Are you a fearful midwife?

I was recently reading a blog entry by Carla Hartley, who set up a distance education midwifery program in the USA. Carla talks about un-learning fear based midwifery. That caused me to reflect on my practice: am I a fearful midwife?

Burnout
As you can see from my profile, I have many roles. Up until this year, I carried a small caseload as a Lead Maternity Carer. Most of my work has been done in the summer holidays so as not to interfere with my teaching responsibilities. However, last year, for the first time in over 20 years, I did not enjoy my work and dreaded phone calls in case they were my clients wanting something. I resented the questions women asked and the time I was spending with them. I found births to be incredibly stressful; I lost all confidence and any enjoyment or satisfaction I got out of my job. Hardly any of the births I attended were straight forward. The crunch came for me when I attended a home birth which I spent the whole time in a state of fear: I felt like a rabbit frozen in a car's headlights. There was no joy or excitement from the home birth which usually makes up for the more complicated births that happen in hospital and invigorates my midwifery soul. Looking back on this year, I was exhibiting all the symptoms of burnout.

So how did I get to this state: an experienced midwife who is 100% committed to women, birth and midwifery? How could I keep faith with students when I had lost the 'spark' that was so necessary to be able to practice as a midwife; when I did not want to be a midwife any more?

Litigation
One of the major contributing factors was the various legal cases that were going on at the time, which led to a concentrated attack on midwives by the media in New Zealand. Whilst midwifery leaders rightly exhorted us to continue with 'business as usual' there was no doubt that the issues brought up by the press impacted on my personal beliefs about midwifery. How could I offer a service that would meet a woman's needs yet keep myself safe as a health professional? I have no doubt that my fears about litigation had an impact, with the effect that I was far more 'conservative' in my approach than I normally would be. By this, I mean that I was quicker to refer to obstetricians which in turn resulted in medical intervention. Whilst this may have been justified, it resulted in a further loss of confidence.

Workload
My own personal workload was another contributing factor: it is not easy being a midwifery educator with the tensions of managing teaching, research, updating qualifications and clinical practice. A further factor was (and is) a chronic back condition. After many years of lifting clients, bending over breastfeeding women, bending over birthing pools and long hours in non-ergonomic positions, I have a vulnerable back and sciatica. Working with women when they are in labour, especially when it is a long labour, sets off my pain. Those people who have chronic back pain will know how much it wears one down and how challenging it is to manage.

Feeling the love?
So, how do I get my midwifery mo-jo back? Firstly, I think it is really important to recognise that it is 'normal' to have times when one doesn't want to do the job, as I have eluded to in other posts. Going back to Carla Hartley, she talks about her belief in normal birth which was supported by several mentors or people who influenced her practice. I believe that maintaining one's belief in normal birth is vital and developing strategies for doing that, whatever the context in which one practices as a midwife. Alongside that is having a mentor or wise woman/person, or similar person who helps to guide and sustain, or be a resource person or adviser. Mentoring or supervision, I believe, isn't just for new graduates but for all midwives, be it in an informal or formal context. I am very blessed to be working with a group of educators who are very firmly grounded in midwifery. They challenge me, but in a way that sustains me when I have my moments of doubt and disbelief. I am truly blessed to know these women (they'll wonder what I've been drinking when they read this!). I also agree with Joan Skinner when she says that rather than going straight to medical staff for advice, first turn to colleagues especially experienced midwives who are likely to be able to help with alternatives to medical interventions. That leaves those of us who are more experienced to make sure we are approachable, especially to new graduates.

Working with midwifery students
I am also very thankful to the students I work with, both in the academic and clinical environment. They are also challenging which can be quite intimidating at times, but that makes me think and helps me clarify things that I may not have thought about for some time. They also have a joy and sense of purpose that invigorates me, and they see things in an uncomplicated way that brings me back to the basics of why I am a midwife; they remind me of the joys of being a midwife because they are not bogged down with things that actually do not matter in the grand scheme of things. For those of you midwives who are thinking abut working with students, I urge you to do so. Yes, it can be hard work at times but it is also very stimulating and extremely rewarding.

Evidence-based practice
One of the things I have done is read about the effect of the media on clinical practice and I found an article written by a midwife called Andrew Symon to be very useful. Andrew urges midwives to be strong and not to let the threat of trial by media to influence practice, pushing them into non evidence-based actions. This emphases the importance of being up to date and clear about evidence-based practice; being able to critique research and policy as well as being self-reflective and questioning. Another great resource is the book Andrew edited called "Risk and choice in maternity care". The book looks at the concept of risk in maternity care and the effect it has on women's choices and midwifery practice.

Sustrainability
Clearly sustaining midwifery practice is a national and international issue, especially for midwives who carry a caseload to provide total midwifery care. Karen Wakelin and Joan Skinner have just published their research which looked at the sustainability of caseload practice in Auckland. They conclude that whilst providing continuity of care supports the sustainability of midwifery, it also threatens it as midwives continue to struggle with issues of time off and financial renumeration. Whilst this isn't necessarily my particular problem, being mindful of workload pressures is. One of the things I have been working hard to achieve is feeling that I can say 'no' to things; 'no' to women, 'no' to colleagues, 'no' to family and friends. Whilst I have found it very difficult, it is getting easier. Just about the only things I will not say 'no' to is a glass of wine with dear friends, and chocolate!

Looking after myself
As for the other issues, as I get older the more I realise how important it is to look after one's health. So I would say to any 'young' midwife who reads this blog: take care of your health, physical and mental. And in particular, look after your back. Take breaks during long labours; don't be afraid to ask colleagues to come and relieve you. Get lots of exercise and pay particular attention to back strengthening. Do not lift women and when you are bending, make sure you are in ergonomic positions. It may sound like a very sensible and obvious thing, but I wish I had $5 for every nurse and midwife I know who are only in their 40s and cannot practice because of chronic back conditions.

I realize that this posting is sounding a bit like the sunscreen song and how I have deviated from the 'fear' theme. However, I hope it has raised some questions that you might wish to respond to. What are the issues that you face in sustaining your practice and midwifery philosophy? What do you do to 'keep the faith'? How would you like the midwifery profession to address the issues of sustainability, not just in New Zealand but overseas? If you are a non-midwife reading this, what are your impressions and perspectives?

Symon, A. (2006). Midwives must not allow publicity to push them into defensive practice. British Journal of Midwifery, Sep; 14(9): 542-3.
Wakelin, K., & Skinner, J. (2007). Staying or leaving: a telephone survey of midwives, exploring the sustainability of practice as Lead Maternity Carers in one urban region of New Zealand. New Zealand College of Midwives Journal, Oct; 37: 10-14.