Midwives, exhaustion and safety

A recent survey of midwives and maternity support workers in the UK, found that the majority were stressed because of their workload and fearful of making mistakes because of exhaustion. Over half of those surveyed had observed errors and incidents which could have caused harm to women and their infants. These stressors are not restricted to the UK. I hear similar concerns from Australian midwives.

This situation is untenable for the midwives and the women and families in their care. 

 

It's about time governments and funding decisions reflect and respect the vital importance of childbearing to the fabric of society and fund maternity care appropriately. 

Better staffing levels are required. 

Staffing of maternity services decisions need to be made in acknowledgement of: 

• The increasing complexity of maternity care
• The fundamental requirement for adequate time for antenatal visits
• One-to-one care from a known midwife in labour 
• The need for adequate postnatal care

Only when these aspects are factored into the staffing model can we ensure that women of all risk and their infants get the care they deserve and the care which keeps them safe. 

Midwifery Continuity models for women of all 'risk' are what's required. 

Whatever model of maternity care is provided however, there must enough staff to provide the service safely - safely for women, their infants and safely for the midwives.

Midwives are dedicated professionals and consistently go above and beyond to care for women and their infants. That dedication should not be exploited. The current practice of staffing to the bare minimum, putting midwives on call after they've already had a full day at work in case there's an increase in activity, coupled with the ever-expanding list of mandatory education and competency requirements means the demands on midwives are creating a pressure cooker environment.  

Running midwives 'ragged' is not good government or health service policy. 

Appropriate and adequate funding of maternity care is essential.

We have a duty of care as a society to care for midwives and other maternity health care providers so they can care for the women and families they work with in the best possible way. 

The future depends upon it. 

Midwives warn of making mistakes due to burnout

The secret life of a midwife: I feel I work in a factory

Staff levels the risk: midwives

Fads, birth and safety

A 'prominent' Perth obstetrician and president of the Australian Medical Association (WA) Dr Michael Gannon, was reported as saying that "an “obsession” with skin-to-skin contact between mothers and babies after birth is a fad that is putting newborns at risk of death and serious injury".  His comment appeared in the article 'Skin-to-skin' fad blamed for deaths of babies published in The West Australian online newspaper 5 March 2016.

The coroner is investigating the death of a newborn at the Fiona Stanley Hospital. The article suggested that the baby is thought to have died 'after the mother fell asleep while holding or breastfeeding the baby'.

The AMA president rightly raised concerns about drug affected, exhausted women:

"New mothers are often exhausted by a long day in labour and there are the side effects of opioid drugs, epidurals or c-section"

 Photo from Midwifery Today site

However, he also criticises what he calls a

" new obsession amongst mothers and midwives with immediate skin-to-skin contact after birth ... which "stemmed from taking whatever possible measures that might lead to small increases in the number of women who breastfeed"

Far from a fad, skin-to-skin contact for women and their newborns at birth and beyond is a well-researched instinctive behaviour. This instinctive behaviour has been shown to not only improve breastfeeding success, but also, combined with breastfeeding attempts, reduce the rate of primary PPH, along with enhancing the sense of safety and attachment for the newborn and her mother. There are implications for the newborn's microbiome and there is some evidence that skin-to-skin experience reduces mothers' stress levels.

The doctor is reported to have said, in response to the claims for skin-to-skin, that:

 “I think that gets over-interpreted. Babies, instead of being in a safe environment like a warming crib, are being left on their mother’s chest”

Now the attitude that a newborn is better off in a warming crib than with its mother is the nub of medicalisation of the childbearing process and the disconnect between the use of technology and our humanity.

The medicalisation of childbirth is a done deal. Whilst physiological birth is appealing from both an evolutionary and capacity building perspective, the reality is the majority of women in the western world, are already heavily socialised into accepting and wanting medicalisation. Whilst choosing and embracing medicalisation and interventions, women are drawn to the idea of having their newborns with them skin-to-skin from birth and in the main, to breastfeed them. There is even a push (excuse the pun) for 'natural' and 'self-assisted' surgical births. Midwives are drawn to 'keeping things normal' and whilst supporting women in their choices; they are also drawn to facilitating skin-to-skin for the woman and her newborn at birth.

