New Zealand College of Midwives • Journal 28 • April 2003 1 journal 28 april 2003 JOURNAL Current issues The midwife in the ‘risk’ society Joan Skinner Evidence and practice “I’m ready for you, baby, why won’t you come?” How long is a pregnancy and how long is too long? Rhondda Davies Research Towards a sustainable model of midwifery practice in a continuity of carer setting: the experience of New Zealand midwives Christina Engel Student corner A breastfeeding journey revisited Tracey Rountree Conference papers The organisation of maternity services by midwives in rural localities within the South Island of New Zealand Chris Hendry Otaki Birthing Centre - He Whare Kohanga Ora Jane Stojanovic
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New Zealand College of Midwives • Journal 28 • April 2003 1j o u r n a l 2 8apri l 2003
J O U R N A LC u r r e n t i s s u e sThe midwife in the ‘risk’ societyJoan Skinner
E v i d e n c e a n d p r a c t i c e“I’m ready for you, baby,why won’t you come?”How long is a pregnancy andhow long is too long?Rhondda Davies
R e s e a r c hTowards a sustainable modelof midwifery practice in acontinuity of carer setting:the experience ofNew Zealand midwivesChristina Engel
S t u d e n t c o r n e rA breastfeeding journey revisitedTracey Rountree
C o n f e r e n c e p a p e r sThe organisation of maternityservices by midwives in rurallocalities within theSouth Island of New ZealandChris Hendry
Otaki Birthing Centre -He Whare Kohanga OraJane Stojanovic
New Zealand College of Midwives • Journal 28 • April 20032
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Philosophy of the JournalPromote women’s health issues
as they relate to childbearing womenand their families.
Promote the view of childbirthas a normal life event for the majority
of women, and the midwifery profession’srole in effecting this.
Provoke discussion of midwifery issues.
SubmissionsSubmit articles and letters to the Editor:
Alison Stewart, School of Midwifery,Private Bag 1910, Dunedin.
“I’m ready for you, baby,why won’t you come?”How long is a pregnancyand how long is too long?Rhondda Davies
Sarah Stewart
Toward a sustainable model ofmidwifery practice in a continuityof carer setting: the experienceof New Zealand midwivesChristina Engel
A breastfeeding journey revisitedTracey Rountree
The organisation of maternityservices by midwives in rurallocalities within theSouth Island of New ZealandChris Hendry
Otaki Birthing Centre -He Whare Kohanga OraJane Stojanovic
Kate Spenceley
C o m m e n t
Current i s sues
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c o n t e n t sJOURNAL 28 ISSUE 1 April 2003
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P o e m
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New Zealand College of Midwives • Journal 28 • April 20034
E D I T O R I A L B O A R D C O M M E N T
C U R R E N T I S S U E S
Welcome to the 28th volume of the New ZealandCollege of Midwives Journal. We are beginningour third year as the Editorial Board and arecontinuing to enjoy the challenge of producing a jour-nal that seeks to be relevant, informative and scholarly.
Articles submitted to the journal undergo a peerreview process. This plays a critical part in ensur-ing that the content of the journal is of a highstandard. Each article is reviewed by two externalreviewers selected for their expert knowledge rel-evant to the topic. Their review is undertakenwithout knowledge of the author’s name and de-tails. An Editorial Board member collates the feed-back and then forwards this to the author alongwith a recommendation which falls into one ofthe following categories; accepted, accepted pend-ing minor revision, major revision required be-fore publication can be considered, or not recom-mended for publication. Often extensive feedbackis provided to assist the author to develope theirwork to a standard required of a peer reviewedjournal. Over the last two years the Editorial Boardhas received 31 journal articles for consideration,of these 14 have been published and several oth-ers are currently being reviewed.
Congratulations to Suzanne Miller whose articletitled “How safe is a tired midwife?” which waspublished in the last issue of the journal, has beensought by MIDIRs for reprinting this year. Thisinternational interest demonstrates that midwivesin New Zealand are producing original and inno-vative work which offers a significant contribu-tion to midwifery knowledge worldwide.
In order to make the journal more accessible tothe wider community the Editorial Board iscurrently negotiating with CINAHL (CumulativeIndex of Nursing and Allied Health Literature)for inclusion in the list of journals accessed by thedatabase. This has involved a review of ourjournal and peer review processes by CINAHL.Incorporation in the database will mean thatNZCOM journal articles will be included inany database search results (where relevant)using CINAHL.
This issue contains an interesting mix of topics.Rhondda Davies has tackled the tricky issue ofprolonged pregnancy. In the student corner, TracyRountree, writes about her personal experience ofbreastfeeding explored through an analysis of the
literature. Joan Skinner looks at ‘risk’, suggestingthat “midwives are faced with a significant paradoxin attempting to work a ‘birth is normal’ paradigmwithin a ‘birth is risky’ context.” Christina Engelpresents some of the findings from a qualitativestudy of New Zealand midwives’ experiences inher article titled “Towards a sustainable model ofmidwifery practice in a continuity of carer setting”.Finally, from the 2002 national conference pres-entations, Jane Stojanovic tells the story of theOtaki Birth Centre, while Chris Hendry offers areport, which looks at the provision of maternityservices offered by midwives in rural localities ofthe South Island of New Zealand. Our regularcontributor, Sarah Stewart, returns with herInternet surfboard in search of practice related sitesfor you to explore. This is also an opportunity todraw your attention to our new column titled“Midwifery Practice Wisdom”, see page 2 October2002 issue. Rhondda Davies is keen to receive yourstories, anecdotes or case studies and her emailaddress is [email protected].
We wish you enjoyable reading and our best wishesto you all for a happy and productive 2003…
IntroductionMidwifery practice in the current New Zealandcontext is beset with both challenges and possi-bilities. As midwives we have achieved our aim ofautonomous practice. The new challenges that arefaced relate now to managing care in an environ-ment which, to a large extent, remains dominatedby a techno-rational model of birth. The visionof providing care which would enhance and pro-tect the normal process has been constrained bysocietal attitudes still dominated by the notionsof modernity: control, technology and individualchoice (Beck, 1999). The key concept which re-flects this state of being, certainly in the Western
world, is that of ‘risk’. Risk plays a dominant rolein Western society and impacts on the lives ofmidwives both in the assessment of risk in thewomen we care for, and in the management ofour own risk within the current medico-legal con-text. This risk paradigm directly challenges themodel of birth as a normal part of human exist-ence and presents challenges for midwives as weattempt to enact in practice this model of nor-mality. Midwives are faced with a significant para-dox in attempting to work a ‘birth is normal’ para-digm within a ‘birth is risky’ context. I proposethat risk and how it is currently constructedcontribute significantly to increasing interventionand escalating medico-legal action. It is a core is-sue for maternity care in general and midwiferyin particular.
This article explores the ‘risk’ environment in anattempt to understand its origins and manifesta-tions, particularly as a social and cultural construct.It briefly presents the ideas of two key risk theo-rists, Ulrich Beck and Mary Douglas, and thenlooks at the implications of this risk discourse for
maternity care and for midwifery, particularly asit relates to the idea of normality and risk screen-ing. It presents several alternative approaches andchallenges midwives to work towards a greater depthof analysis and sophistication in understanding andmanaging its impact on practice and policy.
