Sunday, August 03, 2008

How many midwives do you need?

I was surprised when Sue, who is planning homebirth, told me that Karen, her midwifery student, was not 'allowed' to be present when she gives birth. Karen has come to several prenatal checks, and is doing the 'Follow Through Journey' with Sue.
"Why?" I asked.
"Karen's mentor from the University told her that she was not allowed to be there because you [referring to me] don't require a second midwife at the birth." was the reply. "She (Karen) said she thought it was a requirement of the Nurses Board, so that students aren't expected to stand in as the secondary midwife."

My surprise turned to annoyance. I felt I needed to defend myself. The logical implication was that I was in some way offering care that was of a lesser standard than those midwives who attend homebirths in pairs. In fact, there is NO requirement of the regulatory board, and there is definitely NO expectation that students will stand in as the 'secondary' midwife, whatever that may mean. I felt annoyed that an assumption had been made about my professional decisions in attending this birth. Anyone who has talked with me about my practice, or looked at the names on the calendar on the wall of my office, would know that whenever possible in homebirth I arrange to have a second midwife as an 'apprentice' - a midwife who is working on making the transition from hospital shiftwork to caseload practice. This is done at no cost to the woman, and is a wonderful opportunity for midwives to extend their knowledge and skill. But it's not done because I need the help, or because the birth becomes in any way safer in having another pair of hands. If I wanted that I would be working in a big hospital with emergency buzzers and operating theatres.

Karen's mentor, appointed by the University, is an independent midwife who does routinely book a second midwife for each planned home birth. That puts her practice and mine in competition for business - women may choose me because the fee they would pay two midwives is considerably greater than the fee I charge. The decision to require two midwives is a risk management strategy, in the same way that some people in Melbourne make a booking with a medical practitioner as well as one or two midwives. That doctor is able to extend the possible interventions that are available: antibiotics or Pethidine can be given, or a Ventouse extraction can be attempted - options that a midwife cannot offer. Women planning homebirth in Melbourne's leafy Eastern suburbs have the choice of a solo midwife, or two midwives, or a midwifery group practice, or a midwife and a doctor.

I want to make it clear that I do not intend to argue that a midwife working 'solo' is better than a midwife working with a partner. I do believe each woman planning homebirth needs to make the decision for herself as to what she needs. If a woman feels she will need a lot of 'support', she will probably not ask me to be her midwife.

One of the main arguments presented as the reason for requiring two midwives is that at the time of birth, both mother and baby may require professional attention. Without going into detail in this brief discussion, I would like to outline some major differences in homebirth as I know it, when compared with standard medical models of maternity care.
  • mother and baby are usually well in the labour - no analgesic medications or stimulants of labour are used in homebirth
  • the baby's umbilical cord is not cut at birth, and usually not cut until after the placenta has been birthed
  • because the baby's umbilical cord has not been cut, any resuscitation of the baby must be done with the assistance of the mother. This would usually be done with the baby lying on a towel on the floor, and the mother kneeling near, and facing the baby. The midwife works to resuscitate the baby in this position
  • if the mother is experiencing excessive blood loss after the birth, an injection of synthetic oxytocic may be used by the midwife in quickly managing the bleeding.
It is not possible to guarantee a particular outcome. However, when working 'solo', a midwife is relying on working with the mother in promoting normal birth, rather than relying on the number or the skills of people in attendance.

If I was setting up a maternity care program with government funding so that all prospective mothers could have access to services that are likely to promote the best health outcomes, that program would include the choice of homebirth. Each woman would be in the care of a midwife who is her primary or first midwife, and a second midwife, who backs up the leading midwife, and assists at the birth. These two midwives provide primary care throughout the pregnancy and birthing journey.

One aspect of working in a little team, with a second midwife, and a midwifery student, that I thoroughly enjoy, is the sharing of knowledge, and the reflecting together on events. Midwives learn from each woman, and from other midwives, each time we enter the intimate birthing space of a woman. Midwives learn to access our own intuitive knowledge, sensing the progress and the struggles that women must engage with as they in turn learn to work in harmony with their bodies.

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