|
|
The debate continues: Should midwives take a more active role in patient care? In the July 1981 edition of the magazine `Maternal and Child Health' Professor J. MacVicar who was Professor of Obstetrics of Leicester at the time, pointed out that `there is an increasing number of mothers who come into an obstetric low risk category for themselves and their babies'. He went onto surmise that `This may account for some of the decrease which has taken place in perinatal mortality'.' In 1988 we are dealing with a population at less obstetric risk than has ever occurred in the whole history of womankind - women today are better educated, better nourished and better off than any generation of women have ever been, and most importantly of all, the babies they have are babies which they intend to have. No longer do women have 13 or 18 pregnancies because that is the lot of women - most women have no more than two or three pregnancies during their fertile years and they have those children because they want them. The babies who have always been (and still are) at most risk are the babies who come to the woman who has more than enough children already, the babies who come to women who are still children themselves at 13, 14 or 15. Professor MacVicar also pointed out that nowadays 80 per cent of deliveries occur to women aged between 20 and 35 years the safest years for women to have babies. It is bizarre that in an age when women are at the least risk obstetrically the caesarean rate is going up and up - from 4.3 per cent in 1970 to 11.3 per cent in 1987. And at the same time midwives who provide a service to women choosing to have home births, and especially those midwives who practise outside the National Health Service are at great risk of being hauled up before their Professional Conduct Machinery. I suggest that the two are not unrelated. If most births are now occurring in low risk women their care can usefully be provided by the midwifery profession, with obstetricians dealing with the small number of women who have, or who develop, medical risks during pregnancy or labour. This has several benefits for the community at large, midwifery care is cheaper than obstetric care, not least because of the great discrepancy in the salaries of both professions, women who are enabled to get to know the midwives who will be delivering them need less antenatal admissions (cost saving) they feel more `in control' of the situation during labour, they need less analgesia (another cost saving), they look back on their labour more favourably and they feel more prepared for motherhood. A randomized controlled trial at St George's Hospital in Tooting between women cared for in the usual way and women cared for by a team of four midwives showed' that cost savings occurred in antenatal care because the women cared for by the midwives required less antenatal admissions, women cared for by the midwife team waited less time in the antenatal clinic which probably indicates cost savings for the community at large because employers were deprived of their employees for less time than those of working women in the Control Group. The actual antenatal consultations cost less because women in the Midwife Group were seen by
All these staff cost money to employ. If they are all needed in order to provide the best antenatal care possible that is fine, but women in the Midwife Group much preferred their antenatal care, they found it easier to discuss anxieties, they looked back on their antenatal care more favourably and they saw less personnel during their pregnancy, and the personnel they met were the midwives who would be caring for them during labour - something that women have been requesting for many years. Last year a booklet produced by the National Epidemiology Unit `Where to be born - the debate and the evidence" collated all research into place of birth during this century, they concluded that `There is no evidence to support the claim that the safest policy is for all women to give birth in hospital' and `There is some evidence, although not conclusive, that morbidity is higher amongst mothers and babies cared for in an institutional setting'. Their conclusions and growing evidence from GPs, ° s. statisticians like Marjorie Tew6 (who for years has pointed out that the perinatal mortality rates would have fallen more quickly if women had been encouraged to give birth at home) are part of a rising chorus which claims that childbirth belongs to women and that the type of highly controlled and medicalized birth that most women are subjected to is inappropriate and not always in the best interests of women or their babies. As is seen in the area of caesarean section which is dependent on where the woman lives rather than on her obstetric profile (9.8 in Wessex compared with 12.8 per cent in Wales). Not surprising then, that when this ageing philosophy `that childbirth is only normal in retrospect' (as if the whole of life were any different), a philosophy which has such a profound effect on the controlling of women during a normal physiological function, is under attack, those who hold dear to such philosophy, whose very life's work has been the implementation of such a philosophy, attack back at those who represent most strongly the alternative to that philosophy `Childbirth is a normal physiological function, women's bodies are beautifully and wondrously made and are designed to give birth, and when we interfere we interfere at our peril in a finely balanced process. Intervention should be used only when absolutely necessary and not as a first resort'.The group who represents this philosophy most strongly at the moment are the Independent Midwives who practise outside the National Health Service and deliver women at home, showing by their actions that women are able to give birth at home and midwives are able and appropriate to care for them - perhaps the present attack on them could be seen as the last throes of a dying philosophy. References1. MacVicar, J. (1981). `Changing birth patterns during a period of declining births'. Maternal and Child Health, July. 2. Flint, C. (1988). `Know Your Midwife' Nursing Times, Vol. 84, No 38. September 21. 3. Campbell, R., Macfarlane A. (1987). Where to be born? The Debate and the Evidence. National Perinatal Epidemiology Unit, Radcliffe Infirmary, Oxford. 4. Shearer, J. M. L. (1985). `Five year prospective survey of risk of booking for a home birth in Essex.' British Medical Journal, Vol. 291, 23 November. 5. Damstra-Wijmenga S. M. 1. (1984). `Home confinement: the positive results in Holland.' Journal of the Royal College of General Practitioners, August. 6. Tew, M. (1985). `Place of birth and perinatal mortality.' Journal of the Royal College of General Practitioners. August. Spring 1989 |
|