Risk and societyBeck (1999) traces society’s anxieties about riskback to the beginnings of modernity. Modern life,he asserts, has been constructed around the ideasof progress and controllability. Essentially thismeans that nature exists to be exploited and tech-nology is expected to solve all our (and I talk aboutsociety in general now) problems. Science there-fore is seen as the perfect rational project. Becksays that these ideas have been undermined in re-cent times by globalisation, individualisation,underemployment, and global catastrophes, bothenvironmental and financial. These factors haveled to generalised insecurity and anxiety and acollapse of the belief in controllability and safety.Along with this goes a loss of faith in profession-als and in technology. Modernity itself is being
The midwife in the ‘risk’ societyJoan Skinner RM MA(Applied), PhD Candidate
Joan Skinner is a midwife lecturer and PhDcandidate at the Graduate School of Nursing andMidwifery, Victoria University of Wellington.She has a particular interest in practice develop-ment and in the impact of the medico-legalcontext in which midwives work. Her PhDresearch addresses the impact of 'risk' on practice
New Zealand College of Midwives • Journal 28 • April 2003 5
C U R R E N T I S S U E S
continued over...
challenged yet there are not yet societal and cul-tural structures to replace it. We are, according toBeck, not yet post-modern but are living in whathe calls late modern society where we live withthe paradox of loss of faith in experts yet at thesame time expect that work produced by expertsshould be free of any negative outcome. The lev-els of anxiety that are produced become counter-productive, as Beck (1999, p.4) states.To the extent that risks become the all-embracingbackground for perceiving the world, the alarm theyprovoke creates an atmosphere of powerlessness andparalysis. Doing nothing and demanding too muchboth transform the world into a series of indomita-ble risks. This could be called the risk trap. One thingis clear: how one acts in this situation is no longersomething that can be decided by experts. Riskspointed out (or obscured) by experts at the same timedisarm these experts, because they force everyone todecide for themselves: what is still tolerable and whatno longer?
In terms of maternity care this reflexive culturemeans that maternity practitioners can be con-stantly questioned and challenged. The account-ability that results causes fear and stress not onlyin the practitioners but also in the consumers ofmaternity care as they are required to make choiceswith risks attached which are difficult or impossi-ble to quantify at an individual level. Ironicallythis intent to avoid or control risk in itself createsits own problems. As Annandale (1996, p.417) says,Herein lies the irony, for the panic culture thatemerges, and the negative backlash that it effects, isitself a product of the consumerism and newmanagerialism that seeks, in fact to achieve the op-posite; that is, to enhance rather than underminethe quality of care that is provided.It is this combination of managerialism in the formof protocols and guidelines, and consumerism inthe form of informed choice and consent whichprovides the current background for midwiferypractice. The dilemma then for the midwife is towork in an increasingly constrained environmentwhile at the same time providing care that is flex-ible and truly woman centred. And all this in anenvironment focused on risk aversion.
A further complication of working in this envi-ronment is that choices about which risks to takeor to avoid, are in essence culturally and sociallydefined rather than by rationality or science(Douglas, 1994). Values and uncertainties are anintegral part of these choices and Douglas pro-poses that the choice between risky alternatives isnot value-free. Choice in the end therefore, is es-sentially based on social rather than scientificknowledge (Fischhoff & Lichtenstein, 1981). This
decision-making process can also be seen as po-litical as there is a distinct message about whoshould make decisions, who and what shouldmatter, and whose knowledge is regarded as au-thoritative. The perception of risk is therefore acultural and social process very much related tohow fear is felt and expressed and how power ismanifest (Giddens, 1999). We see this clearly inthe decision-making processes around birth. Takefor example a woman’s de-cision to deliver her breechbaby without interventionas compared to an obste-trician’s decision to deliverher baby by caesarean sec-tion. Or a woman’s choiceto have an epidural anaes-thetic as compared to themidwife’s commitment tonormal birth. Whoseknowledge is authoritative here? How is fear be-ing expressed? And of course, who is at risk?
As a society we live in an environment thereforethat one might say is in transition from moder-nity to something that we might call post-moder-nity for lack of a better word. We have lost faithin the modern project yet we cling to it still in thevain hope that all risk can be managed, that wecan still colonise our future, that technology willsave us. On the one hand we have an understand-ing of risk as being part of being alive, on the otherhand we have the transformation of all risk as be-ing avoidable (Castel, 1991). We have lost faithin the ability of professionals to know all, yet ex-pect that with better risk management profession-als will produce the perfect result. At the sametime we understand that risk and its managementare heavily value and culturally laden.
It is interesting to look at the possibilities for therole of the midwife within this context. One ofmidwifery’s strengths is our ability to be with thechildbearing woman within her social and cul-tural milieu where attitudes to risk can be assessed.We can juxtapose this knowledge with our ownknowledge and risk perspective and go on to placethis within medicine and within the larger socialand cultural context. In a sense then we must dealwith multiple ways of knowing and understand-ing, which is also placed in a political environ-ment. It is a complex task, one might say a post-modern one. Where risk is concerned our task isto assist the childbearing woman through her de-cision making process. The focus on being ‘with’the childbearing woman and her family in whatwe assert is essentially a normal experience cangive us the edge in dealing with risk in its widest
interpretation. Risk then as expressed from a mid-wifery stance can be incorporated into what isconsidered normal childbirth and it is this ideathat runs counter to current risk discourse, whichseeks to isolate risk, manage it and avoid it.
Risk and normalityUnderstanding of what is risky and what is nor-mal both dominate and delineate midwifery prac-
tice and yet are often seenas juxtaposed positions.Midwives claim expertisein the normal, medicine inthe at risk. Midwives inNew Zealand I would sug-gest claim that birth is anormal experience evenwithin complex physicalor social circumstances.Medicine claims that all
birth is risky and that birth is normal only in ret-rospect (Wagner, 1994). It would seem, usingBeck’s analysis that medicine’s claim on this issuemore accurately reflects current risk discourse. Itis worth examining the idea of normality to seehow it has been interpreted and it is here we seethe link between normality and risk. Normalityis, as is the concept of risk, bound to the develop-ment of modernity and science. At the beginningof the 19th century how long one lived was es-sentially a subjective matter. Fate played the keyrole. By the end of that century longevity becamebased on the laws of chance. We had begun tocount populations and their characteristics. Thenotion of probability had a strong relationshipwith the concept of normal and abnormal(Murphy-Lawless, 1998). The normal curve wasdeveloped which plays a fundamental role in epi-demiology and statistics. Normality in essencechanged from being a social to a scientific con-cept as we came to accept the idea that one can’tknow something unless it can be measured (Hack-ing, 1990). This search for regularity and normal-ity was an approach that resulted in the produc-tion of rules in areas where there had been a lackof depth of analysis. An example of this is the de-cision about what constitutes a normal labour. Itneeded to be measurable in some sense, so statis-tical data was superimposed over an individualwoman’s progress. As with risk, deviations fromthe measurable, statistically assessed norm are nowseen as needing management.
