occupations there is. When a midwife has a ‘caseload’, a group of women to whom she is committed through the pregnancy, birth, and postnatal period, the midwife and each woman are able to learn how to work together before the big event.

Usually the ‘big event’ is labour and birth. Occasionally it comes as a decision point before labour; sometimes there are several ‘big events’ or critical decision points.

Midwifery that is woman centred is neither woman-led nor midwife-led. Neither the woman nor the midwife dictate the terms; both recognise their own, and the other’s unique role and capability in the relationship. It is a dance in which there are separate, but interweaving and sensitive roles. And the dance is not just the woman and the midwife – there is the baby of course, whose presence is profoundly significant, as well as anyone else who the mother-to-be has invited into her presence at the time.

No matter how much research or preparation you, the mother, do, an uncomplicated labour and birth is likely to demand more physical and emotional energy than you thought you had; to take you to a place that you didn’t know existed. The time comes in most labours when you need to surrender any conscious control, and allow your body to do its work. This is the normal way babies are born, and it is usually the safest way for both mother and child. The midwife who is ‘with woman’ is with you in this often challenging and frequently demanding journey, and also has to harmonise with and in a different way surrender to the natural process. I usually come away from a birth emotionally and physically spent.

The trust a midwife has in the woman is that she, the woman, will accept the midwife’s professional partnership. The trust a woman has in her midwife is that she, the midwife, will not disturb or interfere with that deeply demanding process of birthing a child, unless ...


Unless a decision point is reached where the mother-to-be is convinced that she is not able or safe to continue in ‘Plan A’ – doing it herself, and accepts an intervention in which she asks another person to take over – ‘Plan B’. It’s that initial decision point of handing over the controls that is the key to interference in normal birth.

This process of making informed decisions is the core of midwifery knowledge and skill. Midwives in all societies can work in harmony with a woman’s natural processes in pregnancy, birth, and nurture of the young – Plan A. Different cultures and different generations have had vastly different options for those who, for whatever reason, move out of Plan A.

The woman is free in our world to ask for, and will often receive, any intervention, including induction, dangerous drugs, regional anaesthesia, or caesarean surgery. In mainstream maternity care there does not seem to be any commitment to working in harmony with the natural process in birth. There does not seem to be any calling to account. Why does Hospital X have such a high rate of caesarean births? What are the midwives doing in Hospital X? Do they not know how to protect and promote normal birth?

A reader might think that the only people committed to working in harmony with the natural process in birth are those on the fringe – independent midwives, and midwives in birth centres or special midwifery caseload programs, who probably account for less than 5% of births. This is not so. By definition, every midwife has a set of requirements, including ‘partnership’ with women, and ‘promotion of normal birth’ (the International Confederation of Midwives’ Definition of the Midwife (2005) is copied below)

Every midwife’s duty of care can be summarised with statements from the Definition.

The midwife:

  • Is a responsible and accountable professional, who
  • works in partnership with women
  • gives the necessary support, care and advice during pregnancy, labour and the postpartum period
  • conducts births on the midwife’s own responsibility
  • provides care for the newborn and the infant
  • (implements) preventative measures
  • promotes normal birth
  • detects complications in mother and child
  • accesses medical care or other appropriate assistance
  • carries out emergency measures
  • engages in health counselling and education

I commenced this piece with the statement “Midwifery in Australia today can be one of the most satisfying occupations there is.” A midwife has a scope of practice and a duty of care that is truly awesome. I hope that some midwives who have read this, and reflect on their own midwifery practice will find ways to make the transition to more woman-centred care in which the midwife and woman work in a partnership based on trust, respect, and reciprocity.

Definition of the Midwife

A midwife is a person who, having been regularly admitted to a midwifery educational programme, duly recognised in the country in which it is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practise midwifery.

The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.

The midwife has an important task in health counselling and education, not only for the woman, but also within the family and the community. This work should involve antenatal education and preparation for parenthood and may extend to women’s health, sexual or reproductive health and child care.

A midwife may practise in any setting including the home, community, hospitals, clinics or health units.

Adopted by the International Confederation of Midwives Council meeting, 19th July, 2005, Brisbane, Australia. Supersedes the ICM “Definition of the Midwife” 1972 and its amendments of 1990.

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