One of the things I have to do for my Midwifery Standards Review in March is reflect on my midwifery case statistics. So I have been thinking about how I can present my statistics in an open way so anyone who is interested can have a look, yet protect the identity of the women involved. The conclusion I have come to is to talk about my stats in general terms in an open environment without becoming specific. This is especially important for me because I had such a small caseload, making it a lot easier to identify individual women.Electronic statistics
In terms of my ePortfolio, my stats are sent to me from the MMPO (the practice management service I belong to) as an electronic file so all I have to do is keep it 'as is' on my hard drive, or upload it onto a password protected website. I can give access to those who need to see the raw data, such as my Reviewers.
Comparison with national statistics
The other interesting thing that came through with my stats is a summary of what midwives who are registered with the MMPO are doing on a national level, so I can compare my stats with national trends.
Lies, lies and damn statistics
I had such a small caseload that it is impossible to make comments about statistical trends - but it's still interesting to have a look. In the year 2006, I attended 7 births:
- I was Lead Maternity Carer (LMC) for 5 of the women for their whole pregnancy, birth and 6 weeks after the birth
- 2 women I was LMC for just the labour and birth
- 2 birth were home births
- 2 births resulted in emergency cesarean section
- 3 were vaginal births in hospital.
Outcome.....................................Sarah..................... National
Induction of labour..................................14%................................. 15.5%
Artificial rupture of membranes ...........28.5% .............................13.1%
Augmentation of labour ..........................43%................................ 28.2%
Epidural/Spinal........................................ 57% ................................15%
Pethidine ...................................................14% ................................13.2%
Normal vaginal birth ...............................71.5% ..............................70.5%
Emergency cesarean section ..................28.5% .............................14.4%
Physiological third stage......................... 14%................................. 21%
Active management of third stage ........71.5% .............................65.5%
Ecbolic following physiological
third stage ................................................14%.................................. 3.9%
Post partum hemorrhage .......................28.5%.............................. 12.3%
Intact perineum .......................................57%................................. 30.7%
Breastfeeding.............................................100%
If you are interested in looking at more New Zealand maternity statistics, have a look at the latest Report on Maternity 2004.
What do my stats tell me
In general it looks like my intervention rates are higher than the national average. This is explained by the fact that two women ended up having emergency cesarean sections and one woman had an emergency induction of labour because she had fulminating pre-eclampsia. These higher intervention rates are nicely balanced by the fact that I had two home births and 100% exclusive breastfeeding at discharge.
Reflecting on my statistics
My main concern has been my epidural rate - four of the five women who birthed in hospital had an epidural for pain relief, and of those four women, two of them had cesarean sections. I have been left with several questions:
- Does Epidural for pain relief increase women's chances of having an cesarean section?
- What can I do to support women in labour so they do not feel they have to resort to epidurals?
- What influences women's decision to have an epidural that I have no control over, and does that reflect on my abilities as a midwife?
The latest Cochrane Review shows no association between epidural and cesarean section but there is a increase in instrumental vaginal births such as forceps. However, this has been disputed by other doctors and researchers who have found that epidurals cause a rise in Cesarean Section. My own feeling is that there is a connection, along with induction and augmentation of labour. It is also my observation that careful management of an epidural in the second stage of labour increases vaginal birth if you let nature take its course, even if it increases the length of second stage.
What am I doing wrong?
Looking at this high rate of epidural, I have been asking myself what I am doing wrong as a midwife? Am I providing adequate support to women? What alternative forms of pain relief should I be offering? Do I "cave in" too early to women's requests for epidural? Should I take the stance that some midwives do - refuse to care for women who want an epidural.
I always consider an epidural to be the last resort. I talk to women before they go into labour about epidurals and try to do the best I can to talk them out of having one. I tell them that they have to ask for one - I will not offer it to them. I try not to take the 'menu' approach to pain relief that Nicky Leap talks about - that I work with women to work with their pain. I am also a great believer in the power of water in labour.
Influence of place of birth
But I am mindful that the place of birth influences both the woman's and midwife's decisions about pain. And because I work in a tertiary maternity unit, I do think that over the years my skills of supporting women in normal birth have been eroded. It is so much easier to arrange an epidural when the anesthetist is practically camped outside the door, and I believe that has impacted on my practice.
Coming to a conclusion about where and how I practice as a midwife
So where does this leave me in regards to epidurals and so on? I have just been looking back over my blog and found several posts I have written over the last few years that reflect on how I feel about being a midwife:"Do I really know what's best for pregnant women?" and "Are you a fearful midwife?".
The decision I have come to is that I no longer want to practice midwifery in a tertiary maternity center because I feel I cannot fully function as a midwife in that environment. And as that is my only choice in Dunedin (apart from home births), I have decided that from now on I will only work in primary units, which means working in rural units in Otago and Southland. This way I will work with women who are committed to normal birth, and I will work to my full midwifery scope of practice.
I would love to hear your views. If you are a midwife, what do your statistics tell you about your midwifery practice? If you are a health consumer, do you ever think about a midwife or doctor's practice statistics? Would they influence how you feel about that health practitioner?
Image: 'It's a GIRL!!!' christyscherrer
http://www.flickr.com/photos/48819968@N00/69174923
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