In essence, science, in the guise of medicine hasrecreated and redefined normal. Normal becamedefined in a purely physical sense and was com-pared with the pathological. Increasingly in medi-cine it has come to be associated with risk, lead-
The dilemma then for the midwife
is to work in an increasingly constrained
environment while at the same time
providing care that is flexible and truly
woman centred. And all this in an
environment focused on risk aversion.
New Zealand College of Midwives • Journal 28 • April 20036
ing to the idea in obstetrics that normality can bedefined only in retrospect. This is a paradoxicalprocess as Wagner (1994, p.99) states.Logically, the abnormal cannot be identified with-out a clear scientific definition of the variations ofthe normal. Obstetrics lacks this because the risk con-cept implies that all pregnancy and birth is risky andtherefore no pregnancy or birth can be considerednormal until it is over. In other words, one cannotclaim both the ability to separate normal from ab-normal during pregnancy and the inability to deter-mine normality until after birth.
It is within this dominant medical discourse thatwe as midwives stay firm in our claim to be prac-titioners in normal childbearing. It is a precariousposition to take given who is defining normalityand who is defining risk. The challenge for mid-wifery is to look beyond medicine’s definitions ofnormal and to claim our own. In the New Zea-land context I would propose that midwifery seesbirth as a normal process, not only physiologi-cally, but also socially, culturally and spiritually.This is reflected in the commitment that mid-wifery has to partnership, to woman-centred care,to continuing lead maternity carer (LMC) mid-wifery in secondary maternity care contexts andto having registered midwives as core hospital staff.One of the dangers of this practice is that there isa real possibility of decreased emphasis on thephysical aspects of what we currently call normalbirth, i.e. birth without intervention. It is this is-sue that is of current concern.
Midwives are in a unique position to understandthe depth and complexity of human existence andto treat the notion of normality very carefully. Thenormal can be found and protected in the mostcomplex of situations. When birth is defined as‘at risk’ and thus no longer normal in a physicalsense it still can retain a core of normality as asocial, cultural and spiritual phenomenon. Weneed to continue to develop our understandingof what normality is, especially if we continue toclaim expertise in this area. We also need to un-derstand the implications and difficulties of riskand how it impacts on the normality of childbirth.
Risk screeningSome of the difficulties with the risk discoursebecome apparent when one focuses more on theminutiae of practice. The key maternity practicewhich impacts most profoundly on normal child-birth is the practice of risk screening. Although itis widely accepted now that individual risk fac-tors are poor predictors of actual risk (Rohde,1995; Rooney, 1992) and that risk screening suf-fers from low sensitivity as well as low specificity
(Schettler, Solomon, Valenti, & Huddle, 1999;Yuster, 1995), it continues to be used (Mohamed,Martin, & Haloob, 2002). Alexander and Keirse(1989) propose that risk screening for the indi-vidual woman is nothing more than tautology.When you include a diagnosis such as previous cae-sarian section for example and give it a risk score youmay give it unwarranted emphasis. Risk screeningperforms poorly because risk factors are not causativeof the predicted outcome. The other confoundingproblem with risk scoring is that they mix up poten-tial and existing problems. The best and most preciserisk prediction is made at a time when there is nofurther need for it, whereas the much more necessaryearly identification is notoriously imprecise. ( p.352)
What effect does risk screening have on women?For the individual woman labelled as being at in-creased risk, both the threat of poor outcome andthe inability to change its course may cause feel-ings of guilt and inadequacy. This is unlikely toimprove maternity outcome (Alexander & Keirse,1989). Risk screening does aim to identify the fewindividuals who are likely to experience an ad-verse outcome. What it does not do however isidentify those whose chances of a good outcomeare so good that they are unlikely to be improvedby whatever obstetrics can offer. It also fails toidentify any risk factors other than physical. Socialand cultural factors are usually ignored. Those scoreswhich do try to look at other issues such as socio-economic factors face significant ethical dilemmas.
Within the New Zealand context risk screening isundertaken in the use of the referral guidelines(Ministry of Health, 2002). The degree of risk isreflected in the numbering from 1 to 3, lower riskto highest risk. Each number has recommenda-tions about the level of need for obstetric referraland transfer of clinical responsibility. Within it,potential and existing clinical conditions are in-cluded together. No research has been undertakenon the effectiveness of these guidelines but theredoes seem to be reasonably widespread acceptanceof their use. Certainly in medico-legal terms theyare used as a marker of appropriate midwifery prac-tice. Whether their existence is political or clini-cal, what effect they have on the women andwhether they are useful remains to be evaluated.Given all previous research on risk screening sofar, I believe it is unlikely that the guidelines willshow a positive predictive value.
Wagner (1994) poses four further limitations aris-ing from the notion of risk screening.• Based on the medical model that birth is risky
and dangerous, the pregnant woman incorpo-rates this into her perception of her pregnancy.
• It focuses on the birth at the expense of all otherareas of care and weakens the interest of otherprofessionals involved.
• The pregnant woman becomes a passive patientand the obstetrician a baby advocate.
• The high tech hospital becomes the pinnacle ofcare, perpetuating the spiral of more risk andmore intervention.
Interestingly, the World Health Organisation(WHO), which promoted risk screening in the1980s as an effective way of combating maternaland perinatal mortality, has now changed itspolicy. The WHO 1998 document states;Risk assessment should not be relied on as the basisfor matching needs and care in maternity services. Itis almost impossible to predict, on an individual basis,who will develop a life-threatening complication.Sensitivity, specificity, and positive predictive valueof risk assessments using such characteristics are poor.WHO now advocates that services be provided asclose as possible to where women live, that conti-nuity of care and well integrated reproductivehealth services are of a high quality and that earlyidentification and appropriate management ofobstetric complications are vital.
Oakley and Houd (1990) also propose an alter-native framework to the risk approach. They sup-port the call to rename risk as “complex need”and isolate the important ingredients in its man-agement as: effective primary care which is adaptedto individual needs, cross disciplinary cooperationand comprehensive care delivery. They proposethat maternity care provided in this way may helpto solve some of the problems of the risk approachand that it should be evaluated both quantitativelyand qualitatively. I believe that complexity in preg-nancy has not benefited from the risk approach.The alternative approaches mentioned above areall focused on the quality of relationships bothwith the consumer and with other health profes-sionals. This may be an improvement but mustalso be placed within current social and culturalconstructions of risk.
Challenging riskThese current social and cultural constructions ofrisk can be seen as a manifestation of anxiety. It isuseful to consider how one might best deal withthis reality and try to see a way forward. This anxi-ety about risk comes at least partly from society’stransition from modernity to what might be calledpost-modernity. This post-modern approach in-corporates many ways of knowing and being inthe world. It will reintegrate science, ethics andaesthetics (Parker, 1998). This new constructionof knowledge is reflected in developments acrossa variety of theoretical perspectives. Interestingly
The midwife in the ‘risk’ societycontinued...
