Wednesday, October 17, 2007

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.

19 comments:

Carolyn McIntosh said...

This is a really good honest and insightful post Sarah. I am sure many midwives will identify with the situations you describe.

I am reflecting on this and writing an entry in my blog http://mymidiblog.blogspot.com/ . I think this posting will stimulate a lot of debate with midwives.

David McQuillan said...

I might add something to your list of recommendations for practicing midwives - Find a good massage therapist & get regular massages.

Massage has been shown to be one of the most effective therapeutic interventions in the management of chronic lower back pain. It has been shown to be more effective than self-care educational materials, muscle relaxation and remedial exercises. (Boduk, 2004)

Bogduk, N. (2004). Management of Chronic Low Back Pain. MJA 2004; 180 (2): 79-83. Retrieved on 22 July, 2007 from http://www.mja.com.au/public/issues/180_02_190104/bog10461_fm.html .

Sarah Stewart said...

Thanks for that, David. It's something I should investigate-I must come and get a massage from your students!

Loving Pecola said...

Great post. Wanna think, I'll be back.

But I did want to add that I do believe in massages and I think that might be the missing link to my "exhaustion" problems. I had been getting regular bi-weekly massages for 2 years before I moved across the country for midwifery school, and I think my body is really missing those massages. Not only my back but also my brain. It was one of the few times I could completely drown everything out, especially when I got the deep tissue because I could only concentrate on what she was doing.

Sarah Stewart said...

Thanks for your comment about massage, Loving Pecola. Do come back-I would love to hear your comments especially as it will be from a student's perspective.

rae hickey said...

well loads of food for thought there Sarah! You have mostly answered all your own questions really - so I think you have a pretty good perspective on the range of issues you have raised.
I totally agree that a baseline belief in and respect for the normality of birth is something that sustains us as midwives.
On the issue of sustainability - it is great to see this issue gaining a profile in midwifery - I commend Karen Wakelin and Joan Skinner for their research in this area for LMC midwives.
Massages all round in my opinion - more people should have this skill so more of us get the benefit of it more often. I personally find that I need regular time away from work - where I engage fully in the other aspects of my life which are fulfilling and sustaining. This sustains me as both a professional and a person and its a stretch to be one without the other. Getting downtime often means developing the confidence to say no and set reasonable boundaries.

Sarah Stewart said...

I completely agree with you, Rae, about the balance of work and home life. The problem comes when you're trying to provide 24/7 midwifery ie being all things to all men or women. It just isn't sustainable. The challenge is providing 'continuity of care' (not carer) without compromising one's relationship with women.

The other issue, sustaining academic life and/or midwifery scholarship is addressed by Liz Smythe. In her article Liz calls for a re-examination of the expectation related to annual practicing certificates that Midwifery Council have placed on midwifery academics. I would welcome comments about this.

Smythe, L. (2007). A hermeneutic analysis of the rise of midwifery schlarship in New Zealand. New Zealand College of Midwives Journal, Oct; 37: 20-26.

Sarah Stewart said...

This comment came to me from a New Zealand midwife:

"I was particularly interested to read about your burnout. I thought as I was reading it this is me!!!! I am burnt out. Its quite hard admitting it - but quite healing as well. It also doesn't have to be a death sentence for midwifery as everyone thinks it is. Burnout seems to a bad word in this profession. I know I can work through it as long as I am sensible and get help. However having said that I have booked 46 women from beginning of Jan to end of May - there is such shortage of midwives here. .... Having said all that I do love this job but wish I could afford more locum support. But what can be done to attract more people into independent midwifery - it seems that everyone is hell bent on making the job harder including the midwifery council. One very competent experienced midwife may leave because she cant make up her points. Another new midwife has just had a mother birth a stillborn baby because of HELLP, she is so distraught she doesn't want to carry on. Another midwife has just had six months off because of a health and disability action against her , And so it goes on . You wonder when its your turn but as you say we must surround ourselves with positive peers and mentors and know that the care we provide women is the best in the world."

Laura Jane said...

Thanks Sarah for your honesty.

I hope you can take some time to renew yourself and recharge your batteries because you are an asset to the profession. Not every experienced midwife takes the time to reflect on their state of burnout and examine their motivations for continuing. But they should.

I am a new midwife just finding my feet and I find my blog is a good reflection tool (www.lovingthequestion.blogspot.com).

I am starting to understand who the burntout toxic midwives are in my unit, and I don't avoid them, but take what they say with a grain of salt. Every one of them has something to teach me and they have probably forgotten more about midwifery than I will ever know. But I hope the learning is two-way, as I have a very clear sense of myself entering the profession as a breath of fresh air for the tired burnt-out ones, and also to be a wake-up call for the cynical heart-not-in-it-anymore ones, who truly should do the profession a favour and get out as they give it a bad name. As short-staffed as midwifery is, women are NOT getting good midwifery care from these midwives, and the profession cannot rebuild and reshape the confidence of the current generation of birthing women with cynicism and grudging rushed care.

Sarah Stewart said...

Thank you for dropping by, Laura. Great to hear from a new visitor to this blog.

I am extremely keen that we are open and honest about how we feel. I was a little anxious about how this post would be perceived especially by my immediate peers and students. However,I wrote it to help generate discussion. Hopefully, it will do that over time.

rae said...

