THE BEST JOB IN THE WORLDwww.thepractisingmidwife.com Volume 16 no 10 • November 2013International Haemorrhage after home birth in the Netherlands Student midwives in Uganda, Gambia and Cyprus Improving maternity care in Nepal Ethnic minority women in developing countries FCRWAEWLIETIESA2HNSL0UTDL1HEA4IRS
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Contents4 EDITORIAL 28 Making maternal health services accessible to all cultures Sarah Edwards explores the barriers to5 COMMENT Maternity: a world of differences maternal health care faced by pregnant women Julie Jomeen from ethnic minority cultures in developing countries6 Sponsored elective placement to Uganda8 NEWS 32 Electing sun, sea and midwifery in Cyprus Helen12 Haemorrhage after home birth: audit of decision Pearce reflects on her elective placement at RAF making and referral In the first of a two-part Akrotiri in Cyprusarticle, Marrit Smit et al outline the background and 35 MIDWIFERY BASICS Role of the supervisor ofmethods used in examining haemorrhage after midwives Rachel Jokhi continues the series onhome birth in the Netherlands midwifery supervision16 Advancing to basics: a student midwife in 39 COCHRANE CORNER Midwife-led continuity Gambia Catrin Elis considers the benefits of models versus other models of care for childbearing developing an international perspective women. Valerie Smith continues our series20 Midwifery in Somaliland Margaret Crichton 41 AROUND THE CONFERENCES Presenting breech describes the challenges of setting up a BSc Mariamni Plested reports from the conference at midwifery programme in Hargeisa, Somaliland James Paget University Hospital24 Midwifery and maternity care in Nepal: the vital 42 PROFESSIONAL DEVELOPMENT link Edwin van Teijlingen, Bibha Simkhada and Padam Simkhada support improved maternity 45 OVERSEAS OPPORTUNITIES care in Nepal 46 LAST WORD The busy world of midwifery Sheena Byrom finds a lot going on in midwiferyEditorial advisory board © 2013 Medical Education Solutions Ltd. 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Midwives around the worldOur International issue this year follows a month with two notable international days: the 6th Julie Wray and Helen Baston,annual global dignity day and the international day for tolerance; both days are dedicated to Joint Editorsthe human rights. For maternity care and childbirth, that is the rights of every parent, babyand family; but also the rights of midwives and midwifery as a profession. The fact that thesedays exist as a means to raising awareness infers that something might be wrong. Dignity and tolerance are fundamental; we know as midwives how important they are andperhaps believe that we embrace them in all that we do. But do we? The UK picture and theglobal experience of maternity care are polarised and many of our papers in this TPM issuehighlight some of the differences and key issues. For example, it is always humbling when we learn from student midwives, writing abouttheir international placements, how strikingly different midwifery is in other countries, butnevertheless dignity and tolerance matter as much or more. Being an 'outsider', with limitedlanguage skills to observe practices, is brave and noble, at the same time perhaps arousinguncertainties about what lies ahead in practice. This month Catrin Elis and Helen Pearce writeabout their experiences on elective placement, and these, together with Cara Mumby’s nextinstalment from our sponsored students in Uganda, describe very different challenges. We have illuminating articles on maternity care in Nepal and for ethnic minority culturesin developing countries, how haemorrhage after home birth is managed in the Netherlandsand the establishment of the first BSc in midwifery in Hargeisa, Somaliland. Treating women, their families and each other with respect, tolerance and dignity is at theheart of this international issue. We can’t be complacent and we hope that you can learnsomething from this issue of TPM to take forward in your daily work.CONTACT: 020 8313 9617 SUBSCRIPTIONS: 01752 [email protected]: 66 Siward Road, Bromley BR2 9JZ All subscription enquiries or back issue orders should be addressed to: TPM Subscriptions Department, Proact Marketing, 12 Mary Seacole Road,Joint Editors The Millfields, Plymouth PL1 3JY. Tel: 01752 312140; fax: 01752 313162;Helen Baston PhD, RN, BA (Hons), RM, ADM, MMedSci, PGDipEd email: [email protected] Midwife: Public Health/ Supervisor of Midwives, SheffieldTeaching Hospitals NHS Foundation Trust [email protected] Personal subscription rates (5% direct debit discount in brackets): UK £60Julie Wray PhD, ONC, RN, RM, ADM, MSc, PGCE (HE) (£57); First year of qualification £50 (£47.50); Student (10% direct debitSenior Lecturer, School of Nursing, Midwifery and Social Work, discount) £36 (£32.40); Europe/Eire £70; rest of world £95 (surface) orUniversity of Salford [email protected] £120 (airmail). Institutional/library rates: UK £134; Europe/Eire (airmail) £160; rest of world (air mail) £190. Payment can be made by chequeManaging Editor: Laura Yeates [email protected] payable to ‘The Practising Midwife’ or by credit/debit card: Mastercard,(editorial/author submissions) Visa, American Express and Switch. TPM is published 11 times a year.News Editor: Mandy Galloway Copyright: © Medical Education Solutions Ltd, 2013. All rights reserved. No part of ‘The Practising Midwife’ may be reproduced in any material formAdvertising Manager: Margaret Floate (including photocopying or storing in any medium by electronic [email protected], 01483 824094 and whether or not transiently or incidentally to some other use of this publication) without the written permission of the copyright holderPublisher: Ian Heslop [email protected] except in accordance with the provisions of the Copyright, Designs and Patents Act 1988, or under the terms of a licence issued by the Copyright Facebook is a registered Licensing Agency Ltd, 90 Tottenham Court Road, London, England W1P trademark of Facebook, Inc. 0LP. Applications for the copyright holder’s written permission to reproduce any part of this publication should be addressed to the publishers. Printed in Great Britain by Williams Press, Maidenhead ISSN 1461-3123 Disclaimer: The sentiments expressed by the contributors and advertisers in The Practising Midwife do not necessarily reflect the views of either the Editors or the Editorial Advisory Board.Subscribe today – 01752 312140
THE PRACTISING MIDWIFE • November 2013 5 Comment Julie JomeenMaternity: a world of differencesIn 2011 the global report into the State of the World’s UK in contextMidwifery (United Nations Population Fund (UNFPA) 2011) We must, however, put this in the context of the globalstated that annually, 358,000 women die during pregnancy picture. We remain fortunate to have maternity services thator intrapartum, two million newborns die within the first 24 are freely available to women. Policy in the UK and otherhours of life and there are 2.6 million stillbirths. developed countries has been underpinned for over two decades by the rhetoric of choice, control and woman-Preventable deaths centred/flexible care. That we can focus on and attempt toThe majority of these occur in low income countries. Only 1 tailor our services to address such issues is a consequence ofper cent of the world’s maternal deaths occur in the US, healthcare provision that proactively addresses maternalCanada, Europe and Australia combined. This huge inequality health and social inequalities, which support better birthand injustice, is underpinned by three key components: the outcomes. We must not lose sight of the potentialoverall health of the woman; her place in society; and the complications of childbirth, as the Centre for Maternal andpresence of a skilled birth attendant. Few would disagree that Child Enquiries (CMACE) report (2011) highlights. There willthe right to life and a safe birth is a fundamental entitlement always be challenges and more that we can do to improvefor all women. The major direct causes of nearly two thirds of care, but most women in the developed world do not live inmaternal deaths worldwide are things we can prevent or fear of dying in childbirth.treat, making maternal mortality figures related to childbirthcomplications such as hemorrhage, sepsis and obstructed UK maternity policy makes the promise that the views,labour clearly unjust. beliefs and values of women will be sought and women themselves will be respected as partners throughout their The World Health Organization (WHO) says that skilled childbearing journey. This exemplifies the elemental andhealth workers at birth are key to improving outcomes (WHO central role of relationships to the provision of high quality2010). Yet 38 of 58 countries surveyed might not meet the maternity care. Whether with international governments toUnited Nations Millennium Development Goal (MDG) target promote the strengthening of health systems and theto achieve 95 per cent coverage of births by skilled attendants delivery of effective interventions or on the ground betweenby 2015 (UNFPA 2011). healthcare providers and women, relationships must keep at their centre a moral obligation to childbearing women toGlobal maternity care promote a safe and respectful birth. TPMThe papers in this issue of The Practising Midwife highlightexperiences of maternity care globally and raise issues for us Julie Jomeen is professor of midwifery at the University of Hullto consider as midwives. Firstly the value of experiencingbirth outside our own context, as well as highlighting Referenceshumbling examples of what, as individuals and/orcollectively, we can do. They also cause us to reflect on our CMACE (2011). ‘Saving mothers’ lives: reviewing maternal deaths to makesituation at home. motherhood safer: 2006–2008. The Eighth Report on Confidential Enquiries into Maternal Deaths in the United Kingdom’. Brit Jour Obs Contemporary maternity services are facing significant Gyn, 118(S1): 1–203.challenges. Public health issues, such as obesity andcontinuing social inequalities lead to poorer obstetric and UNFPA (2011). The State of the world’s midwifery 2011: delivering health,neonatal outcomes and limit women’s maternity choices; a saving lives, New York: UNFPA.shortage of midwives creates enormous pressures and fearsfor the future delivery of high quality maternity care. WHO (2010). Accelerating progress towards the health-related Millennium Development Goals, Geneva: WHO.
Uganda placements Back in the UK and now working as a qualified midwife,Cara Mumby marvels at the teamwork she and fellow students witnessed in Mbarara hospitalBackground Uganda, these issues were apparent from the very first day.In western society childbirth is a normal physiological event The hospital serves a population of 436,400, the majorityin a woman’s life and, although there may be some anxiety classed as rural and unable to reach the hospital effectivelyand worry associated with childbirth, negative outcomes in an emergency (Mbarara District and Local Governmentare very rare, with a lifetime risk of maternal mortality (MDLG) 2011). National life expectancy is 53 years comparedequating to one in 5600 (World Health Organization (WHO) with 80 in the UK, and only 43 per cent of women areet al 2010). In comparison, maternal mortality rates in attended by a skilled birth attendant during labour (NHSUganda and other regions in sub Saharan Africa are 2013). It was evident that basic resources were notamongst the highest in the world; the lifetime risk being a available despite the greater need for them due to theshocking one in 30 (WHO et al 2010). Statistics imply that health complexities associated with developing countriesmaternal mortality rates are more affected by prosperity (WHO et al 2010).than any healthcare indicator (WHO and UNICEF 2013).Reassuringly, maternal mortality rates have steadily Overcrowded wardsdecreased worldwide throughout the last two decades, The ante- and postnatal wards, like the rest of the hospital,although sub Saharan Africa has had the slowest decline of did not have enough beds for all the people they cared for,all (WHO and UNICEF 2013). many women residing on mattresses on the floor. At one time I noted that several of these were occupied by twoLack of resources women. No cots were provided, the neonates also stayingBut, as I have now witnessed in Uganda, it is so difficult to on the beds or mattresses. It was very difficult to moveattain international healthcare targets when there are so around the postnatal ward, due to the mass of mattressesmany additional complex factors to overcome. The five main swamping the floor, and for fear of stepping on a baby. Icontributing factors to maternal death are obstetric was often prevented from standing on a covered baby by itshaemorrhage, hypertensive disorders, non-pregnancy frantic mother. This cramped environment was notrelated infections (including HIV), sepsis and abortion. More conducive to clinical assessment or the maintenance ofdisturbingly, avoidable factors in the healthcare of women dignity, privacy and safety. One wonders how riskare also highlighted as contributable. The poor availability management, health and safety and hygiene are evaluatedof adequate infrastructure, essential lifesaving drugs, in a place where these things seem impossible to achieveequipment, blood products and trained staff means it is an unless women are turned away.uphill battle every day to ensure women are safe duringchildbirth (Parliament of the Republic of Uganda (PRU) 2011). Pain relief a luxury During the second stage of labour women were transferred During our placement in a regional referral hospital in
The Practising Midwife is sponsoring four studentmidwives from Hull University to undertake anelective placement in Uganda. We continuefollowing their progress on these pages.to the labour ward where the inadequate partition curtains allowed me to see the reports for the previous two months.offered no privacy; birthing partners were rarely allowed in During that period there had been 1620 births. Of thoseand the Ugandan culture seemed to promote silence during 488 (30 per cent) had been caesarean sections, there hadbirth. Pain relief is a luxury in developing countries and the been five maternal deaths and 15 still births. However, theuse of analgesia was only available to those requiring a statistics only include events that occur in the hospital, withcaesarian or other surgical procedures. This was restricted dedicated and experienced medical staff. Therefore they doto a diclofenac suppository after the procedure and a single not reflect the true obstetric statistics for the region.shot of pethidine post section. Due to financial constraints,offering analgesia to all women in labour is just not Inspiringfeasible. Therefore, entonox, pethidine, diamorphine and The most inspiring thing was the staff and the women.epidurals simply do not exist for women who have a Despite the lack of facilities and resources, the staffvaginal birth. However, the women I observed labouring remained dedicated to the health of the women and babiescoped very well and their cultural beliefs seem to enable in their care at all times. There were doctors who stayed onthem to perceive the pain differently and cope throughout duty for over 16 hours and midwives who would not leavechildbirth (International Association for the Study of Pain if the unit required them to stay. I noted an immense sense(IASP) 2011). The labour ward was quiet. Even during of support for one another and the teamwork waspainful procedures such as episiotomy (without analgesia), outstanding. I believe this heightened motivation hasdeep breathing and shallow gasps were the only noises. helped them to reach the low maternal mortality rates theyEven though I felt uncomfortable during such events, the have attained. The women showed a strength I had notstaff and women seemed to freely accept it. seen before and were tremendously proud of their infants.Emergencies These memories will stay with me forever. I hope in theThe obstetric theatre was a brand new facility but it was future I can return the kindness they bestowed on usfive-10 minutes away from the maternity unit. If surgery during our stay by fundraising for basic equipment that willwas required, transportation was an old wheelchair that help somewhat with the burden of working in anhad been heavily repaired. The foot rest consisted of string environment surrounded with financial constraints. TPMwrapped around the two front legs of the chair and, as Cara Mumby is now a newly qualified midwifemost of the wheels had been replaced by various styles andsizes of wheel, the women sat at a most peculiar angle. The Referencesporter was always on hand, but had an unenviable tasktrying to negotiate this vehicle and its passenger over IASP (2011). ‘Managing acute pain in the developing world’. IASP: Painuneven concrete, rubble paths and up and down curbs. In clinical updates, 19(3): 1-7.an emergency, this time-consuming trek could be fatal. Oneof the ward sisters explained that this was just another MDLG (2011). District size and population, Mbarara: MDLG.frustration they could not control. NHS 2013. Obstetrics and Gynaecology: UBHT Mbarara Link Programme, Despite this, the staff did a tremendous job, persevering Bristol: NHS.to ensure the women and neonates in their care survived, PRU (2011). The partnership for maternal, newborn and child health,and achieving some outstanding results. They were veryproud of the maternity unit’s statistics, and they kindly 2011. Maternal and child health: Uganda, Geneva: WHO. WHO and UNICEF (2013). Accountability for maternal, newborn and child survival: the 2013 update, Geneva: WHO. WHO, UNICEF, UNFPA et al (2010). Trends in maternal mortality: 1990- 2010, Geneva: WHO.