New Zealand College of Midwives • Journal 28 • April 2003 7
the work of both Beck (1999) and Douglas (1994)deals with this. Beck proposes that one of the in-teresting things about current ‘risk’ society is thatit has begun to combine elements which used tobe considered as separate - “society and nature, so-cial sciences and material sciences, the way risk is ex-pressed and the reality of possible negative outcome”(p.4). Risk itself, he says, does not have a prefer-ence for any one form of knowing. The implica-tion of this is that risk analysis needs to have amultidisciplinary approach. Douglas (1994) alsoproposes this approach suggesting that insightsfrom social anthropology, sociology, politics andculture should be incorporated into the study ofrisk perception and the discussion of responsibil-ity. She says:A more holistic approach to the subject of risk is re-quired, one which is not compartmentalised. It shouldbe across nations, cultures and across disciplines. Riskshould be seen as a joint product of knowledge aboutthe future and as requiring consent about the mostdesired prospects. This may enable us to put the prob-lems into perspective. (p.57)Risk and its management could then be seen as acollaborative process, a coming together of differ-ent ways of knowing in order to reach a consensuswithin any given situation.
Midwifery is in a perfect position to participate inboth the theoretical and practical ramifications ofthese new, post-modern approaches. We have ahistory which was until recent times isolated frommodernity’s mind/body separation, and currentconstructs of midwifery point the way to an un-derstanding of birth which is different (Sandall,2000; Skinner, 2002). Individuals are increasinglyasking for a say in their birth experience, they wantchoice and control, they want a human, not amechanistic birth (Bourgeault, Declercq, &Sandall, 2001; Thomas, 2002). Midwifery in NewZealand has responded to this by developing part-nership as its philosophical base. On an interna-tional front the resurgence of midwifery points toa direction that runs counter to the risk approachand reflects a different way of viewing birth- a moreholistic, inclusive, permissive and expansive model(Lay, 2000). It has been hoped that midwifery willhumanise birth, view women as not only physicalbut also as social, cultural and spiritual beings. Thegrowing movement for consumer participation andrights, the trend towards evidence based practice,the wide variety of choice that women have aboutwhere and how to give birth, and the internationalresurgence of midwifery, all point to a new way ofbeing in the world and of dealing with risk andits consequences.
New Zealand is a fascinating place to examine this.We are at the forefront of this movement and wehave made significant inroads into progressing theplace of the midwife. We have autonomous statefunded midwifery care, equal pay with doctors,direct entry midwifery education at undergradu-ate level, and growing postgraduate education,representation at every level of local and nationaldecision making. The majority of New Zealandwomen now choose a midwife as their LMC. Thereare concerns however about how midwifery careis progressing. There seems to have been minimalrise in the home birth rate, and intervention rateshave continued to rise (Ministry of Health, 2001).This may be a manifestation of the risk trap inwhich midwifery is still required to function. It iscertainly worth exploring.
Looking at risk in maternity care from a variety oftheoretical perspectives poses many questions andcertainly would benefit from empirical evidenceto support or challenge the assertions that aremade. Do New Zealand midwives feel part of the‘risk trap’ and how is this expressed in practice?To what extent do we incorporate social and cul-tural understanding of risk into our practice? Howdo we place the consumer in risk decisions? Howuseful do we find the referral guidelines and whateffect does this have on both the referral for ob-stetric consultation rates and intervention rates?How do we place our practice within the birth isnormal/birth is risky dichotomy? Do we believethat midwifery should concern itself only with carefor normal birth and what does this mean?
ConclusionMidwifery in New Zealand is now a mainstreamprofession and as such is likely to reflect societalattitudes in practice. However, given our philo-sophical base and our political position, we do havethe potential to lead the way in the developmentand application of new theoretical approaches tomaternity care. We have proved that we can dothis in our commitment to partnership. Ourstrength lies in our ability to incorporate newknowledge while retaining the core of our prac-tice which has stood the test of time- that of sim-ply being ‘with’ women. Increasing understand-ing of complexity in care and collaborations willsupport it to be ‘with and beyond risk’.
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pregnancy and childbirth. Buckingham: Open University Press.
Annandale, E. (1996). Working on the front-line: risk cultureand nursing in the new NHS. The Sociological Review, 44(3),416-436.
Beck, U. (1999). World risk society. Malden: Polity Press.
Bourgeault, I. L., Declercq, E., & Sandall, J. (2001). Changingbirth. In R. Devries & C. Benoit & E. R. V. Teijlingen (Eds.),Birth by design. New York: Routledge.
Castel, R. (1991). From dangerousness to risk. In E. G. Burchell& C. Gordon & P. Miller (Eds.), The Foucault effect.Herfordshire, London: Harvester Wheatsheaf.
Douglas, M. (1994). Risk and blame: Essays in cultural theory.London: Routledge
Fischhoff, B., & Lichtenstein, S. (1981). Acceptable risk.Cambridge: Cambridge University Press.
Giddens, A. (1999). Risk. Retrieved 18/04/99, from the WorldWide Web: http://news.bbc.co.uk/hi/english/static/events/reith_99/week2/week2.htm
Hacking, I. (1990). The taming of chance. Cambridge:Cambridge University Press.
Lay, M. M. (2000). The rhetoric of midwifery. Gender,knowledge and power. New Brunswick: Rutgers University Press.
Ministry of Health. (2001). Report on maternity 1999.Wellington, New Zealand: Ministry of Health.
Ministry of Health (2002). Maternity services. Notice pursuantto Section 88 of the New Zealand Public Health andDisability Act 2000. Wellington, New Zealand: Ministry ofHealth
Mohamed, H., Martin, C., & Haloob, R. (2002). Can the NewZealand antenatal scoring system be applied in the UnitedKingdom? Journal of Obstetrics and Gynaecology, 22(4), 389-391.
Murphy-Lawless, J. (1998). Reading birth and death: a historyof obstetric thinking. Bloomington, USA: Indiana UniversityPress.
Oakley, A., & Houd, S. (1990). Helpers in childbirth midwiferytoday. New York: Hemisphere Publishing Corporation.
Parker, J. (1998). The truth, virtue and beauty of midwifery.Nursing Inquiry, 5, 146-153.
Rohde, J. E. (1995). Removing risk from safe motherhood.International Journal of Gynecology & Obstetrics, 50(2), S3-S10.
Rooney, C. (1992). Antenatal care and maternal health: howeffective is it? A review of the evidence. Geneva: World HealthOrganisation.
Sandall, J. (2000). Choice, continuity and control: changingmidwifery towards a sociological perspective. In E. V.Teijlingen & G. Lowis & P. McCaffery & M. Porter (Eds.),Midwifery and the medicalisation of childbirth: comparativeperspectives. New York: Nova Science Publishers.
Schettler, T., Solomon, G., Valenti, M., & Huddle, A. (1999).The role of science in public health decisions. Generations atrisk: reproductive health and the environment. Cambridge:The MIT Press.
Skinner, J. (2002). Love and Fear. The midwife and herrelationship with risk. Birth Issues, 11(2/3), 69-72.
Thomas, P. (Ed.). (2002). The midwife you have called knowsyou are waiting... A consumer view. London: Routledge.
Wagner, M. (1994). Pursuing the birth machine. Camperdown,Australia: ACE Graphics.
World Health Organisation. (1998). World health day 1998:every pregnancy faces risk. Retrieved 11/04/2001, from theWorld Wide Web: http://www.who.int/archives/whday/en/pages1998/whd98_05.html.