I think as a profession we need to respect each others right and desire to set limits around how much of ourselves and our lives we are prepared to give, professionally. If we all undertook to be supportive and understanding next time one of our colleagues is strong and insightful enough to set a limit about what they won't do - we would all benefit. We should all make a personal effort to support each other more in this area and to create a climate where it is accepted that work is just work. Sadly this rarely seems to happen. Often we are our own worst enemies, I believe. Is it really the world, the women, the universe... who expect the earth from us or are we doing this to ourselves and each other?
I choose to be strong and set my own limits but while I do reap the rewards of having a personal life, a family I totally enjoy engaging with above all else and being fulfilled in way that matters to me - I am not oblivious to negativity imposed by some who resent or disrespect this professional limit setting. I think we need to encourage a climate of balanced decision making - as we mature as a profession I think this will evolve.

rae said...

next week. ha joking.
I do think we have some lessons to learn in terms of professional limit setting though. Setting limits is part of being competent, self managing and professional I think. This is especially important in midwifery which can be very greedy and needy and eat people up. As (mainly) a profession of women perhaps this is something we in particular struggle with (ie work life balance, setting limits etc).Historically we have quite an oppressed culture - I just think we are still trying to cope with that. 9thats the royal we not you and me specifically). I quite frequently hear sentiments shared that suggest this is a difficult area for lots of midwives to conquer. Maybe partly it is about personal growth and individual levels of self esteem - or is it something to do with our professional self esteem (meaning the broader profession).
Surely setting limits is going to be an important component of achieving sustainability - both as a profession and personally.

posy said...

Hi

I have just discovered your blog and finding it very helpful - thank you. This discussion interested me particularly as I am a new graduate who has gone straight into independent practice. Although I have a small caseload due to my remote location, I feel terrified most of the time and find being on call 24/7 stressful as I can never completely relax. There is nothing I can do to change this (no group practice options). Sometimes I fantasise about working in the local deli instead.

I could quit independent care and work at the tertiary hospital doing shifts but I know this would mean giving up normal birth (by my definition) and doing a lot of epidural management and synto and theatre care. Yuck. I would miss the continuity and the chance to see lovely candle-lit home births.

I guess there must be other new grads out there going it alone and I would love to know how they cope with the constant on-call and the fear. Does it get better?

Sarah Stewart said...

It does get better from the point of view that as you become more experienced, you become less fearful and more confident. But as for the on-call, being a rural practitioner in an isolated geographical location is very difficult to manage, and I do not have an answer for you on that one.

I believe what is vital for you as a. a new grad and b. a rural practitioner is to get support from experienced people who can mentor you and new grads who you can identify with. If you cant make face-to-face meetings, have you investigated what online midwifery communities are available to join for support?

If you'd like to drop me an email or contact me on Skype (sarah.m.stewart), I can put you in touch with a new grad who is in rural practice who would be a great person for you to network with. The other person to contact is Carolyn McIntosh (http://mymidiblog.blogspot.com) who is an experienced rural midwife who would know more about rural midwifery networks.

So, main message from me, if you have a reasonable Internet connection, is to look at how you can develop your online connections and networks, and maybe even get an e-mentor.

wizzy said...

I too have just found your blog spot sarah and i have been reading it all day .You have touched on so many points. The fear factor is very real in this culture of blame society. I feel it too but on a busy acute unit stating ' this is scaring the pants off me' feels like you are some sort of failure an like you are admitting that ou are no good in a crisis. I have taken careful note of the fact that others feel the same and im going to try using the word 'fear' on labour ward and see what happens.

Sarah Stewart said...

Thank you, wizzy, for your comments. Certainly acknowledging honestly how we feel is a good thing to do and I keep coming back to the fact that we need to support each other.

What I feel we need to do is carefully examine why we feel fearful - is it lack of support, attitudes of colleagues, bullying, lack of knowledge and professional development, over-exaggerated fear of litigation, excessive work load? Once we have acknowledged that these issues are may be reality, then we can look at what we can do about it.

Lisa Aman LM said...

Thanks for posting .I see me in the too! (LM x 26 yrs ) Own large on line school with skills weekends, clinical trips to Uganda etc. I feel burned out with just 1 birth a mo. I am getting more picky..(for sanity reasons) 2 of my clients are daughter in law (again) and a sweet G1 who I delivered her.How can you say no to that !Using apprentices willing help, delivering babies in Uganda and bubble baths all help !

Sarah Stewart said...

Hello Lisa, thanks you for getting in touch. As you can see, its been some while since I wrote this blog post but I still carry the effects of that burn out. So what to do? You've got to put yourself first. We don't do that as midwives...so it's as if we have to give ourselves permission to do that. But we have to look after ourselves so we can keep on looking after each other.

Change of subject: would love to hear more about your work in Uganda. And...have you seen theVirtual International Day 0f the Midwife? This is a free online conference for midwives coming up on the 5th May. You're very welcome to come along and join us.

Maike W. said...

Hi Sarah! My name is Maike Weiss, I am currently in Colombia, where I studied Nursing. I would like to know if there is a chance for to study Midwifery as a Masters or Post-graduate? If not, maybe you know a website or a contact I can ask that! It could be wether in NZ or Australia!

Big thanks!