There is no doubt that 'drug affected, exhausted women' are vulnerable, as are their newborns, to the creation of potentially asphyxiating situations. A review of Apparent Life-Threatening Events in Presumably Healthy Newborns During Early Skin-to-Skin Contact  highlighted the issues for six babies left prone, unsupervised by a midwife or other health professional, on their mothers' abdomens. 

The reality is that midwives are increasingly having to care for postnatal women who are 'drug affected and exhausted'. The current staffing levels are woefully inadequate to care properly for these 'drug affected and exhausted women' together with their newborns.  Some people suggest recruiting partners or other family members to observe the newborn who is skin-to-skin with its mother, but that's a cop-out. 

Daily Mail

Often partners and others don't know what to look for and the bottom line is, the woman and infant's well-being is the responsibility of the institution that provides the 'care'. 

Whilst a decrease in medicalisation of birth would be ideal, that ideal will need a revolution in society's attitudes. In the meantime, what the good doctor and the AMA should be arguing and agitating for is not a separation of a mother and her infant, but for women and their infants to be treated with the profound respect they deserve and adequate midwifery staffing levels so that women and their infants can benefit from best practice and have the support and expertise of the midwife's presence to ensure that experience is a safe one.

Dr Gannon and the AMA need to understand that it is not skin-to-skin experience at birth that is putting newborn babies at risk.

What's putting newborns and childbearing women at risk is the rampant, unfettered medicalisation of childbearing that pervades modern maternity services coupled with ridiculously inadequate staffing levels - that situation is lethal.

The mother whose baby died at the Fiona Stanley hospital deserves our heartfelt love and support, kindness and respect - not blame for her baby having skin-to-skin and breastfeeding at birth - she was doing the very best she could for her baby.

If the little one is found to have succumbed because of airway obstruction, then our society has failed her and her family.  Our society does not value childbearing women enough to provide adequate staffing levels and midwifery expertise to be their guardians through their most vulnerable time. 

Educational Videos about childbearing & newborn care

Global Health Media has a rich, diverse repository of educational videos about childbirth & newborn care. 

 Photo from Newborn Care series

Videos are a powerful way to teach and these videos provide accessible and accurate life saving education about the provision of basic health care for childbearing women and their infants.
Their site states: Our mission is to improve health care and health outcomes in resource-poor areas by developing videos that “bring to life” basic health care information known to save lives.

Their videos can be downloaded in a variety of languages which makes them accessible to health workers and families in diverse areas. They are looking for people who can translate the videos into other languages.

I’ve spent time exploring their site, finding out about the people involved and how they work. Their passion, dedication and desire for safe motherhood and newborn health is exemplary. Please explore their site, share their videos and support them in whatever way you can.

Should Midwifery have its own National Board?

A massive change in the way health professions, including midwifery, are regulated

Four years ago Australia underwent a huge change in the regulatory system that oversees health professions. A National Registration and Accreditation Scheme (NRAS) was created.  This change saw the consolidation of 75 Acts of Parliament and 97 separate health profession boards across eight States and Territories into a single National Scheme. The National Scheme sets a minimum standard for safe practice by health professionals. This minimum standard can be and is, augmented by states, professions and institutions. 

The National Scheme is overseen by the Australian Health Practitioner Regulation Agency (AHPRA); each profession regulated by the National Scheme has its own board apart from nursing and midwifery who have the one board. The Nursing and Midwifery Board is responsible for the regulation of midwives which involves setting midwifery policy, standards and guidelines; managing midwifery registration; dealing with complaints against midwives; and assessing overseas midwives.

Midwifery coming of age as a profession

Whilst for many decades midwifery was seen as a nursing speciality, there has been an increasing recognition of the differences between nursing and midwifery. Australian maternity services and the way midwives are being educated have been changing dramatically in the past two decades in response to consumer demand and an increasing body of national and international evidence on the importance of midwifery models of care in meeting women's needs and resulting in cost effective, best outcomes for childbearing women and their infants (Barclay et al. 2003; McLachlan et al. 2012; Renfrew et al. 2014; Sandall et al. 2013; Tracy et al. 2013). There has also been increasing recognition of the necessity for midwifery to be developed as a separate profession. 

The National Registration and Accreditation Scheme (NRAS) is under review

The review is being led by Mr Kim Snowball, and the public consultation closes today, on the 10th October 2014.  Our Australian College of Midwives has submitted a proposal for a separate Midwives Board to the review: 

http://www.ahmac.gov.au/cms_documents/Consultation%20Paper%20-%20Review%20of%20the%20National%20Registration%20and%20Accreditation%20Scheme%20for%20health%20professions.pdf

Why we need a Midwifery Board!