News analysis8 • November 2013New journal aims to meet needs of allinvolved in first 1001 daysTHE INTERNATIONAL JOURNAL of Birth more likely to be able to make a fathers through pregnancy, birth andand Parent Education is a new quarterly difference if they share their babyhood to infancy. We need to createjournal that brings together the latest experiences, generously offer their ideas a movement for change, sharing ourresearch on the critical period of to colleagues and eagerly accept knowledge, telling our stories andpregnancy and the first two years of life, collaborating – bridging the gapsand how it is applied in practice. colleagues’ ideas that may enhance between practice, systems and their own practice. evidence. A group of us started this Launched at an interdisciplinary process in the Department of Healthconference in October, the journal is ‘The importance of the foundation (DH) in the UK in 2011 with Preparingessential reading for midwives, years is now widely recognised and the for pregnancy, birth and beyond (DHperinatal educators, health visitors, journal hopes to feature papers written 2011). Now we need to reinvigorate thismaternity nurses, family nurses and by experts and practitioners from work and get moving both in the UKothers involved in parent support and around the globe. While we may live in and globally. This journal is an excitingeducation for the transition to very different societies, with varying part of the next stage.’parenthood. political structures and cultures, it remains the case that our youngest Research and developments The evidence for the importance of children, our unborn and newborn Each quarterly issue will present thethe first 1001 days of life is growing at babies, need the same essential human latest research and information aboutan exponential rate, but until now there nurturing wherever they chance to have children's development from the wombhas been no single forum for it to be been born.’ to two years of age; analyse policy inshared between health and social care parent support and education aroundprofessionals, and with parents. In a guest editorial in the inaugural the world; critique developments in issue, Kate Billingham CBE, senior universal and targeted parenting Editor-in-chief Mary Nolan says: ‘The advisor to Nurse Family Partnership support and education programmes;research, no matter how sophisticated, International, and consultant on explore teaching and learning activitieswill only help young families if those of prevention in early life, writes: ‘The for use with individual parents andus who are working in the foundation science is getting stronger all the time; groups; and debate the needs of allyears are familiar with it and then help the evidence is building and we have parents, particularly the needs ofthe mothers and fathers whom we care wonderful examples of families, parents facing social, cultural, mentalfor to apply it to their own communities and practitioners making and physical health challengescircumstances. As professionals, we a difference. Now we need coherent and alongside caring for babies and infants.must have the most up-to-date, focused policy, systems and practice forevidence-based knowledge at our supporting and guiding mothers and Themesfingertips, but we also have to share Forthcoming themes will includethat knowledge with our clients. The education and support for fathers;skills of sharing knowledge, of helping nutrition for babies and parents duringpeople to understand it, to reflect on it the critical 1001 days; support forand to apply it to their own lives are babies and mothers in abusiveevery bit as monumental as those of the relationships; education and support forresearchers who create the new mothers and fathers with learningknowledge for us in the first place.’ difficulties; advising and supporting mothers and fathers with babies whoMulti-professional approach don’t sleep; education and support forThis journal advocates a multi- mothers and fathers with alcohol andprofessional, multi-sector approach to drug misuse problems.parent education and support services.Ms Nolan says; ‘We also believe thatwell informed professionals in thestatutory and voluntary sectors are
News analysis November 2013 • 9Putting knowledge into practice Practitioner articles include: ‘Building at raising the awareness of midwives,Uniquely, each issue includes key papers the relationship between mother and health visitors and family workersfrom the leading authorities on the baby in pregnancy,’ by NCT childbirth about the huge amount of importantsubject, and then provides a and parent educator Joanna Sladden; early years work being done.practitioner account of how the and ‘Transition to parenting – balancingresearch has impacted their own the couple’s needs and expectations,’ by ‘No matter how much societypractice, or how they use it with their Northern Ireland doula and parent achieves in policy change, it is theown clients. educator, Megan Blinn. combination of sound training, wisdom, energy, optimism (and sheer dedication) Among the authors in the first issue Exciting and timely of the people at the ‘sharp end’ thatare Graham Music, consultant child and The journal has a distinguished editorial brings about actual improvements inadult psychotherapist at the Tavistock board, many of whom will be familiar the lives of very young children andand Portman NHS Foundation trust, names to UK midwives, chaired by Mary their parents.’who discusses how the fetus is affected Nolan, the UK’s first Professor ofby a mother’s state of mind; Dr perinatal education, University of ReferencesCatherine Houlston and colleagues, of Worcester.the organisation OnePlusOne, who DH (2011). Preparation for birth and beyond: aexamine the changes for the couple’s Writing in the first issue, Ita Walsh, resource pack for leaders of community groupsrelationship during the transition to director of the WAVE (Worldwide and activities, London: Crown.parenthood; and Robin Balbernie, alternatives to violence) trust, says: ‘Weclinical director of Parent Infant in WAVE are thrilled to be invited to I The International Journal of Birth andPartnerships UK, who writes about the contribute to the launch of such an Parent Education is published byimportance of early relationships. exciting and timely publication…aimed Medical Education Solutions Limited, publishers of The Practising Midwife.Midwives must confirm indemnity statusMIDWIVES HAVE UNTIL early next year a self-declaration statement that the grant of £10 million to ensure they haveto ensure that they can provide level of cover provided is sufficient to adequate litigation cover that wouldevidence that they have professional reflect the risks associated with their safeguard the profession.indemnity arrangements in place or risk individual scope of practice, so that itlosing their right to practise. covers them in the event of a successful In its response to the Department of claim for damages or compensation. Health on the proposed legislation, the The reminder comes from the This also applies to any nurse who is NMC warned that women might haveNursing and Midwifery Council (NMC) self-employed, or who works for more less choice in how they deliver theiras the deadline for the statutory than one employer. babies unless a solution can beobligation for mandatory professional identified.indemnity draws nearer. The Council For most midwives working in thesays: ‘We strongly advise midwives NHS, indemnity is provided The NMC said: ‘Self employedensure they have in place an automatically by the employer, but the midwives have sought indemnity coverappropriate indemnity arrangement UK’s 170 independent midwives have from the commercial insurance marketthat covers all aspects of their found it all but impossible to secure but, partly because of their selfpractice now, and not wait until early cover. employed status and partly due to the2014.’ prevailing legal system in relation to Independent Midwives UK (IMUK) clinical negligence claims in matters of EU legislation has now come into has been in negotiation with an childbirth, commercial insurers haveforce that makes it mandatory for all insurance provider but needs £72,000 continued to refuse to offer affordablehealthcare professionals to have to launch a product that would allow cover. We strongly encourage theprofessional indemnity – but the midwives to ‘stay legal’. According to Department to explore all possiblelegislation has to be adopted in the UK, the Daily Telegraph, so far the options for this group of midwives, as itand is currently being finalised. organisation has raised £70,000 to set would be an unfortunate by-product of up an insurance product to allow them the legislation if the choices available to From early next year, when midwives to practise, and they have asked the women through the pregnancycome to register or renew their Department of Health for a one-off pathway were lessened.’registration, they will need to complete
News analysis10 • November 2013NMC claims ‘substantial progress’THE NURSING AND MIDWIFERY Council has met are: Figure 1 Categories of referral to the(NMC) says it has made substantial NMCprogress in addressing recommendations •80 per cent of investigations are nowby the Professional Standards Authority conducted in house; Fraudulent entry to register(PSA) to put its house in order. <1% •80 per cent of interim orders are now made within 28 days, in order Police Determination investigation by anotherIn its annual Fitness to practise report, to protect patients while a case is <1% body, eg, Irish Nursing Boardthe NMC says there are ‘welcome signs’ investigated; Health <1%that changes it has made as a result of 3%the PSA’s criticisms are starting to have •a new hearing centre has been opened at the Old Bailey, almostan effect. trebling the capacity to conductIn order to improve its performance, hearings. Criminal 16%the NMC has increased the number of In the previous year, only 42 per cent of Lack ofspecially trained investigation officers cases were dealt with within 12 months; competencethat it employs, and has also recruited the NMC’s current target is to complete 17%175 new panel members to hear cases, 90 per cent of investigations within 12 Misconduct 62%but it anticipates that it will take until months – their actual performance was2016 to fully address all the just short of that, at approximately 85recommendations made by the PSA to per cent, with the average time toimprove delivery of its core regulatory complete an investigation of 11 months.functions. However, among the targets it In 2012-2013 around 4,042 cases were referred to theAcupuncture & therapies supplies NMC, which register, 243 were suspended, 160 hadwww.harmonymedical.com represents 0.6 per conditions imposed on their practice and cent of registered 163 received a caution. nurses and The biggest single source of new referrals to the NMC was the nurse or midwives. Of these, midwife’s employer (41 per cent), followed by 25 per cent from a member 863 interim orders of the public or patient and 12 per cent from the police. Six per cent of cases were made to were self-referred. A breakdown of the nature of referrals is shown in Figure 1. restrict or suspend However, the NMC stresses that only registration a minority of nurses and midwives ever come to its attention: ‘Of the 673,567 pending the registered with us (as of 31 MarchMoxibustion for breech outcome of the 2013) [only] around 0.6 per cent came case. More than to our attention because there was a concern about them. An even smallerpresentation 1,500 cases were proportion – 0.2 per cent – received closed on initial some sort of sanction followingModern technology meets traditional practice assessment investigation by us. This means that the vast majority of nurses and midwivest4BGFFòFDUJWFBOEQMFBTBOUNPYJCVTUJPO (screening) and practise safely, and consistently meet the high standards that the publict/PTNPLFOPBTIOPPEPVS 2,015 were sent to rightly expects,’ the report states.t*OTUBOUUSFBUNFOU the Conduct andt$&NBSL Competence5IFQSPGFTTJPOBMTDIPJDFPGBDVQVODUVSFBOENPYJCVTUJPO Committee. ATVQQMJFSCVZFSTHVJEFBWBJMBCMFPOSFRVFTU further 150 cases were referred toHarmony Medical the Health629 High Road Leytonstone Committee. InLondon E11 4PA total, 589 nurses orTel—+44(0)20 8518 7337 midwives [email protected] struck off the
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12 • Haemorrhage after home birth November 2013 • THE PRACTISING MIDWIFEHaemorrhage after home birth:audit of decision making and referralSUMMARY In the Netherlands, 20 per cent of women give SSC factors were determined and assigned incidental, minorbirth at home. In 0.7 per cent, referral to secondary care and major substandard care.because of postpartum haemorrhage (PPH) is indicated.Midwives are regularly trained in managing obstetric Keywords Audit, home birth, postpartum haemorrhage, theemergencies. A postgraduate training programme Netherlandsdeveloped for Dutch community-based midwives called‘CAVE’ (pre-hospital obstetric emergency course) focuses on Authors Marrit Smit, Midwife Researcher at Leidenthe identification and management of obstetric emergencies, University Medical Centre, Anneke Dijkman, Obstetrician atincluding timely and adequate referral to hospital. Reinier de Graaf Groep, Marlies Rijnders, Midwife Researcher at TNO research organisation, Jacqueline Bustraan,This descriptive study aims to identify substandard care Educational Expert at PLATO Faculty of Social and(SSC) in PPH after home birth in the Netherlands. Sixty Behavioural Sciences, University of Leiden, Jeroen van Dillen,seven cases of PPH reported by community-based midwives Obstetrician at University Medical Centre, St Radboud,were collected. After applying selection criteria, seven cases Johanna Middeldorp, Obstetrician at Leiden Universitywere submitted to audit. The audit panel consisted of 12 Medical Centre, Barbara Havenith, Obstetrician and directormidwives (of which seven contributed a case), 10 of an obstetric emergency training company, Boxmeer andobstetricians, an educational expert and an ambulance Jos van Roosmalen, Obstetrician and Professor inparamedic. First, an individual assessment was performed International Safe Motherhood at Leiden University Medicalby all members. Subsequently, at a plenary audit meeting, Centre and EMGO Institute CentreIn the first of a two-part article, Marrit Smit et al outline the background and methodsused in examining haemorrhage after home birth in the NetherlandsIntroduction Virtually all pregnant postpartum haemorrhage (PPH),Virtually all pregnant women in the women in the retained placenta or need for transferNetherlands have midwifery care at Netherlands have of the newborn to a neonatologistsome point during pregnancy, birth or midwifery care at some (Amelink-Verburg et al 2008). In 2008,the puerperal period. Of the 2,444 point during of all intra-partum referrals of womenregistered midwives in the Netherlands, pregnancy, birth or the under the care of a community-based77 per cent are working in a puerperal period midwife, 0.7 per cent were because ofcommunity-based primary care facility. PPH and 0.9 per cent because ofAnother 23 per cent work in hospitals, approximately 32 per cent. If referral is retained placenta (Stichting Perinataleunder the supervision of obstetricians, indicated, however, only 3-5 per cent Registratie Nederland (SPRN) 2008).where they provide care for medium are urgent, such as for fetal distress, A recent review has shown an increaseand high risk pregnancies and births in PPH in industrialised countries(Hingstman and Kenens 2009). (Knight et al 2009); it is unclear whether this rise can also be seen in In 2008, 20.9 per cent (n=37,078) of low risk births. A nationwide study intoall children in the Netherlands were severe maternal morbidity in theborn at home, supervised by a Netherlands identified major obstetriccommunity-based midwife. The referral haemorrhage (defined as a need forto secondary care rate during birth is