Yuster, E. A. (1995). Rethinking the role of the risk approachand antenatal care in maternal mortality reduction.International Journal of Gynecology & Obstetrics, 50(2),S59-S61.
Accepted for publication: February 2003
Skinner, J. (2003). The midwife in the ‘risk’ society.New Zealand College of Midwives Journal, 28 (1),4-7.
New Zealand College of Midwives • Journal 28 • April 20038
E V I D E N C E F O R P R A C T I C E
Introduction“When is my baby due?” “How long do they letyou go?” These are two questions with which mid-wives are familiar. Some women focus with un-derstandable intensity on the actual date theirbaby is due. My intention in this article is to re-view the literature in relation to two concepts,which are fundamental to an understanding ofwomen’s experiences of “going overdue.” The talebegins by indicating the continuing confusion andcontroversy over how the estimated due date iscalculated and the subsequent implications of this.Then I turn to the second concept, which is thesignificance of prolonged (overdue) pregnancy(PP), including what is, and what is not, reassuring.
Dating a pregnancy - a tale of imprecisionPrior to the advent of ultrasonographic fetom-etry1, women and their caregivers relied on calcu-lation of the due date by reference to the first dayof the last menstrual period. In 1836 Franz CarlNaegele (1777-1851) published Lehrbuch derGeburtshilfe fur Hebammen [A Midwife’s Mid-wifery Text] (cited in Gibb, 1984). In this text hereported, from his observations of French women,that a pregnancy lasted ten lunar months or 280days. He suggested that the date when the babycould be expected to arrive be calculated by add-ing nine (calendar) months and seven days to thedate of the first day of the woman’s last menstrualperiod (LMP). Alternatively, three calendarmonths could be subtracted from the first day ofLMP and then one year and seven days added.The belief then was that ovulation occurred soonafter the last day of menstruation. We now knowthat ovulation, for a woman with a regular 28day menstrual cycle takes place around about day14 and conception occurs within 20 to 24 hoursof that. Logic and fairness would seem to suggesta further seven days then be added to the calcula-tion. Nevertheless, for practical purposes, mid-wives and doctors have continued to applyNaegele’s Rule. Larger inaccuracies do occur sincethe occasional implantation bleed can resemble alight period, which if erroneously reported as theLMP can result in the gestation period being overestimated.
The issue of the accuracy of Naegele’s Rule cameunder review by the late 1960’s (Guerrero &
Florez, 1969, cited in Gardosi & Geirsson, 1998).More recently various studies, including largestudies using routine second trimester ultrasound,sought to prove that a pregnancy was more accu-rately dated by adding various other numbers ofdays to the LMP, viz.:• 281 (Tunon, Eik-Nes & Gioltum, 1996, cited
Cardozo (1993), amongst others, emphasises itis only an estimated date of delivery (EDD), thatit is in fact uncommon for a baby to arrive onthat date. The World Health Organisation(WHO) define ‘term’ as in ‘pregnancy at fullterm’, or ‘mature’ (cf. pre-mature, post-mature)as anywhere between 37 weeks (259 days) and42 weeks (294 days) (Saunders & Paterson,1991). A woman may have passed the estimateddate but she is not considered post-term until the295th day or 15 days after the estimated date.This too applies only if her cycle is 28 days, regu-larly. Cardozo (1993, p.840 is daring enough tosuggest “Perhaps we should reconsider whether it isnecessary to give a precise date on which they shouldexpect their baby to arrive”. Others, in recent textson maternity care, stress how important it is toeducate the woman with a clear explanation ofhow her due date is calculated, and to underlinethe approximate nature of the date from the verybeginning of her contact with her carer (Chua &Arulkumaran, 1999; Roberts, 1993). Adding tothe complexity of raising these issues is the factthat many terms, both specific and general, areused interchangeably to refer to this ‘past theEDD’ state. There is no space here to explain thisin full but Enkin, Keirse, Renfrew and Neilsonneatly describe the dilemma in the introductionto their chapter on post-term pregnancy (PTP)in A Guide to Effective Care in Pregnancy andChildbirth (Enkin et al., 1995). When I refer toPP this means any day past the EDD; and to PTPthis means from the 295th day of gestation.
When obstetricians began to check on women’sdates with ultrasound scanning in the first tri-mester, and to use the date provided by the scanrather than what the woman told them aboutLMP, they reported being able to reduce the inci-dence of PP to as low as 1% (Boyd, 1988, citedin Cardozo, 1993; Romero, 1993 cited inChervenak et al., 1998). Previously when relyingon women’s reporting of LMP, the incidence ofPTP (generally agreed in those days as 42 weeksor more gestation), was between 4 to 14%
(Boisselier & Guettier, 1995). This implies thatwomen were responsible for the underestimationof the length of their pregnancy by providing aguessed LMP, or were unsure and their caregiverunderestimated the pregnancy period from clini-cal signs. This in turn inflated the apparent inci-dence of PTPs. With the advent of ultrasoundscanning, the date could be confirmed or ‘cor-rected’ by measuring the baby on ultrasound andworking backwards to a more accurate, probable,LMP. Consequently, the so-called ‘true’ incidenceof PTP was hugely reduced. By deduction thiswould have had a domino effect of decreasing themorbidity that may have resulted from unneces-sary induction of labour (IOL) and increasing therate of spontaneous onset of labour. However,scans in the first trimester (the first three monthsof the pregnancy) have an ‘accuracy’ of predictionof the due date with an error margin of +/- fivedays, second trimester (second three months) +/-seven days, and third trimester (third threemonths) +/- 10 days (Otto & Platt, 1991). Theaccuracy of ultrasound dating is dependent on ageof gestation when first scanned. Which method todate the pregnancy continues to be hotly debated.
The detail of the debate regarding the implica-tions of relying on scans to date pregnancies, theiradvantages and disadvantages will not be exploredin this article. But I would like briefly to summa-rise this on-going, high-level controversy. The pro-tagonists line up roughly along country borders:Americans, Swiss, Icelanders and some Britons,against Swedes, Danes and some other Britons.Simply put, the former group argue passionatelyfor the greater accuracy of the routine ultrasoundscan in the second trimester and the latter groupreason with equal passion and greater logic, fornot relying on the scan and instead for retentionof the calendar method (Mongelli, Wilcox &Gardosi, 1996; Olsen & Clausen, 1997, 1998;Zimmerman & Wisser, 1998; Gardosi &Geirsson, 1998; Hutcheon, 1999). The crux ofthe debate seems to be whether the calculationsused to establish the accuracy of the technologicalmethod, the non-technological method or a com-bination, are made from the actual date of birthin retrospect or by using some inevitably arbitrarynumber, such as 280, to establish irrefutably the‘certain’ LMP. Further trials are on-going, and asystematic, critical literature review is called for.The Danish researchers’ concluding words of their1997 article were: “… there is a limit to the preci-sion of any method, since length of pregnancy is sub-ject to biological variation and other factors. Thecurrent methods, corrected for bias, may well be closeto this limit” (Olsen & Clausen, 1997, p. 1222).
“I’m ready for you, baby, why won’t you come?”How long is a pregnancy and how long is too long?
