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.

Reflecting on my midwifery statistics

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.
  

This comparison is with national statistics released by MMPO from March 2008 to February 2009 - 24,447 labours and 24,715 babies.

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?

Epidural and Cesarean Sections
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
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My ePortfolio: Thinking about my midwifery philosophy

I have done very little work to my ePortfolio in the last couple of weeks. However, I have just finished writing out my midwifery philosophy.

I first articulated this philosophy in the early 1990s. It hasn't changed much over the years. But I would confess that my scope of practice does not extend like it did a few years ago. By this I mean that I do not stretch the boundaries of the care I provide in a way that I used to eg I would not consider a breech (baby coming bottom first) birth at home, whereas years ago I would have.

There are a couple of reasons for this. Firstly, I do not do much clinical work these days because of my other roles of teacher and researcher, so I am probably not so confident as when I was practicing as a midwife full time. The second reason is my concern about litigation. I have written about this before and constantly challenge myself to ensure that I am not a fearful midwife. But it can be hard at times.

Please feel free to have a look at my midwifery philosophy and give me feedback. What aspects would you agree with and in what areas would your beliefs differ?

Image: 'Grin'
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