THE PRACTISING MIDWIFE • November 2013 Haemorrhage after home birth • 13transfusion of four or more units and/or As students, midwives evaluating care provision which often Membolisation or hysterectomy) in 1.6 are taught to start leads to constructive discussion withinper 1000 home births compared to 6.1 intravenous access at a medical team on policy and quality ofper 1000 hospital births (Zwart et al home for stable care (van Dillen et al 2008; 2010).2008). transport to hospital The aim of this study was to audit In case of an obstetric emergency adequate referral to hospital (Havenith cases of PPH after home birth in orderafter home birth, community-based and van der Ploeg 2010). Although this to identify SSC. And, if SSC factors aremidwives require skills to adequately programme is not mandatory for present, lessons for improvement canmanage these complications and licence renewal, over 90 per cent of all be drawn and used in guidelineprovide optimal care. As students, community-based midwives have development.midwives are taught to start intravenous attended (www.hotabc.nl, in Dutch).access at home for stable transport to Although rare and unexpected in low Methodshospital. Due to the low prevalence of risk pregnancies, PPH is a serious Ethical approval was not required; allsuch emergencies, these skills should be complication of childbirth, which can cases were anonymously provided andregularly updated and taught repeatedly have immense consequences directly not accessible for the researchers or(Draycott et al 2006). At present no for the mother and for her future in panel members (except for the midwifeguideline exists in primary midwifery childbearing. Studies have shown that presenting the case).care for the management of PPH after substandard care (SSC) can be identifiedhome birth in the Netherlands. A through audit, an effective method of Participants and data collectionpostgraduate pre-hospital obstetric All community-based midwives (n=366)emergency course (‘CAVE’) specifically who registered for the ‘CAVE’ coursedeveloped for Dutch community-based were asked to participate in this study.midwives, focuses on the identification From April 2008-April 2009, participantsof obstetric emergencies and their were asked to report the followingmanagement, including timely and obstetric emergencies to the researchers
14 • Haemorrhage after home birth November 2013 • THE PRACTISING MIDWIFEupon finishing the course: PPH (> 1000 e-mail linked to a password secured outcome. Anonymous medical files,mL blood loss, estimated or weighted), internet site. When obstetric emergencies discharge letters and laboratory resultsincluding retained placenta, shoulder were reported, participants were asked were requested. If data weredystocia, prolapsed umbilical cord, to fill out a detailed case registration incomplete or inconclusive, theunexpected breech birth, (pre) eclampsia form (CRF) containing information on participants were contacted for missingand resuscitation of the newborn or received care during pregnancy and documents to be completed.mother. Participants received a monthly birth and maternal and neonatal Previous to the audit, selectionTable 1 Substandard care scoring items as used in the audit form and their criteria were determined by the studycontribution concerning general care and specific management of PPH after the group containing the authors. Cases of PPH were eligible for audit if: PPHindividual audit. occurred after home birth under care of a community-based midwife; referral toGeneral care scoring items n per cent hospital by ambulance was necessary; complete documentation of the casePatient 23 7.5 was available; and if the community based midwife was able to attend thePatient delay consulting doctor/midwife 13 4.2 audit meeting.Refusal of medical help or advice 10 3.3 Methods of audit The audit panel consisted of 12Midwife 108 35.3 midwives, 10 obstetricians, an educational expert and an ambulanceInadequate risk selection 25 8.2 paramedic. Of the 12 midwives, sevenInadequate antenatal care 12 3.9 were working in the community andDelay in recognition of symptoms/signs 27 8.8 they all contributed a case for the audit.Delay in referral to obstetrician 44 14.3 Almost all panel members work daily inObstetrician 13 4.2 obstetric care and some actively participate in (perinatal) audits andInadequate risk selection 3 0.9 guideline development.Delay in recognition of symptoms/signs 2 0.7Delay in treatment after diagnosis 8 2.6 Substandard care factors have beenHealthcare system 162 52.9 previously described and successfully applied in cases of maternal morbidityHomebirth influenced outcome 60 19.6 and mortality (van Diem et al 2010; vanMedical assistance arranged too late 44 14.3 Dillen et al 2008; van Dillen et al 2010;Quality of transport influenced outcome 32 10.4 Schutte et al 2008; Zwart et al 2008).Ambulance was not present within acceptable time 26 8.5 The scoring system suitable for thisTotal 306 100 audit on PPH was developed by consulting various sources; nationalSpecific management of PPH scoring items n per cent guidelines for PPH in secondaryOxytocin was not administered according to guidelines 56 10.5 obstetric care and obstetric emergencyNo uterine massage was administered 17 3.2 course manuals were scrutinised inInadequate maternal monitoring (pulse, blood pressure) 52 9.7 order to establish a list of factorsNo oxygen was administered by midwife 91 17 contributing to care in case of PPH afterNo oxygen was administered by gynaecologist 42 7.8 home birth (Dutch society of obstetricsNone or too late bladder catheterisation 44 8.2 and gynaecology (NVOG) 2006;Inadequate stabilisation of patient for transport 15 2.8 Havenith and van der Ploeg 2010;No intravenous line was started by midwife/GP 87 16.2 Johanson 2003). A list of 32 items wasIntravenous line was started too late overall 45 8.4 established, divided into two sections:No volume replacement was started by midwife 46 8.6 general care and specific care in case ofSuboptimal treatment of PPH according to guidelines 41 7.6 PPH (see Table 1).Total 536 100 Each panel member was asked to perform an individual assessment of
THE PRACTISING MIDWIFE • November 2013 Haemorrhage after home birth • 15medical records of all cases (individual Panel members a descriptive study’. Brit Jour Obs Gyn (BJOG),audit) before the plenary audit meeting. 115: 570-578. assessed whether SSC Draycott T, Sibanda T, Owen L et al (2006). ‘Does Panel members assessed whether training in obstetric emergencies improverisk selection prior to the decision to factors had been neonatal outcome?’ BJOG, 113: 177-182.give birth at home had been Havenith B and van der Ploeg J (2010). CAVE:appropriate and whether SSC factors present during Pre-hospital obstetric emergency coursehad been present during pregnancy and syllabus (in Dutch), Netherlands: Boxmeer.birth at the level of the patient, the care pregnancy and birth Hingstman L and Kenens (2009). Cijfers uit deprovider or the healthcare system (see registratie van verloskundigen: peiling 2008Table 1). Care was considered 2003). The grading system consisted of (in Dutch), Utrecht: NIVEL.substandard if it deviated from national three levels of SSC: incidental: lessons Johanson R and Cox C (2003). MOET courseguidelines or, in the absence of can be learned from the case, but a manual, London: RCOG Press.guidelines, if care deviated from best different policy would not have Knight M, Callaghan W, Berg C et al (2009).available evidence or expert opinion. changed the outcome; minor: different ‘Trends in postpartum hemorrhage in highAdditional SSC items concerning care would probably have led to a resource countries: a review andspecific management of PPH, referral better outcome; and major: different recommendations from the Internationaland transport to hospital were also care would definitely have given a Postpartum Hemorrhage Collaborativescored. Panel members were required to better outcome. Consensus was Group’. BMC Pregnancy Childbirth, 9: 55.send the audit forms back by post prior reached if the majority of the panel NVOG (2006). Guideline: Haemorrhagia Postto the plenary meeting, and the forms (>50 per cent of the members) classified Partum (2006). Available at: http://nvog-were analysed by calculating the the care as substandard. documenten.nl/index.php?pagina=/site/paginumber of SSC factors per scoring item na.php&id=54321.(see Table 1). For example, when the I Next time Richardus J, Graafmans W, Verloove-Vanhorick Sitem ‘Inadequate risk selection’ has a Part 1 has outlined the background and et al (2003). ‘Differences in perinatalhigh score, it indicates that a majority methods of this audit. In Part 2 we shall mortality and suboptimal care between 10of assessors judged that SSC was present the results of the audit and European regions: results of an internationalprovided on this item, in this particular discuss the findings. TPM audit’. BJOG, 110(2): 97-105.case. The maximum score for SSC was Schutte J, Schuitemaker N, van Roosmalen J et alcalculated using number of assessors x Marrit Smit is a midwife researcher at (2008). ‘Substandard care in maternalnumber of cases x 32 scoring items: 24 Leiden University Medical Centre, Anneke mortality due to hypertensive disease inx 7 x 32 = 5,376 items. Dijkman is an obstetrician at Reinier de pregnancy in the Netherlands’. BJOG, 115: Graaf Groep, Marlies Rijnders is a midwife 732-736. During the plenary audit meeting, all researcher at TNO research organisation, SPRN (2008). Perinatal care in the Netherlandscases were discussed. The community- Jacqueline Bustraan is an educational (in Dutch). Utrecht: SPRN.based midwives who submitted the expert at PLATO Faculty of Social and van Diem M, de Reu P, Eskes M et al (2010).cases supplied background and Behavioural Sciences, University of Leiden, ‘National perinatal audit, a feasible initiativeadditional information, when necessary. Jeroen van Dillen is an obstetrician at for the Netherlands!? A validation study’. ActaThe ambulance paramedic could supply University Medical Centre, St Radboud, Obstet Gyn Scand, 89(9): 1168-1173.the panel with background and /or Johanna Middeldorp is an obstetrician at van Dillen J, Lim F and van Rijssel E (2008).contextual information on the Leiden University Medical Centre, Barbara ‘Introducing caesarean section audit in aresponsibilities and procedures during Havenith is an obstetrician and director of regional teaching hospital in Thetransfer to hospital. After discussion, an obstetric emergency training company Netherlands’. Eur Jour Obs Gyn Reprod Biol,panel members re-assessed the case for in Boxmeer and Jos van Roosmalen is an 139(2): 151-156.SSC using the same audit form and obstetrician and professor in International van Dillen J, Mesman J, Zwart J et al (2010).were requested to rate each case Safe Motherhood at Leiden University ‘Introducing maternal morbidity audit in theindividually and anonymously in order Medical Centre and EMGO Institute Centre Netherlands’. BJOG, 117: 416-421.to assure an objective judgement. Zwart J, Richters J, Ory F et al (2008). ‘Severe References maternal morbidity during pregnancy, Finally, at the plenary session, panel delivery and puerperium in the Netherlands:members were asked to make a Amelink-Verburg M, Verloove-Vanhorick S, a nationwide population-based study ofclassification of SSC, a grading system Hakkenberg R et al (2008). ‘Evaluation of 371,000 pregnancies’. BJOG, 115: 842-850.derived from the Confidential enquiry 280,000 cases in Dutch midwifery practices:into stillbirths and deaths in Infancy andapplied in other audits (Richardus et al
16 • A student midwife in Gambia November 2013 • THE PRACTISING MIDWIFEAdvancing to basics: a studentmidwife in GambiaFollowing her two-week SUMMARY As a student midwife I wanted to experience the delivery ofexchange visit to Gambia, midwifery care in a setting that was completely different from what I wasCatrin Elis considers the used to, and had the opportunity to join a team of 10 medical students on abenefits that can be gained two-week exchange visit to Gambia as part of the Swansea–Gambia link.from developing aninternational perspective I worked on the maternity unit at the Royal Victoria Teaching Hospital (RVTH) in the capital city, Banjul, the national referral centre for Gambia. The Swansea-Gambia link was formed from ‘Wales for Africa Health links’ – a unique response, from Wales, to the United Nations Millennium Development Goals (United Nations Development Plan (UNDP) 2009). I am thrilled that my involvement with the link has now established the opportunity for two Swansea midwifery students to visit Gambia each year as an elective placement. Keywords Student midwife, elective, Gambia, international placement Author Catrin Haf Elis, 3rd year student midwife at Swansea UniversityBackground It is their practice not to trained staff, but also because I had MGambia is a small country on the West inform women of a returned with a changed perspective.African coast; it has a mainly rural fetal death as it wouldpopulation of around 1.8 million. It is interrupt the progress Communicationstill recovering from the effects of a civil of labour On my first day in the Gambia I waswar during the 1990s. The maternal warmly welcomed by the midwife onmortality rate is 360 per 100,000 births benefit, as well as being beneficial to duty who orientated me to the maternityand the infant mortality rate, 49 per the institutions involved in exchange ward. Her thorough explanation of the1000 births (World Health Organization schemes. As a midwifery spokesperson, way things worked at Banjul gave me a(WHO) 2010). This compares with 4.7 I now hope to encourage other student true insight into the life of a midwifeper 100,000 maternal deaths (Centre midwives to be involved in a Swansea– there, and what challenges the womenfor Maternal and Child Enquiries Gambia exchange programme. face in labour. Around 14 to 20 women(CMACE) 2011) and an infant mortality are admitted each day to the eight-rate of 4.1 per 1000 live births in the UK After my return from Gambia to bedded ward. It is usual for there to be(Office for National Statistics (ONS) 2011). Swansea it was difficult not to embrace only one midwife on duty on each shift, the first midwife I met! Not only accompanied by a couple of medical Midwifery benefits from its because I was glad to be back in a well- students. Communication is a majorinvolvement in international health resourced environment, with highly challenge; Gambia is a tribal country(Chief Nursing Officers of England, with over 10 main languages. Most ofNorthern Ireland, Scotland and Wales the Gambian midwives can speak, or at(CNOs) 2010) and I believe that, as a least understand, two or three of thesestudent, developing an international languages, but barriers inperspective can be of great personal