The ACM has provided a list of concerns about the current combination of both nursing and midwifery professions under the current board in their document above.  They also identify that midwifery must be regulated by midwives in the form of a Midwifery Board, in order to ensure that:

• Midwifery practice issues are assessed and regulated by a full Board who are both credible and cognisant of the issues in the provision of contemporary, safe maternity care

• Issues associated with privately practising midwives and eligible midwives would receive attention from individuals who are appropriately qualified and experienced

• Complaints are managed in an appropriate and timely manner which includes the application of the principle of natural justice i.e. to be judged by peers who are competent to make a judgement

• Protection of the public is increased through the nimbleness of a midwifery focussed Board thus improving responsiveness to emerging issues associated with rapid escalation

• There is an increased understanding of the regulatory context for midwives in private practice providing a fee-for-service model

• Community representatives who are aware of the relevant issues for childbearing women and families are recruited to the Board thereby ensuring accurate assessment of practice-related issues for midwives

• Cost effectiveness is achieved by appropriate regulation and protection of the public

• Data collection about practising midwives is improved, which will improve workforce planning

• The issue of midwifery invisibility in the legislation, and its consequences, would cease 

• The Nursing Board would be free of the time consuming complexities of midwifery issues and able to concentrate fully on the important issues for nursing.

Do you support an Australian Midwifery Board? 

If you do agree that midwives should be regulated by midwives, please make your voice  heard by writing to Mr Snowball by close of business today, the 10th October and attach the ACM submission:

(http://www.midwives.org.au/scripts/cgiip.exe/WService=MIDW/ccms.r?PageId=10162)

or write a letter outlining why you think midwives should have our own Board and email to: nras.review@health.vic.gov.au

Share the ACM submission with colleagues, even if they are not ACM members, and encourage them to make their own submission.

Any questions about the NRAS Review or the ACM submission, please contact Sarah Stewart, ACM Professional Officer: sarah.stewart@midwives.org.au or phone (02) 6230 7333.  

Quotes for Midwives

My last meeting with the lovely midwifery students I've been working with in Papua New Guinea is this morning.

 Pacific Adventist University Midwifery Students PNG

I've been surfing the net, looking for quotes that relate to midwifery, women and birth that I thought would inspire them.   I've come across the following and thought I'd share them with you.

"You are a midwife, assisting at someone else’s birth. Do good without show or fuss. Facilitate what is happening rather than what you think ought to be happening. If you must take the lead, lead so that the mother is helped, yet still free and in charge. When the baby is born, the mother will rightly say: “We did it ourselves!”  - From The Tao Te Ching

Speak tenderly to them. Let there be kindness in your face, in your eyes, in your smile, in the warmth of our greeting. Always have a cheerful smile. Don’t only give your care, but give your heart as well. ~ Mother Teresa

Ask me for strength and I will lend not only my hand, but also my heart. ~ Unknown

If you lay down, the baby will never come out! ~ Native American saying

Offer hugs, not drugs ~ Adina Lebowitz

Someday, after mastering the winds, the waves, the tides and gravity, we shall harness for God the energies of love, and then, for a second time in the history of the world, man (sic) will have discovered fire. ~ Pierre Teilhard de Chardin

  Just as a woman's heart knows how and when to pump, her lungs to inhale, and her hand to pull back from fire, so she knows when and how to give birth. ~Virginia Di Orio

You gain strength, courage and confidence by every experience in which you really stop to look fear in the face. ~ Eleanor Roosevelt

For God hath not give us the spirit of fear, but of power, and of love, and of a sound mind. ~2Timothy 1:7

If I had my life to live over, instead of wishing away nine months of pregnancy, I'd have cherished ever moment and realized that the wonderment growing inside me was the only chance in life to assist God in a miracle. ~Irma Bombeck

Making the decision to have a baby – it’s momentous. It is to decide forever to have your heart go walking around outside your body. ~Elizabeth Stone

What's done to children, they will do to society. ~Karl Menninger

A woman
in harmony
with her spirit
is like
a river flowing.
She goes
where she will
without pretense
and arrives
at her destination,
prepared
to be herself
and only herself.
~Maya Angelou

Strengthening Midwifery in PNG

Giving birth and being born is dangerous in Papua New Guinea.

