Saturday, July 13, 2013

What should I say to the students?

Over the years I have spoken to each new intake of midwifery students at Deakin University in Burwood about the midwife in private practice.   I feel privileged to be invited to give this lecture.  I stand before a room full of fresh and eager young women (usually), who want to become midwives.

Yesterday I asked Martina, a young midwife who asked me to mentor her in homebirth and private practice, who had been in that same lecture room a few years ago, what she thought I should focus on.  She was quick to reply: "normal unmedicated birth, physiological third stage, leaving the cord un-clamped - these are basic midwifery, but students may rarely experience them as they complete the practical requirements of the course."  

Yes Martina, I think you are right.  This truly is basic midwifery.  Students may find that their courses emphasise so strongly the complications and illnesses that can devastate a woman in pregnancy and birth, yet undervalue the body of scientific and clinical knowledge around protecting spontaneous normal birth, breastfeeding, and mothering.  Teachers may take it for granted that students will learn how to be 'with woman' when the woman is strong and well and intentional about working with her own body's natural power in childbirth, while they prepare the students for obstetric emergencies, neonatal and maternal resuscitation, and other potentially life-saving measures.

Working in harmony with natural processes in birthing is indeed a wonderful thing.  Midwives sometimes refer to ourselves as 'oxytocin junkies', and anyone who has spent time repeatedly in the zone of healthy spontaneous birthing will know what I mean by that phrase.  We come away from birth with a renewed sense of awe and wonder each time, and we never exhaust its potential. 

Yet I need to balance that fact against the reality that a midwife's place in birth is not a passive one.  If there were no serious professional role for the midwife in a 'natural', spontaneous birth, it would be reasonable for women to be attended by their sisters, friends, or a sub-professional group of birth attendants.  A midwife attending planned homebirth is watching the woman's response to her body's intuitive work, watching the baby's response to the labour, and assessing progress over time.  While an inexperienced midwife might become frustrated when progress is poor, the seasoned midwife seeks an understanding, weighing up what she observes against her knowledge of normal. 

Midwives entering the profession today face a distinct set of challenges:

  • Basic midwifery
Mainstream maternity service providers in cities like Melbourne - the employers of the majority of midwives - are pretty good at dealing with the complicated aspects of birth.  They have educational and research arms that impress colleagues around the world.  But, in general, they do not do a good job at 'basic midwifery'.  There are few strategies that protect wellness.  The rates of various interventions, from induction of labour for non-medical reasons, to rates of caesarean, or rates of serious perineal trauma, or rates of admission of babies to neonatal intensive or special care nurseries - all performance indicators - could be improved. 

It is the job of midwives to insist on 'basic midwifery' improvements to the care of women.  We can't expect the obstetric services director - a medically trained specialist in surgery - to champion midwifery which is outside the scope of an obstetrician's expertise.  (Mind you, some obstetricians do understand, and champion, the work of the midwife) 

  • increasing medicalisation of life events
This challenge point is linked to the previous one.  Our society has, to a great extent, lost its knowledge of and trust in wellness.   There is a point at which additional medical interventions fail to improve outcomes, and possibly increase the risk of poor outcomes.  Midwives today carry knowledge of protecting and supporting spontaneous birthing processes.  We must value our knowledge and skill.

  • increasing bureaucratic red tape
Midwives have lobbied successive governments over many years for equity and fairness in access to public funding for midwifery services.  This challenge continues, even though we are now able to provide Medicare rebates for some midwifery services, and other extensions to practice such as requesting tests and investigations, and prescribing some medications.  There are many bureaucratic requirements attached to these new professional benefits, and only time will tell if we meet the expected standard.

Private midwifery practice in Australia today focuses on homebirth.  Homebirth offers midwives an opportunity to experience 'basic midwifery', because the only way to access the obstetric component of maternity care is to transfer care to a hospital.  

Over the years of my midwifery practice I have become more and more committed to the protection, support, and promotion of the spontaneous natural processes in pregnancy, birth, and breastfeeding, and this has been predominantly through planned homebirth.   It makes sense.  It leads to better outcomes for mother and baby.  Over the years of my midwifery practice I have also valued greatly the appropriate use of medical and surgical interventions.  In situations where the natural process is not likely to lead to good outcomes, we have excellent processes for 'Plan B'.  This is good.

I am happy to encourage the new group of midwifery students to give all they can to this profession, and I believe they may discover that midwifery will satisfy and challenge the most critical mind.

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