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18 • A student midwife in Gambia November 2013 • THE PRACTISING MIDWIFEThere are only twofunctioning powerpoints so priority mustbe given to theelectrical item which isthe most important atthe timecommunication occur frequently. Royal Victoria Teaching Hospital minute and was making no respiratory Woman-centred care is our mantra in effort. Inflation breaths proved and looked so white. I’d been told that unsuccessful as the mask was far toothe UK. Midwives collaborate with she was aware her baby had died, yet big. Shouting for Momodou to comewomen so that they have informed clearly this was not the case. I was later back I showed her how to perform achoice (Nursing and Midwifery Council told that it is their practice not to double-handed jaw thrust so that I(NMC) 2008). Women in Gambia, inform women of a fetal death as it could repeat the inflation breaths andhowever, are often not talked to by would interrupt the progress of labour. maintain a seal around the baby’s nosehealth professionals at all, and the and mouth. The baby responded with aprinciples that we consider Neonatal resuscitation rising heart rate. As I was drying andfundamental in the UK play little or no In the Royal Victoria Teaching Hospital stimulating this baby, Momodoupart in the midwifery role. It was also (RVTH) there are no paediatricians or returned from theatre with the othernoticeable that the Gambian women neonatal nurses on the labour ward and twin who also needed resuscitation.did not appear to express their feelings. resuscitation facilities are limited. There Both babies were persistently ‘floppy’I gathered that they are brought up to is one resuscitaire, on which only the and pale and required oxygen followingbe strong and resilient – and this is no heater works properly, an adult-sized resuscitation. “They need to get used toless true in labour. Even as they face bag-valve-mask, a suction machine and sharing from an early age”, I thought, asdeath, they express little emotion. one oxygen machine. There is only one I rotated the oxygen supply between set of adult-sized nasal prongs to them! Soon afterwards I heard my One woman stands out in my mind. deliver oxygen, and the catheter used name being called – another birth hadShe had suffered a placental abruption on the suction machine is rarely taken place. This time the baby’s skinand had been diagnosed as having had changed, as it is considered more cost was tinged green and there was evidencean intrauterine death at term. She was effective to use the catheters for the of thick meconium in the baby’s mouth.in a poor condition; she was labouring women themselves. There are only two He needed oral suction to reduce thealone, but was disorientated, hypo- functioning power points so priority potential for meconium aspiration and,perfused, cold to touch, hypotensive must be given to the electrical item as the twins seemed to be coping byand tachycardic. She had been which is the most important at the now, I could discontinue their oxygen incommenced on oxytocics, but no fluid time – a distressing decision to make order that the suction machine could beresuscitation had been given. I gave her where there might be two or more plugged in and used instead.a sheet to provide some warmth and babies requiring assistance.pushed through some fluids. She The process of drying and gentlydelivered her baby well but, as we On one of my labour ward shifts, stimulating the newborn after birth isexpected, he had no signs of life. I dried *Momodou, a theatre porter, brought part of routine care in the UK (Newbornand wrapped him and wanted her to the first of a set of twins born by Life Support 2006). In Gambia, babiessee him before he was placed with the caesarean section at around 33 weeks who make no respiratory effort at birthother babies who had died. She told the gestation to the resuscitaire. The first are neither dried nor stimulated but leftmidwife she would like to see him, but baby had very poor tone and colour, hadas I showed her her baby, I was stunned a heart rate of about 60 beats perwhen she asked why he wasn’t moving
THE PRACTISING MIDWIFE • November 2013 A student midwife in Gambia • 19on the bed until they take - or don’t - They were keen to of the poorest citizens being deliveredtheir first breath. I shall never again by a skilled birth attendant comparedunderestimate the difference these learn, enjoyed the to 90 per cent of those richer.basic, yet essential interventions canmake – I thought perhaps even computer lessons and One of the main aims of antenatalreducing the 70 deaths per month. care in the UK is to identify those for they did find the whom additional care is necessaryAntenatal care (National Institute for Health and CareBeing on the labour ward enabled me information, which was Excellence (NICE) (2008). Appropriateto see the effect of a lack of antenatal management of hypertension, forcare and education on a woman’s pleasing example, starts with the initialexperience of childbirth. Maternal identification of a raised blood pressuremortality rates are high, yet the causes check with a referral to the RVTH if reading. I came to appreciate fully thatare often secondary to complications necessary, although subsequent early observations like these, that maysuch as hypertension, grandmultiparity management is limited, in part due to seem mundane, are fundamental to theand sepsis – conditions which can be the lack of ultrasound scanning best outcomes for mother and baby.relatively easily diagnosed and facilities and appropriate treatments.monitored during the antenatal period. ConclusionWomen died from pulmonary It was inspiring to be able to spend It was a privilege to have been able toembolism, placental abruption, even time with a health centre midwife who do this elective placement and I amstatus epilepticus; blood pressure is not was clearly passionate about women’s grateful for the opportunity I had tooften measured during pregnancy. health and wellbeing. On the wall of challenge my thinking, question my her clinic were posters advertising MDG practice and redefine my own personal Some antenatal care in Gambia is goal 5 and the Safe Motherhood standards of care.provided by health centres located Strategy. She explained how she hadthroughout the country, and taken it upon herself to go into the Experiencing maternity care infortunately I was able to spend a day at more rural areas and provide teaching Gambia has helped me appreciate howone of these clinics. Often the women to the traditional birth attendants. She important attention to the ‘basics’ is tofind it difficult to attend due to explained that these carers are hungry a mother’s wellbeing during pregnancytransport difficulties, the cost of the for knowledge and grateful for the and beyond. TPMservice (the equivalent of £2 per visit), teaching she gives. The socioeconomic Catrin Elis is a 3rd year student midwife atthe distance from their homes, and the inequalities within the country were Swansea Universitypracticalities of having many other most starkly demonstrated in the areachildren to care for. If women are able of maternity care with just 20 per cent *names have been changed to protectto attend they will have a full antenatal confidentialityThe team: proudly sporting the newest (and brightest) additions to our wardrobes References CMACE. (2011). Saving mothers’ lives: reviewing maternal deaths to make motherhood safer: 2006-2008, London: CMACE. CNOs (2010). Midwifery 2020: delivering expectations, London: Department of Health. NICE (2008). Antenatal care: routine care for the healthy pregnant woman, London: NICE. NMC (2008). The code: standards of conduct, performance and ethics for nurses and midwives, London: NMC. ONS (2013). Childhood, infant and perinatal mortality in England and Wales. 2011, London: ONS. UNDP (2009). The millennium development goals report, New York: United Nations Department of Economic and Social Affairs. WHO (2010). Maternal and infant mortality in 1990–2010, Gambia, Geneva: WHO.
20 • Midwifery in Somaliland November 2013 • THE PRACTISING MIDWIFEMidwifery in SomalilandMargaret Crichton describes the SUMMARY During the civil war in Somaliland (1982-1991),challenges of setting up a BSc health facilities were devastated and many healthcare workersmidwifery programme for nurses were killed or became refugees. Since then the country hasand midwives in Hargeisa, struggled to rebuild hospitals and health centres and increaseSomaliland the number of healthcare professionals. Many non government officers from a variety of countries are assisting throughout the country. In 2011 I accepted a post establishing the first BSc in midwifery in Hargeisa, the capital of Somaliland. I was employed by Tropical Health Education Trust (THET) in conjunction with Edna Adan University hospital. The students were to be nurse- midwives; the hope was that they would go on to become the movers and shakers in Somaliland. Little did I know how big the challenge would be. Keywords Somaliland, midwifery degree, challenges in teaching Author Margaret Crichton, BSc lead tutor at the Edna Adan Hospital in HargeisaI arrived in Somaliland’s capital I had worked in East Somaliland is located in the Horn of M city, Hargeisa, to set up a BSc Africa some years Africa, south of the Sahara, and you Midwifery programme for previously, but this was know you are living in a semi desert qualified nurses and midwives. very different from because of the heat and the dust.The work would take 18–20 months anything I’dand I was to live in the Edna Adan experienced before The hospital has electricity andUniversity Hospital, a non profit running water but the latter has to becharitable hospital that educated Edna helped me settle into a very bought, at great cost, and transferred anurses, midwives, pharmacists and new and different cultural considerable distance by tanker.laboratory technicians. environment. I had worked in East Medicines have to be purchased from a Africa some years previously, but this local pharmacy in the city and sold atBackground was very different from anything I’d the hospital. Charitable organisationsEdna Adan Ismail is the owner and experienced before. in places around the world supply adirector of the hospital, which she paid variety of medicines, dressings,for and built in one of the poorest parts instruments and sometimes largerof the city between 1998 and 2002, pieces of equipment, such as beds andonly ten years after the country had infant resuscitation equipment.been decimated by a bloody civil warending in 1991 (Ali et al 2008). During The hospital has fairly regular visitsthat time Hargeisa had been razed to from doctors, with special skills, fromthe ground, as were some other cities. various countries, who come and do a series of essential operations that the families could not normally afford, such
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22 • Midwifery in Somaliland November 2013 • THE PRACTISING MIDWIFEClockwise, from top left: Antenatal clinic; Student giving health education session; Students preparing for taping research;Edna Adan University Hospitalas repair of vesico-vaginal fistula, repair Charitable have midwifery knowledge, they couldof cleft palate and hare lip or insertion organisations in places not always express it well: English wasof valves to correct hydrocephalus, to around the world a problem for many; very few had thename but a few. supply a variety of use of a laptop or computer; and no- medicines, dressings, one had read an abstract in research Somaliland is a poor country, with instruments and before. These difficulties were what hadmany people unemployed and a great sometimes larger to be managed first: the English classesdeal of poverty. The greatest problem pieces of equipment were increased and computer lessonsfor the current government is to make were started with the intention ofsure the people have a water supply, programme in Hargeisa, as the students eventually introducing how to find awhich will be difficult and expensive would have knowledge of midwifery, relevant article and then how to obtainwithout some help. If the country could which could be built on and expanded. I and read an abstract.be recognised as an independent state, was particularly looking forward towhich is stable and peaceful, it would teaching research. The curriculum had to be modified ashelp job availability. the demands were out of students’ However, though the students did reach in the first instance. This was theDeveloping the course first time such a programme had beenThe first term of the BSc was difficult. I taught in Somaliland and thereforehad come from a background of modifications were to be expected. Theteaching a top-up degree (eighteen end product was to be a 6000 wordmonths) and also teaching the new dissertation and an introduction tothree year programme for students many aspects of management, teachingentering straight from school. I had and learning, critical incident analysisoriginally felt very confident about and many others. In short it was ateaching the eighteen months power-packed programme that was
THE PRACTISING MIDWIFE • November 2013 Midwifery in Somaliland • 23going to be very difficult for the They were keen to managers who visit. Some of the thingsstudents and their tutor. learn, enjoyed the I have asked for were not in the original computer lessons and budget, but they have somehow found The course was divided into three they did find the me what I have needed.terms of 22-23 weeks each, comprising information, which was400 hours per term in the evenings. pleasing ChallengingStudents had to work and study at the This was a very hard and challengingsame time, and daily prayers, special After a great deal of practice, question project and it continued to be so. I knewholidays and Ramadan had to be taken testing, consent form signing and that the next few months were going tointo consideration. verbal permission to tape by each be very difficult indeed, as the students participant, the students were very tried to make sense of their research As most knowledge is gained involved out in the clinical area and and write up their findings. Once thegradually and built on in a systematic reporting back to class at regular dissertations were written up, weway, I decided to divide the dissertation intervals every week. would know more about how peopleinto three and ask for a 2000 word felt about a variety of topics inessay at the end of each term so that by Transcribing from Somali to English Hargeisa, the students would be morethe end of the course we could put all was a problem and delayed the time knowledgeable and they would bethree together to form the end product. schedule somewhat. Fortunately THET research aware. It was to give them aTopics were negotiated and an was very supportive, both personally new impetus to continue to exploreintroduction to the topic would be the and financially and, as a result, I was their profession and make it better andfirst part of the work. These turned out able to put together a panel of people stronger than it before, because it isto be very short as the students had not who could translate and validate the research based. At that early stage, theywritten essays in English before. I asked findings. were asking about what they wouldthem to write about their country and look at next. If I’d needed any otherthe terrible civil war that had occurred, Support reason to keep going it would be in theas all of them were very proud of their Now that we are in the third term of knowledge that I opened a few mindsheritage and the changes that had the degree, the students are busy with just so they can make things better fortaken place in the country since the war. the research topics, and help has been themselves and the women andWhilst some of the women had been given to each one of them during children in their care.very young during the war, most had English and computer classes, twice anot yet been born. This proved week. Since writing this article, of the 31problematic, but they managed to do it, students who began the course, 21with a great deal of help from the I have had support from a variety of have graduated.Internet. They were keen to learn, different sources: Edna visits regularlyenjoyed the computer lessons and they to make sure the students are working The graduation ceremony wasdid manage to find the information, hard; my programme organiser is a fine attended by the Somaliland Presidentwhich was pleasing. They came to young man who keeps a tight ship for and his wife, the First Lady, whorealise that plagiarism was not me and is well qualified in nursing and presented the graduation certificates.acceptable in a degree, particularly not teaching; and my support teacher has athe BSc in Midwifery. great deal of knowledge of Somaliland Despite the huge challenges faced and Ethiopia, having spent most of her during the experience, I am contentThe inaugural course life teaching midwifery in both places. that the midwives are now able toThe course began with 31 students in conduct research and implement bestthe first term, although we lost six on I am lucky enough to have made practice to improve lives in Somaliland.the way, as some found it too difficult, some very good friends, who have TPMand four more did not pass the end of helped me when I have needed it, and Ifirst term examination. Twenty one do have constant support from THET Margaret Crichton is BSc lead tutor at thecommenced term two and were Edna Adan Hospital in Hargeisaintroduced to research in practice,which involved using tape recorders to Referencesrecord pre-arranged questions and playthem back in class. The students Ali MO, Mohammed K and Walls M (2008).enjoyed this and I felt that the whole Peace in Somaliland: an indigenous approachthing was beginning to take shape. to state-building, Hargeisa: Academy of Peace and Development.
