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Being a Midwife in a Medical-Model System

The best midwives 1) compensate and/or innovate to give the best care within the confines of the existing system and, 2) in doing so, challenge and potentially change the dominant system.

Amy Romano

on 3 April 2010

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Transcript of Being a Midwife in a Medical-Model System

Being a Midwife
in a Medical Model System However you practice, know your scope of practice Know what comprises...
Midwife means "with woman"...
...but we work within a system. Also... What are your plans for continuity?
We must compensate and innovate to give the best care within the confines of the existing system. By doing this, we challenge and potentially change the dominant system. How does information flow? What is your continued role in care/support/management? At what point (if any) and for what aspects of care will you reassume independent management? To give safe, effective, optimal care, we may need to rely on the active participation of:
The woman and her support system
Maternal-fetal medicine doctors
Other specialist providers Optimal scenario is uncomprimised ability to practice within our own scope and unhindered access to whatever specialist services the woman or baby require. But... Midwives may delay or avoid engaging consulting physicians because we
Think we should know the answer or be able to handle the situation
Want to protect our clients from over-intervention
Fear professional consequences (loss of back-up, hospital privileges)
Will lose income
These barriers compromise safety, but we don't necessarily control them. (Except in the first case.) The best we can do is:
Give exemplary care
Understand the context in which we practice
Do our best to overcome challenges to providing safe, effective, satisfying care
This sometimes mean choosing battles.
Or making trade-offs.
Which we will all make.
Because our system gives midwives two choices: Health Care Reform Priorities for High Quality, High Value Maternity Care
Childbirth Connection, 2009

"Most childbearing women and fetuses/newborns are healthy and at low risk. They are best served by access to safe, low-intervention primary maternity care that supports their innate capacities for birthing, breastfeeding and attachment, avoids overuse, and gives priority to prevention, wellness, and appropriate referral and treatment as needed. Primary maternity care also offers improved value for payers over present approaches." Midwife-led verus other models of care for childbearing women
Cochrane Systematic Review, 2008
Systematic review of 11 trials involving 12,276 randomized women in which antepartum, intrapartum and postpartum care in the experimental arm were all midwife-led.
In only one study involving 218 women, no care in the control group was provided by midwives.
Midwife-led care reduced use of regional analgesia/anesthesia (11 trials, 11,892 participants, RR 0.81), instrumental vaginal birth (10 trials, 11,724 participants, RR 0.86), and episiotomy (11 trials, 11,872 participants, RR 0.82) and increased use of no intrapartum analgesia/anesthesia (5 trials, 7039 participants, RR 1.16), attendance at birth by a known midwife (6 trials, 5525 participants, RR 7.84), spontaneous vaginal birth (9 trials, 10,926 participants, RR 1.04), breastfeeding initiation (1 trial, 405 participants, RR 1.35), and high perceptions of control in during labor (1 trial, 471 participants, RR 1.74). No difference in other outcomes.
No evidence of harm for low-risk or mixed-risk populations.
by Amy Romano, MSN, CNM
Instructor, Yale School of Nursing
N582 - January 12, 2010 Independent management Consultation Collaboration Referral Safe, effective care BTW, pay no attention to the sizes of the circles!
...or be marginalized But doing this... Will help us ultimately change the system. What is the optimal system? Well, we know it's not this... Integrated, midwife-led primary maternity care system "Midwifery care" has benefits in its own right...
Less operative delivery
Less maternal morbidity
Less or equivalent newborn mortality/morbidity
Less genital tract trauma
Less use of potentially harmful interventions
Higher satisfaction
But we can offer even better results the closer we can get to this... In summary... It's this: The dimensions of exemplary midwifery practice. (Kennedy 2000) and work toward this... References

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