New Zealand College of Midwives • Journal 28 • April 2003 9
Menstrual, clinical, ultrasonographicAs has been said, midwives understand that awoman’s estimated date of birth can be roughlycalculated by assuming she will ovulate and con-ceive mid-cycle. By convention the length of ges-tation from the date of conception is taken as ap-proximately 266 days. As it is still unusual for awoman to know exactly when she conceived, agestation length of 280 days is used (to includeall possible conception days from day 7 to day21). This is calculated from the first day of herlast menstrual period (FDLMP).
Whichever way the date is decided on, in the clini-cal setting there are assessments of fundal heightagainst which to compare the calculated gestationfor confirmation. Measurements of increases infundal height are made using finger widths fromthe landmarks of the mother’s xiphisternum,umbilicus, and symphysis pubis; or by tape, meas-uring in centimetres the distance from pubes tofundus. There is also the timing of feeling the firstmovement, or ‘quickening’ of the fetus, which formultiparous women would be around 16 weeksand for primiparous, about 20 weeks. There re-mains an approximate lining up of LMP, move-ments and fundal height to confirm the baby isappropriately grown.
There is now a computer software program beingused in some maternity units, e.g. Darlington,USA, whereby head circumference, biparietal di-ameter, abdominal circumference and femurlength are used to predict a customised due datewithout reference to LMP (Hutcheon, 1999).Everywhere else where ultrasound dating happens,these measurements are matched to a gestationalage, the ‘virtual’ LMP calculated and then Naegele’s164 year old rule applied to supply the woman withan EDD (ibid; Weiner & Baschat, 1999).
Irrespective of who is ‘winning’ the complex de-bate outlined above, when it comes to allottingsignificance to a woman’s knowledge of her indi-vidual cycle, technology appears to be gaining as-cendancy over woman’s self-knowledge. In realitythe power and glamour of the ultrasound scan-ning tool tends to dominate over most women’sunique and exclusive awareness of their body’ssubtle changes. The issue for a midwife, and forwomen centred practice, is – what is the price paidfor such complete reliance upon high technologyas being superior to a woman’s self-knowledge?
The issue of safetyA separate, but closely related topic is the physi-ology of the onset of labour. This is the subject ofanother article entirely, as there is no room hereto set down in necessary detail the latest theory asto why labour starts, and what can already be es-tablished. I would like to summarise the most re-
cent theory we have, by saying the baby is thetrigger (Hamilton, 1998). A hunger stress in thebaby is believed to set off a series of complex physi-ological steps that begin labour. The baby liter-ally signals a need to move on from the sustenanceof the placenta to the next growth and develop-ment climb that demands breast milk. Midwiferylore suggests that for some women this is regu-larly at 36 weeks for every pregnancy, and forsome, as long as 43 weeks every time. It seemsagreed that nature has a mechanism. Mostly themechanism can be trusted. Also spontaneous la-bours up to 41 weeks reknown to have better out-comes and reduced risks formother and baby than pro-voked labours. (Crowley,1999). However many la-bours these days are in-duced and one major ra-tionale is PP (note: not PTP). So, why not justwait until the labour begins by itself? I am usingthis question to conclude this article on the dat-ing of a pregnancy and the significance of the so-called prolonged pregnancy, since both topics leadnaturally to this issue. The female body is designedto experience labour; the baby is mature; what isthe twist in this tail?
Post term, i.e. longer than 42 weeks (294 days),pregnancy is regarded as a concern by obstetri-cians and paediatricians because it is associatedwith increased perinatal mortality and morbidity(Crowley, 1999). The increased mortality is partlydue to congenital malformations. The other maincause of death is asphyxia. Neonatal seizures arebetween two and five times higher in infants bornafter 41 weeks. Meconium-stained fluid is a com-mon feature among the babies who die (Enkin,Keirse, Renfrew & Neilson, 1995).
How common is PTP? The incidence of PTP (seeabove definition, and compare with PP) whenpregnancies are dated by first trimester ultrasoundscanning is less than 5%; otherwise incidences arereported from 3 to 10%, or more (Chua &Arulkumaran, 1999). Women who have had oneprevious PTP have a 30% chance of it recurring,and those who have gone overdue with two preg-nancies, have a 40 % chance they will again alsohave a PTP with their third (ibid). It could be, ofcourse, that the length of a pregnancy is individualto each woman. From discussion with colleaguesit seems experienced midwives have observed somewomen, in each of their pregnancies, always ‘carry’for 36 to 38 weeks, some for 42 to 43 weeks.
Hilder, Costeloe and Thilaganathan (1998) ret-rospectively studied the gestation specific risks offetal and infant mortality with prolonged preg-nancy analysing 71,527 births during 1989-1991.
They concluded: “There is significant increase inthe risk of still birth, neonatal and post neonatalmortality in prolonged pregnancy” (ibid, p.169). Itis relevant to point out that many of these studiesuse data collected prior to widespread first trimes-ter scanning to regularise the dating. Also it ispertinent to repeat that even first trimester scanshave an ‘accuracy’ of prediction of plus or minusfive days (Otto & Platt, 1991). As has been said,this method of dating a pregnancy is widely toutedto reduce the true incidence of prolonged preg-nancy dramatically (Romero, 1993, cited in
Chervenak et al., 1998;Usher, Boyd, McLean, &Kramer, 1988; Chua &Arulkumaran, 1999). Un-less all pregnancies weredated similarly, there mustbe a question mark overthe inclusion criteria se-
lected and logically over the conclusions formedby the study of the resulting data.
Frye (1996) on the other hand questions the trueextent of the problem as it is propagated by themedical profession. She believes: “congenitalanomalies, infection and intrauterine growth retar-dation account for much of the perinatal mortalitygenerally lumped in to the post mature category” (ibid,p. 29). Goer (1995), in her review of the researchshe accessed, with a stated aim of eliminating themyths, rebuts all the rationales put forward forevidence of younger and younger gestations be-ing regarded as PP. She challenges the methodol-ogy of randomised controlled trials (RCTs) butdoes acknowledge there is risk.
Postdates pregnancy is far from cut and dried. Test-ing in order to induce selectively introduces risks.Routinely inducing creates more problems than itsolves. Letting nature take its course is generallybest, although that is not risk free either. No courseof action (or inaction) guarantees a good outcome.The result is you pay your money and you takeyour choice (ibid, p.183).
In 1994 the National (United States of America)Institute of Child Health and Human Develop-ment Network of Maternal-Fetal Medicine Units(NICHHDU) reported on their RCT of 440women who either underwent immediate induc-tion at 41 weeks, or had nonstress testing andamniotic fluid volume assessment twice a weekuntil there was a concern or they laboured spon-taneously. They found that from the perspectiveof perinatal morbidity or mortality that eithermanagement approach was acceptable. Despitedifferences in protocols, their conclusions matchedthose of the Hannah Trial (3407 PP women)(Hannah, Hannah, Hellmann, Hewson, Milner& Willan, 1992). These results showed that in
continued over...
In reality the power and glamour of the
ultrasound scanning tool tends to dominate
over most women’s unique and exclusive
awareness of their body’s subtle changes.