24 • Maternity care in Nepal November 2013 • THE PRACTISING MIDWIFEMidwifery and maternitycare in Nepal: the vital linkEdwin van Teijlingen, Bibha SUMMARY Nepal is one of the poorest countries of the world and itsSimkhada and Padam people suffer from many health problems associated with poverty.Simkhada support improved Maternity care is underdeveloped, women do not always seek maternitymaternity care in Nepal care or the help of a skilled birth attendant, even if the service is available. One key underlying problem is that Nepal lacks proper midwifery, as defined by international standards. There have been some very positive developments towards recognition of the distinct skills required for midwifery. In this paper, we describe a maternal health promotion intervention funded by a London-based Buddhist organisation. The intervention is community-based and works with women’s groups in rural areas. Keywords Low-income country, poverty, South Asia, development, politics, family, decision-making Authors Edwin van Teijlingen, Professor in the centre for midwifery, maternal and perinatal health at Bournemouth University, Bibha Simkhada, Chair of a maternal and child healthcare charity and Padam Simkhada, senior lecturer in the School of Health and Related Research at the University of SheffieldIntroduction Seeking maternity care that the decision to attend antenatal MNepal has many of the characteristics We know many factors can affect the care was often not the woman’s toof a developing country such as a young decision to seek maternity care; some take, but was a family decision heavilypopulation, fairly low literacy rates are barriers and others, facilitators. In influenced by her mother-in-law.(especially amongst older people and Nepal we see individual factors such aswomen) and high maternal mortality women’s age or education level or their In rural Nepal young womenrates. Many pregnant women do not perceptions of the maternity care generally have low status and theirreceive appropriate antenatal care and available. There are also more societal mobility outside the house or their owntwo-thirds of Nepali women give birth or cultural influences, such as the community can be limited. They have towithout a skilled birth attendant perceptions and values of a woman’s work hard inside and outside the home.(Ministry of Health and Population family and women’s place in society. Some mothers-in-law had a positive(MOHP) et al 2012). Such low usage of Geography plays a role, especially influence, encouraging women to goexisting maternity services contributes distance to health posts, and it affects for antenatal care. More often theyto the relatively high maternal the quality of the health services discouraged them. Several mothers-in-mortality in Nepal. available and travel costs. law interviewed by Bibha had not used antenatal care when they were Apart from problems associated with Bibha Simkhada explored opportunities pregnant years ago and they did notlow income, Nepal is beginning to and barriers to antenatal care uptake in see any benefit to it. Often theyexperience some of those we face in her PhD thesis (Simkhada et al 2010). regarded pregnancy and birth asthe UK, such as the effects of feeding She conducted interviews with new normal events in a woman’s life cycleinfants with formula and rising rates of mothers, their mothers-in-law and that do not need any antenatal care orcaesarean section births (CS). husbands in rural Nepal. Bibha found check-ups unless something is wrong.
THE PRACTISING MIDWIFE • November 2013 25
26 • Maternity care in Nepal November 2013 • THE PRACTISING MIDWIFEAlso they thought their daughters-in- and maternity care providers, the aim is women in the group. For example, adlaw were too busy in the house or the to improve the quality of their services hoc issues have included domesticfields and could not spare the time to in existing health facilities. There is violence and ideas for incomewalk to a health post or the money for little point in improving services if generation for local women.public transport. Some who had perhaps women are unable to access them dueconsidered sending their daughters-in- to cultural and psychosocial barriers. Midwifery in Nepallaw for antenatal care perceived the The programme aims to improve access Many of the maternity problems listedavailable services to be of poor quality. by addressing both these areas. One key above could be alleviated or even intervention has been the setting up avoided if Nepal had professionalWoman-centred intervention and running of women’s groups in the midwives. Nepal is one of the countriesInternational organisations, the community. Some consist of women of which has not yet reached theGovernment of Nepal and many childbearing age and others of professional standard for midwives setdevelopment organisations have been mothers-in-law. The charity recognised by the International Confederation oftrying to improve maternity care and its that improving antenatal care uptake Midwives (ICM) (Bogren et al 2013).uptake. One of these development requires cultural and attitude changes. Midwifery education is one of the keyorganisations is a UK charity for In order to make such changes, the aspects judged not to be achieving thematernal and child healthcare in Nepal. beliefs of mothers-in-law should be level required by the ICM. Moreover,The charity focuses on health promotion addressed as well as the poverty which midwifery is regulated under nursing inintervention rather than on the more also prevented some who might have Nepal, which limits the growth oflimited notion of ante- and postnatal wished to receive care from doing so. midwifery as an independentcare. The intervention introduced by Rural women may benefit from sharing profession.them is fairly unique in Nepal, as it is the experiences of more educated ormultidisciplinary, theory-based and informed mothers-in-law in their There are, however, some positiveevidence-based (see Table 1) (van communities and hearing why they signs: the growing strength of theTeijlingen et al 2012). It targets women supported their daughters-in-law and Midwifery Society of Nepal (MIDSON),of childbearing age and their family encouraged them to seek antenatal care. which held its first national midwiferymembers, particularly mothers-in-law. conference in September this year in Over the past four years the health the capital, Kathmandu; the support for About 85 per cent of Nepal is rural, promotion intervention had been midwifery from the MOHP; and thewith women walking three hours to the implemented in over 40 groups Global midwifery twinning project bynearest health facility; one aim of this (reaching over 1,100 people). The the Royal College of Midwives (RCM).programme was to understand why groups follow a health promotion The latter aims to improve standardspregnant women do not access existing curriculum designed to be accessible to and the status and position ofservices and to help improve uptake, as illiterate women. The curriculum is midwifery education and practice inwell as strengthening existing service flexible to allow the facilitator to three low-income countries, namelyprovision. Working with the local health discuss issues brought up by the Cambodia, Nepal and Uganda (RCM 2013).Table 1 Underlying philosophy of the health promotion intervention The Government of Nepal is alsoThe intervention needs to be: committed to enhance maternity1 Community-based. services by providing financial incentives for women. Recently, after a2 Culturally appropriate. successful programme for women3 Woman-centred, including working with those affecting women’s access to improved attending antenatal care and having anhealth (such as mothers-in-law, husbands). institutional birth in some districts of4 Small-scale. Nepal, the Government expanded the5 Sustainable. programme to the whole country.6 Making best use of existing non/governmental resources. Under this incentive scheme, women in the mountains receive payment if they7 Low cost. have their baby in a health facility. The8 Involve all stakeholders to increase ownership and chances of sustainability. level of payment varies according to the relative difficulty women face reaching the facility; in the mountains, where women may have to walk for many hours to a health facility, the incentives
THE PRACTISING MIDWIFE • November 2013 Maternity care in Nepal • 27are highest. Women get 1,500 Nepali surgical interventions. Having midwives Referencesrupees (NR) in the Himalayan mountain in the healthcare system would help toregion, 1,000 NR in the central hill area keep childbirth normal for many Bogren MU, Bajracharya K, Berg M et aland in the Tarai, the sub-tropical south women, although midwives may have a (unpublished). ‘Nepal needs midwifery!’ Journear the Indian border, 500 NR. They difficult task trying to do so in private Manmohan Mem Inst Health Sci (accepted).receive an extra 400 NR if they also hospitals where every procedure bringsattend four antenatal check-ups and in more money. Bogren M, van Teijlingen E and Berg M (2013).one postnatal visit. The health facilities ‘Where midwives are not yet recognised: aalso receive an incentive for each birth. Midwives are needed in Nepal to feasibility study of professional midwives in bring maternity care to those getting Nepal’. Midwifery, 29(10): 1103-1109.Not all change is for the better none or too little and to limitAs Nepal develops it takes over a lot of unnecessary intervention and stop the MOHP (Nepal), New ERA and ICF Int Inc (2012).the ‘bad’ characteristics of the disempowerment of the women using Nepal demographic and health survey 2011,developed world. Breastfeeding rates private facilities (Bogren et al Kathmandu: MOHP, New ERA and ICF Int Inc.are very high in Nepal (apart from the unpublished). TPMfirst day or so), something we in the UK Edwin van Teijlingen is Professor in the RCM (2013). Global midwifery twinning project,could learn from. Now we begin to see centre for midwifery, maternal and London: RCM.formula milk on the shelves of the perinatal health at Bournemouthcities, and in the private hospitals in University, Bibha Simkhada is Chair of a Simkhada B, Porter M and van Teijlingen EKathmandu, we see a growing epidemic maternal and child healthcare charity and (2010). ‘The role of mothers-in-law inof CS. Many middle-class, educated Padam Simkhada is Senior Lecturer in the antenatal care decision-making in Nepal: awomen are ending up with unnecessary School of Health and Related Research at qualitative study’. BMC Preg and Childbirth, the University of Sheffield 10(34): doi:10.1186/1471-2393-10-34. van Teijlingen E, Simkhada P, Stephen J et al (2012). ‘Making the best use of all resources: developing a health promotion intervention in rural Nepal’. Health Renaissance, 10(3): 229-235. ta655_IND_LifestartAd_PracMidwife_83x120_v2_Layout 1 05/09/2013 1Homeopathic Remedies and Neonatal Resuscitation Creams for Pregnancy, Unit to support Delayed Cord ClampingChildbirth and the newbornThe Helios Homeopathic childbirth collection comprises 18 safe and Practical andgentle remedies for use during pregnancy, labour and postnatal Convenientsymptoms. A free information booklet with an A-Z list of complaintsand materia medica section detailing the traditional uses of the ™ is designed to allowremedies is available with every collection. Our natural plant based resuscitation of the newborn withcreams, free from lanolin and petroleum derivatives, are formulated the umbilical cord intact.to cover a wide range of minor ailments from varicose veins to nappy • Provides an ergonomic, stable,rash and cradle cap. variable height platform that isPlease contact Helios mobile and compact.Telephone:01892 537254 • Can incorporate all resuscitationEmail: [email protected] equipment, including patientWeb: www.helios.co.uk warming, CPAP ventilation, blender and suction. Inditherm Medical, Houndhill Park, Bolton Road, Rotherham, S63 7LG, United Kingdom Telephone: +44 (0)1709 761000 Fax: +44 (0)1709 761066 Email: [email protected] www.inditherm.com/medical
28 • Maternal health services for ethnic minorities November 2013 • THE PRACTISING MIDWIFEMaking maternal health servicesaccessible to all culturesSarah Edwards SUMMARY Childbirth poses a much greater risk for women in developingexplores the countries than it does for those in wealthy ones, but there are also hugebarriers to disparities in health within developing countries.maternal healthcare faced by Complications and death from childbirth and pregnancy-related causespregnant women from ethnic are much more common amongst women from cultural and ethnicminorities in developing minority groups than women from mainstream cultures.countries. This article explores the reasons behind the disparity and suggests some solutions, including culturally appropriate health services, and training women from minority communities to act as a cultural bridge and ensure women access state health services. Keywords Indigenous people, ethnic minorities, international development, international maternal health, global health Author Sarah Edwards, Head of Policy and Campaigns at an organisation working to improve maternal health in countries across Asia, Africa and Latin AmericaBackground Women from cultural The disparities are huge, but why? MIt’s well known that women living in and ethnic minoritydeveloping countries are much more groups are much more Discriminationlikely to die from pregnancy related likely to face In being poor, female and from acauses than women in wealthy ones. complications and minority, these women face manyWhat’s less well known is that there is death from childbirth layers of discrimination and manyalso a huge disparity in the chances of than women from barriers to good health. As well as thesurvival between different ethnic and mainstream cultures broader issues of poverty,cultural groups within developing marginalisation and discrimination,countries. per 100,000 births, while for the non- pregnant women from minority groups indigenous population it is 147 per face several tangible barriers to In countries across Asia, Africa and 100,000 births (PAHO 2006). This is just achieving good midwifery care.Latin America, women from cultural one example; in some countries womenand ethnic minority groups are much from ethnic minorities may be almost The simple fact that many healthmore likely to face complications and twice as likely to die as women from services charge fees means women aredeath from childbirth than women mainstream cultures (Health Poverty often put off using them from the start.from mainstream cultures, and often Action (HPA) 2013). Then there are the long distances manythese statistics are hidden. In Honduras, have to travel, as ethnic minorityfor example, maternal mortality rates communities are often inwere successfully cut by 38 per cent geographically remote locations. Butbetween 1990 and 1997 (Pan-American even for the women who manage toHealth Organization (PAHO) 2006), but find the money to pay the fees, and arethis average conceals the fact that the able to make the journey, there arematernal mortality rate amongst the more barriers to face once they get toindigenous community is 255 deaths the health centre.
