Sunday, November 23, 2008

Some thoughts on evidence based midwifery

I know the' talking head' is a little boring, but couldn't resist the opportunity to test the camera of my new Ausus eee PC.

This video will be a resource for midwifery students thinking about the value of research in their practice.

How do you feel about what I've said - any thoughts or comments?


Pamela Harnden said...

Hi Sarah,

I like the video.

I do believe that when you described the care given during second stage of labour it is important to maintain the value of both practices. I tend to be a bit of a multi personality person when with women in labour. I frustrate some of the ward midwives because I`m not a loud encouraging shouter and I actively discourage them from doing so if they come into the room as the second midwife. Mostly this approach works well and I always want to achieve the women feeling like they have birthed their babies, I would rather women walked away from labour and forgot who I was, feeling they have done the most amazing thing than to walk away and say, "I couldn`t have done it without you." This is important for me because the process is not about me it is about them and their family. But on saying that there are those women who that process doesn`t work and so a louder approach may be needed, sometimes that can be a reflection on the research that whilst in the majority of women the quiet, listening to the body approach works, there will always be those few who need more encouragement and to discount the method as not a part of your practice means that you have thrown away one of your tools. This ties in I believe with your comment about approaching women as individuals.

I have come across in many cases the problem of feeling leaned on by women and the expectation that I will spoon feed them all the information that they need. There has sometime become an inbalance in the partnership which some midwives, I possibly believe use to ensure that the women book with them again in future pregnancies, this is merely an observation not a researched observation.

Bill Perry said...

Well done, Sarah! The quality is excellent. What did you use to do the recording?

Sarah Stewart said...

@Bill. Thanks for the feedback. I didn;t think the quality, especially the sound, was that good, so thanks for your perspective.

@Pam. Thanks for the comments. Re: management of 2nd stage. Yes, you're right, some women need more active encouragement, but the point I was trying to make is that shouldn't be routine - 'managed' second stage with enforced pushing has no benefit & can actually harm the baby. Yet, it is a practice that still prevails.

Partnership: know what you're saying & would say myself that that is not a partnership - women have to do 'their bit', take responsibility/control, or else it isn't a partnership - it's something else. How would you define that sort of relationship?

Pamela Harnden said...

Hi Sarah,

I`ve been trying to rack my brain and think of the name of the type of relationship where there is an inbalance of the midwifery relationship but I can`t think of the correct wording. However Chris gave me a book to read, The Inner Consultation by Roger Neighbour and he talks about Models of Consultation. I do believe that I have seen midwives use some of these models and I`m sure I`ve probably used some of these myself.

Midwife-centred or woman centred consultations.
This is where the visit is driven by the midwife/woman`s own agenda, process and the outcome is determined by either one of them.

Task or behaviour orientated models.
I have heard and seen so often midwives race through the visit rhyming off a list of information which must be covered to the extent that the woman looks shell shocked when she comes out or I have had women come to me following a change of LMC because they felt totally swamped at previous midwife visits.

The task orientated model, I believe, possibly generates a dependent woman and an inbalance in the relationship begins to occur.

I tend to hold more to a Health Belief Model, whereby the beliefs, thoughts, feelings and past experience the woman brings to her antenatal visits strongly influence the understandings she takes away with her and passes on to her family.

I wonder how many midwives have considered their discussion style in the antenatal visits?

This book is obviously medically driven but it is about consulting in primary care so some of the principles could be adapted so far I have found some elements useful.

Sarah Stewart said...

This sounds a great book - very interesting. I'll have to take a look when I get a chance :)

Anonymous said...

hi sarah
just a comment about the partnership thing - I think there is scope to negotiate roles within a partnership and there may be areas where one partner leaves the other with more responsibility at times - which could be ok if the other party is happy to or comfortable taking that area on more. I think this weaving happens in midwifery partnerships and as long as it is negotiated or agreed by the partners involved thats ok - or perhaps addressed if not satisfactory or desirable to one party.
I think we need to get over the whole idea of counting who does what - whats important is that power is shared / balanced. If i as the woman decide to let you take control or responsibility for an area of my life - or to drive that - and you agree to because you can or are comfortable - its partnership - negotiated.If i give you too much control over my life - and you are not comfortable with that - you can discuss that issue with me and negotiate areas I need to work on taking some control over.
If I think of my life partnership - we don't do everything equally all
the time so there's scope to delegate some roles - he earns a lot more than me so he takes responsibility for saving for our retirement - or I am working hard this week so he cooks the food for everyone...

Sarah Stewart said...

Anonymous: I like this explanation. Thank you. But is it partnership or a relation ship, or is there no difference? Does it actually matter? All questions I keep thinking about and to be honest, it changes with every woman I work(ed) with.

Pamela Harnden said...

@Sarah and anonymous I`ve finally had emerge from the depths of my brain and with finding a couple of sources some of the stuff I was trying to get at about the partnership/relationship. I remembered John Heron`s, Handbook of facilitation where he describes the six category intervention analysis and I figure that depending on what sort of midwife you are or what sort of personality the woman is demonstrates how far into his intervention analysis you get. A midwife maybe an 'Authoritive' and takes a more dominant role taking responsibility for the woman by giving advice and direction. She also gives knowledge, informatrion to the woman by giving instruction and is confronting by challenging the woman`s behaviour by direct feedback.
On the other hand the midwife may be 'Facilitative' where she seeks for the woman to become more autonomous and take more responsibility for themselves. In doing this Heron describes that you can be 'cathartic' helping the woman to express and overcome powerful thoughts and emotions and demonstrates empathy. He then describes the 'catalytic' helping the woman to reflect, discover, learn and ask questions. This then leads to the 'supportive' part building the woman`s confidence, praising, valuing her contribution and supporting her decision making. This means that some people whether it be women or midwives sometimes have to move from control to risk and from structured formats to the vageness of waiting to see what happens next. There again you will always have those who are waiting to be told what to do next.
The thing to also remember is that in Competency One from the Midwives Handbook for practice it says,
"The balance of 'power' within the partnership fluctuates BUT it is always understood that the woman has control over her own experience."

Sarah Stewart said...

Pam: yes, but do women reallt have that control, especially when they birth in hospital?

Anonymous said...

yes good question - and I think the answer depends entirely on the midwives ability to let it be - perhaps - depending on their philosophy...some midwives are just not comfortable with letting the cards fall where the woman tossed them and do feel a need to dominate and control. Others are more process driven - and understand birth as being about making mothers...
Can you think of times in practice when women couldn't or wouldn't decide stuff - and so you let it be and thats how it was? We can often do that in birth cos - its a normal process and the outcome normally essentially fine despite us all.
(ok obviously there are times when we would use our wisdom and intervene as appropriate - but so often we can not act- allow the woman to experience her power and all is well)