According to the National Department of Health Ministerial Taskforce on Maternal Health in Papua New Guinea the staggering rate of maternal mortality in PNG is a national emergency.

Every day, at least five women die of preventable childbirth related causes. Sixty per cent of childbearing women do not have access to skilled birth attendants and because there are only 270 registered midwives in the whole country, outside of the understaffed and under resourced regional hospitals, maternity and newborn care falls on the shoulders of community health workers and nurses.

In  September 2000, Papua New Guinea committed to combat poverty, hunger, disease, illiteracy, environmental degradation and discrimination against women and signed the United Nations Millenium Declaration, along with the other 190 UN member states. Eight Millenium Development Goals  were derived from this declaaration with specific targets and indicators. The PNG National Department of Health is targetting the 4th (reduction of infant mortality) and fifth goal (reduction in maternal mortality).

Midwives are internationally recognised as the number one primary health care professional for optimal safety for mothers and babies at birth. Even though there is recogntion of the vital role of midwives in optimising maternal and infant wellbeing and thereby reducing maternal mortality and morbidity in Papua New Guinea, the capacity to produce midwives too low and the number of midwives has remained stagnant. The midwifery workforce is aging and the registered midwives, few as they are, are rapidly approaching retirement.  Over the last five years, reports on the state of Midwifery Education and Maternal Health together with the National Health Plan have all focussed on increasing the midwifery workforce with the aim of having a midwife in every health centre and a skilled birth attendant for every childbearing women.

The reality is harsh. Too many women. A failing health system. Not enough midwives.

A sobering article in the Sydney Morning Herald in 2009 captured the issues and conditions succinctly on this date two years ago. Those issues and conditions are unchanged or worse.

Against this backdrop, the National Government of Papua New Guinea has partnered with the Australian Government to strengthen midwifery and capacity build the existing educational systems. Eight midwives started a month ago to work in pairs in four university programs with the educators and students to ensure the PNG National Standards and Competencies are achieved.

I'm fortunate to be one of the midwives, based at Pacific Adventist University (PAU) and working clinically with students and educators in the women and babies wing of Port Moresby Hospital.

The midwifery facilitation team, minus one and plus two!
From right to left Sue Englend (visiting Port Moresby), Lois Berry (based at Madang) Tarryn Sharp and her daughter Willoughby (PAU), Marie Treloar (based at Goroka) Alison Moores (University of PNG at Port Moresby), Glenda Gleeson (Mandang) Annie Yates (the Kiwi: University of PNG) and yours truly (PAU).  Missing from the photo is Heather Gulliver, who is also at Goroka with Marie.

Today, there was another big step in the right direction of strengthening midwifery in PNG.

The PNG Midwifery Society had their inaugural meeting in the conference room of the women and babies wing of the Port Moresby Hospital.

Fifty one midwives, nurses with midwifery education (unregistered) and student midwives crowded into the conference room to discuss professional midwifery matters.

Student midwives from PAU.

We booked a bus to bring the students and educators from PA University (about 30 minutes away from the hospital) and take them home again after the meeting. The students loved the experience. A very new experience for everybody.

The students are great fun and keen to learn. The educators are amazing people who are very welcoming and want their programs to meet the profession's needs and the Council's regulations. The midwives are appreciative of the students' work on clinical days as the midwifery workforce is scanty and the workload is huge. There is a lot to do to get things right in PNG.

Following the business of the meeting, the buzz was electric as the society member's shared food and conversation

                                                           

As part of the Australian College of Midwives committment to supporting and strengthening midwifery in our closest neighbour nation, four members of the society, two from Port Moresby and two from Goroka have been sponsored by the College to attend the Biennial Australian College of Midwives Conference in Sydney. Another initiative in strengthening midwifery in PNG is the  International Midwives Twinning Project. Two members of the PNG society are being sponsored by the Australian College of Midwives to go to the Hague, with two Australian College members to discuss and explore professional matters at the end of the month.

We know that when there is a strong and autonomous midwifery profession, mothers and their babies do well. The PNG Midwifery Society has the potential to play an enormous role in strengthening midwifery and creating a proud and powerful professional group for midwives, which in turn, creates a safety net for the  mothers and newborns of PNG.


Judging by today's conversation and the turn out for the meeting, the Society is well and truly up for the job!