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30 • Maternal health services for ethnic minoritiesCommunication Indigenous women in Peru not usually trained with the benefit ofI was recently told about a woman modern medical knowledge. Known ascalled Ana Luisa, from Peru. She went to harmful to the mother or baby, yet the Traditional birth attendants (TBAs),give birth at a clinic in Ayacucho and state health services made no these women usually learn their skillswas assigned a midwife who did not provisions for this tradition, so for many from older attendants in thespeak her native Quechan. She felt too years Mayan women were prevented community. When a woman from aintimidated to stay at the clinic and from following it. This meant that minority culture becomes pregnant shegave birth on the roadside on the way almost no indigenous Mayan women chooses a TBA who visits herhome. The need to communicate at used the state health services, putting throughout her pregnancy. Whensuch a vital time should not be them at an unnecessarily high risk of labour starts, she will send for her TBAunderestimated. death or injury during or after labour. as this is the person she has been seeing all along.Culture and tradition Making improvementsAnother, perhaps less obvious barrier to Making sure birthing facilities are Providing midwifery education formaternal care is that health centres do culturally appropriate will ensure more women from minority communitiesnot consider the health practices of women attend health centres. In rural who already have a role in advising andmarginalised cultures. In Guatemala, Ayacucho, Peru, in 1999 only 6 per cent assisting pregnant women to act as afor example, the Mayans have a of births in the Santillana district took cultural bridge is key to ensuringtradition that women give birth in a place at a health clinic. By recognising women access state health services.crouching position rather than lying the need for culturally appropriate When TBAs from minority communitiesdown. The woman supports herself services in health clinics, such as know how to recognise complicationswith a rope hung from the rafters or in allowing women to squat rather than during pregnancy they ensure womenthe arms of her partner. Instead of lie down, and having health staff speak go to health centres. When theypainkillers, a woman puts her braided the local language, by 2007 this figure accompany women to the healthhair between her teeth and bites down had soared to 83 per cent of births. centres they can overcome languageon it. These practices are in no way barriers and prevent women feeling Clearly, culturally appropriate health intimidated by the conventions of an services make a huge difference – alien culture. They can also be taught to which means services that are in give advice on issues such as keeping with ethnic minorities’ breastfeeding and nutrition. traditions of health and wellbeing, provided in their own languages and in Inclusive of minorities a culturally appropriate setting. But At the forefront of measures to address there is another key aspect to ensuring the maternal health of indigenous women have proper midwifery care. women, then, is the need for health services that work with the grain of Traditional birth attendants these minority cultures, and with those Every culture throughout time has had ‘wise women’ who could build bridges women who have the role of midwives, across communities. women who support others through pregnancy and labour. Marginalised It is only when we take an inclusive communities do, too; however they are approach to minority groups that the maternal health of all women will improve. TPM Sarah Edwards is Head of Policy and Campaigns at an organisation working to improve maternal health in countries across Asia, Africa and Latin America References HPA (2013). Every mother counts: the case for disaggregating data, London: HPA. PAHO (2006). Health of the indigenous population in the Americas, Washington: PAHO.
32 • Elective placement November 2013 • THE PRACTISING MIDWIFEElecting sun, sea andmidwifery in CyprusHelen Pearce reflects on SUMMARY Towards the end of the three-year midwiferyher elective placement at education programme, students at Glasgow CaledonianRAF Akrotiri in Cyprus University are given the opportunity for professional development in an aspect of midwifery practice that they would not usually experience. This is in the form of an independent module, including a planned and negotiated three-week placement. As a military wife for over 20 years and a senior midwifery student, my decision to combine personal and professional experience to enhance my professional development was simple. This article provides a reflective account of a self-initiated clinical placement at Royal Air Force (RAF) Akrotiri in Cyprus. Keywords Elective placement, professional development, reflection, student education Author Helen Pearce, midwife at NHS Greater Glasgow and ClydeReflection Four women attended DescriptionAlthough many reflection models exist, the clinic for routine On my arrival at RAF Akrotiri, Cyprus, inI chose the Gibbs reflective cycle (1988), antenatal care. The August 2012, I was met by one of myas it provides a logical progression appointments lasted mentors, who arranged my securitythrough an event, offering a high level from 30-45 minutes pass and drove me to myof direction. The cycle begins with a accommodation. At eight the followingfactual description of events and group, when requiring high risk morning, in the blazing sun, I was givenexploration of thoughts and feelings. care. a brief tour of the base, including manyFurther steps include an evaluation, of its amenities such as the swimminganalysis of the situation and finally Although not included here, for pool, cinema and various cafés,reframing and examining any future assessment purposes a critical catching glimpses of the blue waters ofaction. Self-assessment has been evaluation of the quality of the learning the Mediterranean Sea as we drovemeasured against objectives set prior experience and the evidence available along the beach road, arriving at theto commencing the placement. These in relation to maternity care provided medical centre for a morning antenatalincluded: for this client group was also clinic beginning at 8.30am. Four undertaken in full. women attended the clinic for routine • participation in maternity services antenatal care. The appointments for childbearing military wives and lasted from 30-45 minutes. families Maternity care • evaluation of the suitability of the Although still on the base, The Princess midwifery model of care used Mary’s Hospital (TPMH) is • identification of some of the procedures in place for this client
THE PRACTISING MIDWIFE • November 2013 Elective placement • 33Dreamers Bay: a secluded area of beach within the confines of the base I was fortunate enoughapproximately two miles from the was initially excited but over the first to witness two births Mmedical centre. The maternity unit three days I began to feel more anxiouscomprises one ward situated on the and isolated. However, this was mainly and participate infirst floor of the hospital, providing due to the lack of my own transportantenatal, intrapartum and postnatal and, because it was the holiday season, hospital basedcare to healthy women with the base was extremely quiet. Duringuncomplicated pregnancies. Women my working hours within the team, I intrapartum andwith any potential or significant welcomed the opportunity tomedical/obstetric/social risk factors participate in all aspects of midwifery postnatal care andwere referred to hospitals in Larnaca or care and actually felt more confidentNicosia for further assessment. At the than in all previous placements. community postnatalend of my shift I was given a tour of the However, towards the end of the firsthospital and introduced to more of the week, I began to panic and explore carematernity team. My typical shift options to return to the UK. I eventuallypattern was between 07.00-15.00 or managed to admit my feelings to my observed between the maternity care12.00-20.00 with community hours clinical mentor who immediately offered in the UK and Cyprus was thedepending on workload. I also had the arranged for me to attend various social caseload, with approximately only 75opportunity to attend aquanatal, events with her and the maternity women a year receiving some of theirvarious preparation for parenthood team, and spend a few hours relaxing maternity care in British Forces Cyprussessions and infant feeding support on the beach. As I gained more of a from a team of 13 midwives (Soldiers,groups. Although the estimated birth balance with work and a social life, I Sailors, Airmen and Families Associationrate at TPMH is only 150 births was able to enjoy the rest of the (SSAFA) 2012). The average attendanceannually, I was also fortunate enough placement and concentrate on fulfilling at a three-hour antenatal clinic duringto witness two births and participate in my objectives. the placement was four women, whichhospital based intrapartum and enabled each woman to discuss anypostnatal care and community Evaluation significant issues at length.postnatal care. Although working towards set learning outcomes allowed me to focus on my Although the antenatal care wasFeelings reasons for being in Cyprus, on similar to the care I had provided in theAlthough this placement had involved reflection, these were difficult to UK, other differences were in theextensive planning and organisation, on measure. However my participation in paperwork, computer systems used andreflection, I felt that I had not actually most aspects and all areas of the the fact that some blood or screeninggiven consideration to how I would feel maternity services, in both the hospital tests could not be performed in Cyprusleaving my family, travelling alone for and the community environment was and were consequently sent to the UKthe first time, being in a new and evident through a daily diary which was for analysis. In addition, the commonstrange environment or dealing with continually reviewed by me with my topics discussed differed from the UK,the extremes of temperature. Prior to mentor. such as air travel information, minorthe placement and on arrival in Cyprus, I skin disorders due to the heat (on One of the major differences I average 29°C) and passport applications for children. Furthermore, due to local complexities, no planned home birth service was available in Cyprus (SSAFA 2012). The TPMH midwifery service provides a team midwifery model of care but, due to the small workload, in reality, many of the midwives in Akrotiri provided caseload midwifery, described as being the gold standard, with women receiving all their care from one named midwife whom they have come
34 • Elective placement November 2013 • THE PRACTISING MIDWIFEto know and therefore trust (Warren The maternity team Action Plan2003). Successful caseloading requires A comprehensive literature review priorthe practitioner to develop a radically provided more than I to this placement revealed an overalldifferent orientation to work and life, gap in the experiences of midwiferywith personal aptitudes and originally anticipated, care for UK childbearing military wivescircumstances often supporting or and families, which therefore warrantspreventing this orientation. even during a time of further research to be undertaken toNevertheless, the needs of women and ensure the needs of this group oftheir families should determine the anxiety and upheaval in women are met. However, thismodels and location of care (Chief placement allowed me to witness andNursing Officers of England, Northern their own careers participate in midwifery care beyond aIreland, Scotland and Wales 2010). This gold standard and I feel that I not onlywas evident in Cyprus, with many facility. Childbirth in Cyprus tends to be met all of my learning objectives butmidwives living on the base with the highly medicalised, with a current surpassed them. The maternity teamwomen, participating in local support caesarean section rate of 43 per cent provided more than I originallygroups with their own children and in public hospitals and as much as 60 anticipated, even during a time ofoften completing home visits outside per cent in private clinics (Panayiotou anxiety and upheaval in their ownnormal Cyprus working hours. and Hadgigeorgiou 2011). This is not careers. I would like to return to Akrotiri only due to a large number of at some point, not only to compare andChildbirth in Cyprus obstetricians but to a lack of midwifery contrast the midwifery care providedHigh risk maternity care is provided by education, which has resulted in a following the relocation of services butthe Larnaca General Hospital or the serious lack of midwives in both the also to ensure that I continue toArchbishop Makarios III (ABM 111) in public and private sectors (Panayiotou appreciate the beneficial effects ofNicosia (SSAFA 2012). Due to the and Hadgigeorgiou 2011). continuity of carer and excellentplanned closure of TPMH soon after my community support, resulting in goodplacement and the subsequent move of Analysis quality midwifery care. TPMobstetric services to Ygia Polyclinic in Due to the isolation I initially felt, I wasLimassol, the largest private hospital in able to empathise even more with the Helen Pearce is a midwife at NHS GreaterCyprus, many issues were raised while I women and quickly realised the Glasgow and Clydewas there. I was fortunate enough to be importance of good communityable to visit this Cypriot hospital, purely support. The set learning objectives Helen would like to thank SSAFAas an observer along with some of the were successfully met; however, on personnel for this opportunity and thewomen planning to give birth at the reflection, my own transport would support they provided have allowed me more freedom to visitA relaxing birthing room at TPMH other bases nearby, to compare the care References provided by the rest of the team or even be on call for situations as they arose. Chief Nursing Officers of England, Northern Ireland, Scotland and Wales (2010). Midwifery Due to the relocation of intrapartum 2020: delivering expectations, London: services, the situation for the forces Department of Health. maternity teams is changing. Despite this they are keen to liaise with their Gibbs G (1988). Learning by doing: a guide to Cypriot colleagues to share best practice teaching and learning methods, Oxford: and influence reduced caesarean Oxford Centre for Staff and Learning section rates, greater breastfeeding Development. rates and informed choice for all women. However, more focus must be Panayiotou N and Hadgigeorgiou E (2011). The given to ensure information needs are state of the world’s midwifery: midwifery in met to safeguard informed choice, Cyprus, New York: United Nations Population empowerment and communication, Fund. while allowing for debriefing following birth in a Cypriot hospital. SSAFA (2012). How we help – health and social work, London: SSAFA. Warren C (2003). ‘Exploring the value of midwifery continuity of carer’. British Journal of Midwifery, 11(10): 34-37.