New Zealand College of Midwives • Journal 28 • April 200310
post-term pregnancy, the rates of perinatal mor-tality and neonatal morbidity are similar with thetwo approaches to management, i.e. induction at41 weeks, or serial antenatal monitoring and spon-taneous labour. Caesarean section rates werehigher in the expectant (awaiting spontaneousonset of labour) group of the Canadian (Hannah)study. However these happened because of higherlevel of diagnosis of fetal distress, and criteria forfetal distress were not controlled. In other words,more fetal distress, seeming to require birth bycaesarean section, was decided on, and criteriaused to reach this decision, varied.
The findings of the systematic reviewof the research into management of PPThe systematic review is regarded as the pinnaclein the hierarchy of evidence to inform clinicaldecision making (Greenhalgh, 1997). The con-clusion of The Cochrane Library’s systematic re-view Interventions for preventing or improving theoutcome of delivery at or beyond term2, after carefulselection of 26 randomized and quasi-randomizedtrials of interventions involving the intention toinduce labour at a specified gestational age, in-volving women with apparently certain dates, was:“…routine induction of labour after 41 weeks ges-tation appears to reduce perinatal mortality”(Crowley, 1999, p.1). In addition to the referenceto the length in the period of history of the trials(18 out of 26 trials date prior to 1990), Crowleyalso describes the methodological quality of thetrials as variable Returning to the conclusion ofthe review, in other words, it may be that fewerbabies die if routine IOL takes place between 41and 42 weeks. Interestingly both the Hannah andthe NICHHDU, both of which clearly concludeno advantage to waiting or to inducing, studieswere included in this review.
On the basis of the meta analysis carried outwithin the systematic review, it was calculated thatfor every 500 (at least this number but possiblyas many as 1000, i.e. the number needed to pre-vent harm) low risk women at, or beyond 41weeks gestation, induced without (other) need,one baby would be protected, i.e. not die as anunexplained stillbirth (odds ratio: 0.20; 95% con-fidence interval: 0.06 to 0.70). Crowley cautionsthat the number (500) of inductions required toprevent one perinatal death may be biased. Sheexplains that the Henry trial, held prior to 1969,reported a high perinatal mortality rate. So: “Itmay be that the number of inductions of labour re-quired to prevent a single perinatal death may behigher in present day practice” (Crowley, 1999, p.4).
ConclusionAs the earlier discussion indicates, controversiescontinue about PP. Dating of a pregnancy is im-precise but best evidence recommends offeringIOL after one week beyond term. Given that thetiming of ‘term’ is imprecise, so then is term plus7 days. This is concerning when spontaneous on-
set of labour increases the woman’s chances ofhealthy, possibly more satisfying, spontaneousoutcomes and overall less morbidity. Whose priceis it to pay? Such information as I have offered,and subsequent reflection, may be useful to helpmidwives understand, support and inform womenwhose pregnancies are prolonged and who facethe choice of induction of labour or further wait-ing for spontaneous onset of labour. Anecdotally,from discussion with midwifery and obstetric col-leagues throughout the country, the ‘evidence’ iscompelling that otherwise low risk women arebeing booked to have labour induced, barely hav-ing reached term. I read recently a midwife’s re-sponse to the prompt in the required hospitaldocumentation: “Indication for Induction” Shehad written: “At term.”!
My exploration of the issues around dating andgoing “overdue” with a pregnancy uncovers, I feel,a trail that is mired with imprecision, lack of con-sensus, uncertainty and incomplete knowledge.Why is it important? The pendulum seems to beswinging right back to the 1970’s when IOL ratessuperseded spontaneous onset of labour in manymaternity hospitals in the developed world untilconsumers and health professionals loudly ques-tioned the practice (Cartwright, 1979, Kitzinger,1976). Do we watch the pendulum’s slow swing,or do we influence it’s direction, and steady it,with good, current information and careful ex-planation to the women?
ReferencesBergsjo, P., Denman III, D.W., Hoffman, H.J., & Merik, O.
(1990). Duration of human singleton pregnancy: Apopulation based study. Acta Obstetricia GynecologicaScandinavica, 69, 197-207.
Boisselier, P., & Guettier, X. (1995). Prolonged pregnancy.Review of the literature. Journal of Gynecology, Obstetrics,Biology and Reproduction, 24 (7), 739-46.
Cardozo, L., Fysh, J., & Pearce, J.M. (1986). Prolongedpregnancy: the management debate. British Medical JournalClinical Research Edition 293, 1059-1063.
Cardozo, L. (1993). Is routine induction of labour at term everjustified? British Medical Journal, 306, 840-841.
Cartwright, A. (1979). The dignity of labour? A study ofchildbearing and induction. London: Tavistock Publications.
Chervenak, F.A., Skupski, D.W., Romero, R., Myers, M.K.Smith-Levitin, M., Rosenwaks, Z., & Thaler, H.T. (1998).How accurate is fetal biometry in the assessment of fetal age?American Journal of Obstetrics and Gynecology.178, (4),678-687.
Crowley P. (1999). Interventions for preventing or improving theoutcome of delivery at or beyond term (Cochrane Review). In:The Cochrane Library, Issue 2, 1999. Oxford: Update Software.
Enkin, M., Keirse, M.J.N.C., Renfrew, M., & Neilson, J.(1995). A guide to effective care in pregnancy and childbirth,(2nd ed.). New York: Oxford University Press.
Frye, A. (1996). Postdates vs postmaturity. Midwifery Today,Summer, 38.
Gardosi, J., & Geirsson, R.T. (1998). Routine ultrasound is themethod of choice for dating pregnancy. British Journal ofObstetrics and Gynaecology,105, 933-936.
Gardosi, J., Vanner, T., & Francis, A. (1997). Gestational ageand induction of labour for prolonged pregnancy. British
Journal of Obstetrics and Gynaecology, 104, 792-797.
Gibb, D. (1984). Prolonged pregnancy. In J.W.W. Studd (Ed.),The management of labour, (pp.108-122). Oxford:Blackwell, Scientific Publishers.
Goer, H. (1995). Obstetric myths versus research realities.London: Bergin and Garvey.
Greenhalgh, T. (1997). How to read a paper. London: BMJPublishing Group.
Hamilton, G. (1998). Let Me Out. New Scientist, 10 January,25-28.
Hannah, M.E., Hannah, W.J., Hellmann, J., Hewson, S.,Milner, R., & Willan, A. (1992). Induction of Labour ascompared with serial antenatal monitoring in post termpregnancy. New England Medical Journal, 326,1587-1592.
Hilder, L., Costeloe, K., & Thilaganathan, B. (1998). Prolongedpregnancy: evaluating gestation-specific risks of fetal andinfant mortality. British Journal of Obstetrics andGynaecology, 105, 169-173.
Hutcheon, D.J.R. (1999). Routine ultrasound is the method ofchoice for dating pregnancy. [Letter to editor]. British Journalof Obstetrics and Gynaecology, 106, 616.
Kitzinger, S. (1976). Brief Encounters. Effects of induction onthe mother-baby relationship. The Practitioner, August, 262-267.
Mittendorf, R., Williams, M.A., Berkey, C.S., & Cotter, P.F.(1990). The length of uncomplicated human gestation.Obstetrics and Gynecology, 75(6), 929-932.