THE PRACTISING MIDWIFE • November 2013 Role of the supervisor of midwives • 35 MIDWIFERY BASICSMidwifery supervision2. Role of the supervisor of midwives Midwifery supervision is the 13th series of‘Midwifery basics’targeted at practising midwives.The aim of these articles is to provide information to raise awareness of the impact of the work of midwives on women’s experience and encourage midwives to seek further information through a series of activities relating to the topic. In the second article of the series,Rachel Jokhi discusses the role and responsibilities of the supervisor of midwives and considers how this statutory function can support the provision of high quality care.Scenario Introduction High quality statutory supervision ofJane is the Supervisor of Midwives In the UK the midwifery profession is midwifery is nationally recognised as(SoM) on call and receives a call regulated by the Nursing and Midwifery providing a pivotal role in promotingfrom the labour ward co-ordinator Council (NMC), which lays down the the core role of the midwife andabout a woman, Mary, who has rules and standards which determine enabling the provision of safe, effective,been in labour at home for several the preparation and practice of family centred care (Chief Nursinghours with no progress. The midwives (NMC 2012a). The statutory Officers of England, Northern Ireland,community midwives with her have function of the NMC is to safeguard the Scotland and Wales 2010). As a modernadvised her that it would be wise to health and wellbeing of the public. In regulatory practice, statutorytransfer to the consultant unit, but midwifery this is achieved largely supervision of midwives supports theMary does not wish to come into through the supervision of midwives. protection of the public throughhospital. Statutory supervision of midwives has promoting best practice and excellence existed within the UK for over 100 years in care, preventing poor practice and and has developed to become a means intervening in unacceptable practice, M by which midwives are supported in, (NMC 2006) (See Figure 1). and with, their practice. The purpose of supervision is to protect the public and Roles and responsibilities support and promote good midwifery Rule 9 of the Midwives rules and practice. It plays a critical role in standards (NMC 2012a) states the roles developing the profession and ensuring and responsibilities of a SoM, although the standards and policies are this does not prescribe what a SoM developed to provide safe, high quality might be expected to do. Supervisors of delivery of services (Kingscott et al Midwives undertake a range of 2010). activities, which include providing
36 • Role of the supervisor of midwives November 2013 • THE PRACTISING MIDWIFE MIDWIFERY BASICSFigure 1 Responsibilities of the SoM need and circumstances without Access to a supervisor of midwives compromising the safety of women. The Midwives Rule and Standards (NMCIntervening in unacceptable practice Preventing poor practice Normally the ratio of supervisors to 2012a) state that all practising midwives will not exceed 1:15 (NMC midwives should have 24 hour access to 2012a). a SoM, whether that is the midwife’s named supervisor or another SoM. This Supervisor of Figure 2 Summary of main responsibilities of a SoM midwives (adapted from Kingscott 2010 and Yorkshire and Humber LSA 2013) Promoting best practice and excellence in care Provide professional leadership to create a practice environment that empowers professional practice through evidence-based decision making.guidance on professional issues andpractice development. Figure 2 Monitor standards of midwifery practice through record audits and review of clinicalsummarises the main focus of the outcomes, taking action where appropriate.supervisor’s role. Contribute to activities such as clinical governance and risk management strategies Activity 1 and any other relevant enquiry relating to the maternity services. Ask your supervisor what supervisory activities she Contribute to activities such as standard setting, clinical audit and the development undertakes on a monthly basis. of evidence based guidelines and protocols. Which individuals and groups does she engage with in her role as a Contribute to curriculum development of pre-registration and post-registration SoM? education programmes for midwives.Named supervisor of midwives Participate in and liaise with the Local supervising authority (LSA) during theThe LSA has to ensure that each investigative process and the reporting of serious incidents concerning midwiferypractising midwife and student practice and professional conduct.midwife within its area has a namedSoM who will offer support and Be available for midwives to discuss issues pertaining to their practice and to provideguidance (NMC 2012a). Being able to support. This includes those midwives who practise outside an NHS trustchoose a SoM can facilitate midwives environment.being able to access support fromsomeone they feel is approachable and Be available to guide and support midwives through difficult clinical situations,meets their professional needs (NMC through a 24 hour access to a supervisor system.2010), although this recommendationis no longer stipulated (NMC 2012a). Arrange regular meetings with individual midwives and maintain agreed records atThe LSA must ensure that the ratio of least once a year to help them evaluate their practice and identify areas forsupervisors to midwives reflects local development. Activity 2 Provide guidance about the maintenance of registration, identifying updating Reflect on your supervisor of opportunities in relation to statutory requirements. midwives. Did you feel you had a choice regarding who is your SoM? Ensure that midwives have access to the statutory rules, standards, codes and Do you know how you can change guidance; LSA standards and guidelines and local policies to inform their practice. your SoM? What qualities do you consider to be important in a SoM? Receive and process Intention to practise (ITP) forms. Monitor the integrity of the service to ensure that safe and appropriate care is available to all women and their babies, reporting relevant concerns to the LSA (NMC 2006). Participate in the identification and preparation of new supervisors of midwives. Identify when peer supervisors are not undertaking the role to a satisfactory standard and take appropriate action. Support opportunities for women to engage actively with maternity services and influence their development. Support midwives who are facilitating women in specific care options and ensure advocacy for the women (NMC 2012b).
THE PRACTISING MIDWIFE • November 2013 Role of the supervisor of midwives • 37 MIDWIFERY BASICSmay be for a number of reasons Supervisors of issues (NMC 2002). M midwives are ideally•including: placed to work with Intention to practise To offer advice and guidance on midwives to act as their A statutory responsibility of a SoM is to the statutory supervision of advocate to help receive and process Intention to midwives and the NMC negotiate a plan that is practise forms (ITP) that midwives are •professional standards acceptable to the required to complete, giving notice to To offer advice and support to woman and ensures each LSA in whose area she intends to ••midwives safe, high quality care commence practising. Whilst it is the To provide professional leadership individual midwife’s responsibility to To offer guidance and support to This may be for a number of reasons, complete and return the form to their women accessing maternity but queries should relate to issues named SoM, it is the SoM’s services and ensure that these concerning the statutory supervision of responsibility to ensure the statutory services respond to the needs of midwives and should not be confused practice requirements have been met vulnerable women who may find with seeking managerial advice from and then ensure the forms are •accessing care more challenging managers regarding organisational uploaded electronically onto the To offer guidance and support to national LSA database so that they can women who are experiencing Activity 3 be processed by the NMC. By difficulty in achieving their care Have a discussion with one or submitting the ITP, this ensures •choices (NMC 2012a) and more of the supervisors in your midwives are ‘live’ on the NMC register To be informed of any practice or local team. What is the ratio of of practitioners. If a midwife has not service issue which may affect a supervisor: supervisees in your submitted an ITP s/he may not practise midwife’s ability to care for locality? How does your local area anywhere in the UK except in an women and their babies or could ensure 24 hour access to a SoM? emergency – in which case an ITP must directly impact on the safety and be submitted to the relevant LSA within protection of the public (NMC 48 hours (NMC 2012a) 2012c). (LSA Midwifery Officers (LSAMO) Clinical governance Forum UK 2013a) In terms of midwifery practice the purpose of clinical governance is to A SoM may be contacted at any time ensure women receive the highestby midwives, members of the public, quality of care possible. SoMs supportmanagers or other health professionals.
38 • Role of the supervisor of midwives November 2013 • THE PRACTISING MIDWIFE MIDWIFERY BASICSThe SoM has a complex safety (LSAMO Forum UK 2013b). intervening in unacceptable practice by Midwives must make the care of the acting as an advocate for both womenrole with wide and woman their first concern, treating her and midwives. Midwifery supervision as an individual and respecting her should therefore enable midwives tovaried responsibilities, dignity, whilst supporting her right to provide safe and effective care, and accept or decline treatment and care supervisors of midwives to supportboth statutory and (NMC 2008). Supervisors of midwives midwives to practise with confidence are ideally placed to work with (NMC 2006). TPMthose based on local midwives to act as their advocate to help negotiate a plan that is acceptable Rachel Jokhi is a midwifery lecturer and aneeds and systems to the woman and ensures safe, high supervisor of midwives at the University quality care but that does not of Sheffieldlocal clinical governance through three compromise safety or accountability formain approaches – accountability, the midwife, thereby engendering a Referencesquality of service (through clinical audit culture of co-operation andand policy development) and collaboration (LSAMO Forum UK 2013b). Chief Nursing Officers of England, Northernsafeguarding of standards (through Ireland, Scotland and Wales (2010). Midwiferyrobust risk management strategies and Reflection on the scenario 2020: delivering expectations, London:incident reporting) (Kingscott 2010). Jane is faced with a situation that needs Department of Health.Indeed, the SOM must ensure that to be resolved quickly but how couldadverse incidents, complaints or this situation have been avoided? Why Kingscott A et al (2010). Preparation ofconcerns about midwifery practice or might a SoM be involved in this case? Supervisors of Midwives resource pack.allegations of impaired fitness to Identify any significant issues that the Birmingham: Birmingham City University.practise against a midwife are reported SoM would need to consider and whatto the LSA (NMC 2012a). should her actions be? Women choose LSAMO Forum UK (2013a). Contacting a to have a home birth for a range of supervisor of midwives: 24 hour access,Supporting women and promoting reasons and it is important that London: LSAMO.normality midwives understand the hopes andSoMs are specifically appointed to aspirations of the women they care for. LSAMO Forum UK (2013b). Workingprotect women and babies, to ensure Developing a relationship in the collaboratively with women and their birthmaternity services respond to the needs antenatal period and discussing the supporters, London: LSAMO.of women, to support women in their plan of action for a range of scenariosuse of maternity services, to advocate can help women understand why NMC (2002) Preparation of supervisor offor women and to actively promote a certain courses of action might be midwives resource pack, London: NMC.safe standard of midwifery practice recommended and the options that are(NMC 2009). The focus of all involved available. Supervisors of midwives can NMC (2006). Standards for the preparation andshould be to work together to achieve a support midwives to develop strategies practice of supervisors of midwives, London:safe and positive outcome for the to enhance this process and provide a NMC.woman, her baby and family. This can be listening ear and supportive presence ifachieved through mutual respect and challenges arise. NMC (2008). The code: standards of conduct,an understanding of the statutory and performance and ethics, London: NMC.personal contribution each individual Conclusionmakes. To best support midwives to The SoM has a complex role with wide NMC (2009). Modern supervision in action,work with women and their birth and varied responsibilities, both London: NMC.companions, SoMs need to ensure that statutory and those based on localmidwives clearly understand their needs and systems. The aim of NMC (2010). Midwives rules and standards,statutory roles and responsibilities and midwifery supervision is to protect the London: NMC.are skilled at working with service users public, by promoting best practice,and their carers to maintain public preventing poor practice and NMC (2012a). Midwives rules and standards, London: NMC. NMC (2012b). How supervisors of midwives can help you, London: NMC. NMC (2012c). Supervision, support and safety: NMC quality assurance of local supervising authorities 2010-2011, London: NMC. Yorkshire and Humber Supervisors Guideline Development Group (2013). Guideline 3: Role description for a Supervisor of Midwives, Leeds: Yorkshire and Humber LSA.
THE PRACTISING MIDWIFE • November 2013 Cochrane corner • 39Midwife-led continuity modelsversus other models of care forchildbearing women. Valerie Smithcontinues our seriesThis month we highlight a SUMMARY The aim of this bi-monthly column is to highlight CochraneCochrane systematic review Systematic Reviews of relevance to pregnancy and childbirth and toby Sandall et al (2013) on stimulate discussion on the relevance and implications of the review formidwife-led continuity practice. The Cochrane Collaboration is an international organisation thatmodels versus other models prepares and maintains high quality systematic reviews to help peopleof care for childbearing make well-informed decisions about healthcare and health policy. Awomen,which was published systematic review tries to search for, appraise and bring together existingin Issue 8 of 2013 of the CDSR. research to answer a specific research question. The Cochrane Database of Systematic Reviews (CDSR) is published monthly online. Residents in countries with a national licence to The Cochrane Library, including the UK and Ireland, can access the Cochrane Library online, free of charge, through www.thecochranelibrary.com Keywords Models of maternity care, midwife-led care, shared care, obstetric-led care Author Dr Valerie Smith, lecturer in midwifery, and post doctoral midwifery research fellow at Trinity College DublinBackground views on pregnancy and childbirth: ambiguous and ill-defined at the best MIn August of this year there was great pregnancy and childbirth as a normal of times (Smith et al 2012), theexcitement as the findings of a physiological event; and pregnancy and consequence of this is the over-extensionCochrane review hit national headlines childbirth as a pathology becoming of intervention to routine use in allwith reports that ‘pregnant women fare normal only in retrospect. These views, childbearing women (Wagner 2002).better under midwife-led care’ (Siggins arguably, are likely to influence the care This, in turn, is likely to have a effect on2013). Prominent midwives and that women receive as they journey pregnancy and childbirth outcomes.obstetricians were invited to express through pregnancy and childbirth. This review explores different models oftheir views on radio programmes across Factors influencing the care women maternity care and provides evidence ofthe country and lively debates ensued. receive, however, extend beyond simply their effect on maternity outcomes.For many midwives, these findings may these views, and the ‘how’ and ‘where’have come as no surprise; however, up of care provision have an important role Methodsto this point, no single source of also. Mead and Kornbrot (2004), for Studies that reported on cluster- andsynthesised evidence on the example, found that midwives working quasi-randomised trials that comparedeffectiveness of midwife-led continuity in high interventionist birth settings midwife-led models of maternity caremodels of care compared with other generally perceived risks associated with other or shared-care models ofmodels of care, was available (Sandall with childbirth as higher compared care were eligible for inclusion in theet al 2013). Midwives are likely to be with their colleagues working in low review. A midwife-led model of carefamiliar with two long-held parallel interventionist units. Although risk is was described as a model of care where
40 • Cochrane corner November 2013 • THE PRACTISING MIDWIFEa midwife was a woman’s lead Overall, a higher level of implication emerging from this reviewprofessional throughout her pregnancy satisfaction was is evidence of benefit with no evidenceand birth. Other models of maternity reported by women of adversity for midwife-led continuitycare were described as those where the receiving a midwife-led models of care over other and shared-physician or obstetrician was the lead model of care care models. As a profession, midwiferyprofessional and midwives and/or in high-resource countries now hasnurses provided care under medical •fetal loss/neonatal death before strong evidence for a model of care thatsupervision or where the physician 24 weeks offers a safe and effective alternative toprovided the majority of care. Shared They were more likely to experience medical-led or other models of care.care was described as care where the Arguments advocating the superiorlead professional changed as a woman’s a spontaneous vaginal birth safety of medical-led models ofpregnancy progressed. Two review maternity care are robustly dispelled byauthors independently assessed each •• no intrapartum analgesia/ the findings of this review. The challengestudy for inclusion in the review with anesthesia facing the midwifery profession, indeferral to a third review author where striving to achieve improved maternitythere was uncertainty about the • a longer mean length of labour care for women and in embracing birtheligibility of a study. All review authors (on average 30 minutes longer) as a normal, physiological part of theassessed the methodological quality of cycle of life, is mobilising maternity careeach study and two review authors • attendance at birth by a known providers, health care governing bodiesindependently extracted each study’s carer and health care policy makers todata. The review authors listed 39 support the widespread developmentseparate outcomes of interest in the There were no statistically significant and implementation of midwife-ledreview, seven of which were considered differences found between the different continuity models of care. The evidenceprimary outcomes. These were regional models in any of the following speaks for itself and the time has comeanalgesia, caesarean birth, instrumental outcomes; caesarean birth, intact to truly advocate for women, andvaginal birth, spontaneous vaginal perineum, overall fetal loss and demand that midwife-led continuitybirth, intact perineum and overall fetal neonatal death, antenatal models of care become an available andloss and neonatal death. hospitalisation, antepartum accessible option for women accessing haemorrhage, induction of labour, our maternity services. TPMFindings oxytocin during labour, opiateIncluded in the review were thirteen analgesia, perineal laceration requiring Valerie Smith is lecturer in midwifery andstudies, which were conducted in suturing, postpartum haemorrhage, post doctoral midwifery research fellow atAustralia, Canada, Ireland, New Zealand breastfeeding initiation and mean Trinity College Dublinand the UK, and involved 16,242 length of postnatal hospital stay.women. Eight studies compared Referencesmidwife-led with shared-care models, Nine of the included studiesthree compared midwife-led with measured maternal satisfaction. Mead M and Kornbrot D (2004). ‘The influencesmedical-led models and two compared Although this was assessed on different of maternity units’ intrapartum interventionmidwife-led models with various options aspects of care, with various rates and midwives’ risk perception forof standard care. Eight studies included satisfaction scales and at varying times midwifery led care’. Midwifery, 20(1): 61-71.women of low risk for complications during pregnancy, overall, a higher levelonly. The remaining five studies of satisfaction was reported by women Sandall J, Soltani H, Gates S et al (2013).included women of low and high risk. receiving a midwife-led model of care. ‘Midwife-led continuity models versus other Five of the included studies performed models of care for childbearing women’. Women receiving midwife-led an economic comparison of the CDSR, 8: CD004667. doi:continuity models of care compared to different models of care. Overall there 10.1002/14651858.CD004667.pub3.other models of care were statistically was a trend towards cost-saving withsignificantly less likely to experience: midwife-led models of care. Siggins L (2013). ‘Pregnant women fare better under midwife-led care’. Irish Times, August 21. regional analgesia Implications for practice The single most important clinical Smith V, Devane D and Murphy-Lawless J (2012). •instrumental vaginal birth ‘Risk in maternity care: a concept analysis’. Int •preterm birth Jour Childbirth, 2(2): 126-135. •amniotomy ••episiotomy Wagner M (2002). Pursuing the birth machine: the search for appropriate birth technology, Australia: ACE Graphics.
Around the conferencesMariamni Plested reports fromPresenting breech20th March 2013 James Paget University HospitalHeads up! Data indicated a around the safety of vaginal birth inJames Paget University Hospital (JPH) is upright positions which may, in time,home to an innovative breech clinic run decreased need for serve to stem the tide of near universalby specialist breech midwife Shawn recommendations for the termWalker. The ‘Heads Up!’ breech clinic, manoeuvres and a singleton breech to be born via CS;shortlisted in this year’s RCM awards, these have dominated thehas developed a woman centred care decrease in the management of term breechpathway, which offers continuity of pregnancies since the publication of thecarer and a counselling service for incidence of minor Term breech trial (Hannah et al 2000).women and families experiencing abreech pregnancy, with options injuries to the baby, Into the breechincluding external cephalic version, Other features of the study day covered:elective caesarean birth and vaginal with upright birthing the normal mechanism of breech birthbreech birth. illustrated with markers of reassuring positions progress; description andStudy day demonstration of new manoeuvres inPerhaps the most refreshing and what is ‘normal’ for breech. addition to adaptations of existinginspiring aspect to this study day was manoeuvres for resolving breechthe diverse nature of both the team Dr Anke Reitter dystocia in upright birth positions; thebehind the initiative and the study day Especially valuable was the key most appropriate ways of screening forparticipants – a truly mixed bag of presentation by Dr Anke Reitter, fellow breech presentation and issuesmidwives, obstetricians and others of the Royal College of Obstetricians surrounding the undiagnosed breech inworking collaboratively towards and Gynaecologists (RCOG), who labour; counselling for informed choice;developing breech skills to enable a safe presented the data from a large cohort risk management issues around breechand woman-centred service. The day study in Frankfurt. The data included birth; and especially stimulating wasunpacked important questions around outcomes for planned vaginal breech the question of what constitutes anhow breech presentation is categorised births compared with caesarean experienced breech practitioner.and whether it is an abnormality (as sections (CS), which indicated nousually perceived by obstetricians) or an significant difference in outcomes. Of This is a shining example ofunusual variation of normal (as particular interest were the data innovation in care provision and the dayperceived by midwives who have regarding outcomes for supine demonstrated that the experience andpreserved breech skills). compared with upright (all-fours) birth expertise in breech are out there for the positions, which indicated a decreased taking. TPM Collaboration was central to the need for manoeuvres and a decrease inphilosophy of the day and thus the the incidence of minor injuries to the Mariamni Plested is a midwife researcherpresentations moved beyond the baby with upright birthing positions.dichotomy of a midwifery vs medical This was further supported by Dr Referencesmodel of care, with a compelling and Reitter’s presentation of MRI researchcareful fusion of research evidence, into the significant increase in mid- Hannah ME, Hannah MJ, Hewson SA et alexperience, observation and simulation pelvic and outlet diameters of women (2000). ‘Planned caesarean section versusfrom a woman-centred team of in an ‘upright squat’ position. These planned vaginal birth for breech presentationhealthcare professionals focusing on data contribute significantly to the at term: a randomised multicentre trial’. evidence base which is fast growing Lancet, 356(9239): 1375-1383.
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PROMPT 2:Train the Trainers Special rates for midwives!Joint RCOG/PROMPT Maternity Foundation Save over a third on RCOG meetingsMeeting Masterclass in Management of PPHTraining Dates for 2014 25 February 2014 14 March 2014 13 June 2014 A one-day workshop where delegates will learn about recent innovative topics such as the 3 October 2014 role of the pelvic vascular surgeon and the extrapolation of military eld strategies to massive obstetric haemorrhage.This is a hands-on workshop with practical clinical tips from expertsPROMPT (PRactical Obstetric Multi-Professional on uterine compression sutures and balloon tamponade.Training) is a multi-professional obstetric emergencies This event was fully booked in 2013,secure your place early to avoid disappointment.training package that has been developed to providemulti-professional interactive drills and workshops, Maternal Medicine: Medical Complications in Pregnancy“hands-on” experience of practical skills anddecision-making skills in simulated situations. 5–6 March 2014 Joint RCOG/BMFMS MeetingPROMPT 2 includes Structured to address current maternal medicine issues across all medical subspecialties withyNew modules: Maternal Sepsis,Twin Birth, speci c relevance to obstetrics, this course will address topical maternal medicine issues and Major Obstetric Haemorrhage (includes ante- will be of value to clinicians with a maternal medicine and high-risk obstetric practice. partum haemorrhage), Uterine Inversion and Anaesthetic problems in pregnancy. Early Pregnancy and Emergency GynaecologyyUpdated modules:Teamworking, BLS and 19–20 March 2014 Maternal Collapse, Eclampsia, Cord Prolapse, Joint RCOG/AEPU Meeting Shoulder Dystocia,Vaginal Breech Birth, Fetal monitoring in labour and Newborn resuscitation. This course will provide an update on recent developments in clinical practice of early pregnancy and emergency gynaecology management and provides a forum for disseminationyPROMPT ‘Course in a Box’ containing: and discussion of principles of evidence-based practice. Participants course manuals,Trainer’s manual, CD-Rom of lectures and multi-media Women’s Health Patient Safety DayyTraining for up to 4 multi-professional members 21 March 2014 of staff A multi-professional event sharing the experience and expertise of others, showcasingy 12-month telephone support practical and ef cient examples to improve maternity patient safety in your own unit. Be inspired by the practical solutions from national and local speakers. Registration Fees Management of the Labour Ward £4,000 (£3,334 +VAT) per team, for teams that are new to PROMPT training. 17–20 June 2014 Joint RCOG/BMFMS Meeting £2,000 (£1,667 +VAT) per team, discounted price for maternity units/Institutions that have Update and advance your knowledge regarding management of the labour ward. already sent a team to a PROMPT 1:Train the The programme includes a variety of authoritative speakers with ample time for discussion, Trainers day. INCLUDES extended 12-month debate and networking throughout the course of the meeting. telephone support package. For more information or to register please visit To book your place contact our website www.rcog.org.uk/events Kim Helm: [email protected] RCOG Conference Of ce, 27 Sussex Place, BOOK ONLINE +44 (0) 207 772 6468 London, NW1 4RG. Email: [email protected] SAVE Tel: 020 7772 6245 Fax: 020 7772 6388 © Royal College of Obstetricians and Gynaecologists 2013. Registered Charity No: 213280
Professional development NEW! Acupuncture in midwifery course Expectancy is pleased to offer the UK’s first acupuncture course specifically for midwives. The course complies with WHO requirements and we are applying for RCM accreditation. Six month course (one weekend per month) commences 1st February 2014 in London. www.expectancy.co.uk [email protected] 08452 301323 registered charity number 1086814 Now available to subscribers online Understanding newborn behaviour and supporting www.ingentaconnect.com/ early parent-infant relationships content/mesl/tpm Training courses in the • Register free at Neonatal Behavioural Assessment Scale (NBAS) and Neonatal Behavioural Observations (NBO) www.ingentaconnect.com/register/ (Recommended in the Healthy Child Programme) • Following registration, select Personal For practitioners working with newborn babies subscriptions or Set up subscriptions (0-3 months old) and their parents For registration: for institutionalwww.brazelton.co.uk [email protected] • Select the TheFor all your advertising needs, please THE BEST JOB IN THE WORLD Practising contact our advertising manager Midwife and enter Margaret Floate on 01483 824094 Volume 16 no 10 • November 2013 your subscription [email protected] number Internationalwww.thepractisingmidwife.com • You will be HbiarethmionrtrhheagNeeathfteerrlahnodmse notified by email SUtguadnednat,mGiadmwbiviaesainnd once your online Improving maternity Cyprus access has been care activated in Nepal Einthdneivcemloipnionrgitcyowuonmtrieens FCRWAEWELITEIA2SHN0LSLD1TUH4AERIS
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46 November 2013 • THE PRACTISING MIDWIFELAST WORDThe busy world of midwifery Sheena ByromS eptember was a busy and The midwifery world The first was for the NMC, regarding exciting month. For the first has so much to thank the agreed model of revalidation for time as a newly appointed Tricia Anderson for, nurses and midwives, and the other Trustee of the Iolanthe and through her was part of the Royal College ofMidwifery Trust, I helped prepare for, writings and influence Midwives (RCM) conference organiser'sand attended the Midwifery Awards on others, her spirit effort to chat to RCM members aboutceremony in Bournemouth. As well as lives on their use of social media. The chatsmeeting inspirational student midwives were interesting and useful, andand midwife award winners from following day I presented at the student stimulated lots of debate about bothacross the UK, I met up with some midwives Theme day at Bournemouth topics!colleagues and had a great catch up. University. I was delighted to meet several students whom I've connected RCMTricia Anderson tribute with via Twitter, and I was overwhelmed Lastly, I spent an afternoon at the RCMBut the evening was particularly special to hear heart-lifting presentations from headquarters in London, chairing theas it was a celebration of the Tricia students reflecting on their elective Campaign for normal birth meeting.Anderson Award, which has been placements. Wow! That night as I There's lots of exciting activity in thepresented for the past five years. We travelled home I reflected on the two pipeline, including a drive to gatherwere fortunate to listen to each of the days. I am incredibly lucky to be in a member views on what they would findfive winners, and how their projects position where I witness such useful to help them to promote andreflected Tricia's philosophy and her life's motivation and innovation from future support normal birth. We are alsowork. Mary Stewart gave a sincere and midwives who want to change the pursuing opportunities to includemoving tribute to Tricia, and we heard world. It certainly gives me so much antenatal and postnatal care, as part ofabout Trica's life, her passion for confidence and hope for the future of promoting normality throughout themidwifery, and her hopes and her fears maternity care in the UK. childbirth continuum. At the RCMas she faced terminal illness. Tricia's Conference we shall launch Ten top tipshusband and daughter were present to Tweet for parents, which mirrors thehear how Tricia was loved by all who met Later in the month I was delighted to be midwives' version. These will beher and, as Mary recounted excerpts invited to help with two 'tweet chats'. available to download on the web soon.from Tricia's poems, the emotion in theroom was palpable. The midwifery world So much is going on in the midwiferyhas so much to thank Tricia Anderson for, world. It feels good to be part of it all.and through her writings and influence TPMon others, her spirit lives on. Sheena Byrom OBE is an independentThe future in our students midwifery advisor, Chair of the RCM’sThe positivity continued and the Campaign for normal birth and patron of a student midwife web-based organisation
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