Mongelli, M., Wilcox, M., & Gardosi, J. (1996). Estimating thedate of confinement: ultrasonographic biometry versus certaindates. American Journal of Obstetrics and Gynecology, 174(1, Pt 1), 278-281.
National Institute of Child Health and Human DevelopmentNetwork of Maternal-Fetal Medicine Units (1994). Aclinical trial of induction of labor versus expectantmanagement in postterm pregnancy. American Journal ofObstetrics & Gynecolog, 170 (3), 716-723.
Olsen, O., & Clausen, J.A. (1997). Routine ultrasound datinghas not been shown to be more accurate than the calendarmethod. British Journal of Obstetrics and Gynaecology, 104,1221-1222.
Olsen, O., & Clausen, J.A. (1998). Reply to correspondence.British Journal of Obstetrics and Gynaecology, 105, 1227.
Otto, C., & Platt, L.D. (1991). Fetal growth and development.Obstetrics and Gynecology Clinics North America, 18 (4),907-931.
Roberts, L. J. (1993). Induction of labour. [Letter to the editor].British Medical Journal, 307, 66-67.
Saunders, N., & Paterson, C. (1991). Effect of gestational age onobstetrical performance: when is “term” over? The Lancet,338, 1190-1192.
Usher, R.H., Boyd, M.E., McLean, F.H., & Kramer, M. S.(1988). Assessment of fetal risk in postdate pregnancies.American Journal of Obstetrics & Gynaecology, 158, 259-264.
Weiner, C.P., & Baschat, A.A. (1999). Fetal Growth Restriction:evaluation and management. In D.K James, P.J. Steer, C.P.Weiner & B. Gonik (Eds.), High risk pregnancy managementoptions. (2nd ed.). 291-308. London: W.B. Saunders.
Zimmermann, R., & Wisser, J. (1998). Ultrasound has not beenshown to be more accurate than the calendar method. BritishJournal of Obstetrics and Gynaecology, 105, 1126-1127.
1 This is the measurement of crown-rump length, femur length,bi-parietal diameters, and abdominal circumference byultrasound (sound waves) radiation to compare with tables ofmean measurements of these lengths and therefore calculate anestimated gestation or age of the fetus.
2 The last substantive amendment to the review was made inOctober, 1996.
“I’m ready for you, baby, why won’t you come?”How long is a pregnancy and how long is too long?
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Accepted for publication: February 2003
Davies, R. (2003). “ I’m ready for you, baby, whywon’t you come?” How long is a pregnancy andhow long is too long? New Zealand College ofMidwives Journal, 28 (1), 8-10.
New Zealand College of Midwives • Journal 28 • April 2003 11
Sarah Stewart RM, DPSM, BSc(Hons) MA(Applied)
142 Musselburgh Rise, DunedinMidwifery Lecturer, School of Midwifery,Otago Polytechnic, DunedinEmail: [email protected]
Believe it or not, the summer in Dunedinhas been so good that I have been surfing inthe sea and not on the Internet. However, Ihave found some great web sites that areparticularly pertinent to clinical issues.
If you are interested in the “Term BreechTrial”, visit Maggie Banks’ web site that has acritique of the research(www.birthspirit.co.nz). Maggie has alsouploaded an article she wrote for ‘ThePracticing Midwife’ entitled “But Whose ArtFrames the Questions?” In this article shequestions the effect of guidelines onmidwifery practice.
The Department of Health (UK) has aninformation leaflet about vitamin K forbabies, available for downloading(www.doh.gov.uk/vitamink/index.htm).It is available in various languages such asHindi, Turkish and Bengali. It is a usefulleaflet to give women even though it has aBritish context.
Sara Wickham is a British midwife who haswritten the book “Anti-D in Midwifery -Panacea or Paradox?” Sara now has her ownweb site (www.withwoman.co.uk) and hasmade various articles available coveringtopics such as care of the perineum, anti-D,lotus birth, and use of the Pinard. Thesearticles have been previously published inmidwifery journals such as ‘The PracticingMidwife’ and ‘MIDIRS Digest’. Sara is achallenging and entertaining writer so it iswell worth checking out her web site. Myespecial favourite is “An ode to the oopstrial” which is Sara’s commentary on theHOOP trial.
Sherryl Wright is a midwifery student andprovides a myriad of links to web sites ofinterest to midwives (www.geocities.com/cyberbirth/links.htm). Several of the linksI checked out were EndocrineWeb.com,which has information about thyroidproblems and pregnancy(www.endocrineweb.com/pregnancy.html); Everybody.co.nz which
has produced information for women aboutgroup strep B (www.everybody.co.nz/docsd_h/groupb_strep.html); and the Mental HealthFoundation of New Zealand(www.mentalhealth.org.nz). This web siteprovides detailed literature in the form of pdf andword documents that can be downloaded,covering topics such as postnatal depressions,bi-polar affective disorder and schizophrenia.It also supplies links to various support groupsand sources of further information.
The Cook Children’s Medical Center is achildren’s hospital in Texas, USA(www.cookchildrens.org/CC/Ped/hrpregnant/hrpregnant_home.htm). This web site providesa detailed section on high-risk pregnancy, whichis a good resource for midwifery students. It dealswith numerous situations such as pre-termrupture of membranes, pregnancy-inducedhypertension, post partum hemorrhage and sicklecell disease. I have not carefully perused eachsection so I cannot say how up to date theinformation is. It is medicalised and its perspec-tive is American, which is a different context thanhere in New Zealand. However, it is a goodstarting point for midwives investigating certainmedical conditions.
The Women’s Health Information web site ismanaged by an English obstetrician called DrDanny Tucker (www.womens-health.co.uk).This web site deals with all sorts of issues such aspolycystic ovary syndrome, shoulder dystocia andcardiac disorders in pregnancy. It is worth havinga look and certainly the articles appear to becredible work. My only reservation is that the website hasn’t been updated for a couple of years soyou need to remember that the information maynot be up to date.
The March of Dimes is an American non-profitcharity that works to prevent birth defects andincrease infant mortality through research andhealth campaigns (www.marchofdimes.com).The web site is very professional in its appearanceand provides areas for both professionals andwomen. The professional section includes factsheets on a huge range of topics and issues such aslow birth weight, sexually transmitted disease inpregnancy, amniocentesis, and cleft lip and palate.The fact sheets are current and presented in aclear, proficient manner, with credible referencing.They are also available in Spanish. Again, theseare written with an American perspective so needto be treated accordingly.
The National Electronic Library of Health(www.nelh.nhs.uk) is an interestingresource for midwives. It has links to theMIDIRS Informed choice leaflets, NICE,Medline/PubMed, and many more. It alsolinks to an online tutorial that is designedfor midwives to “teach themselves” how touse the Internet (www.vts.rdn.ac.uk/tutorial/nurse). The tutorial is probablymore useful for “newbies” than midwiveswho are more experienced Internet users.
PubMed (www.ncbi.nlm.nih.gov/entrez/query.fcgi) is an American database ofmedical and health journals. The databasecarries references and abstracts of articles inmidwifery journals such as ‘Maternal andChild Health’, ‘The Practising Midwife’,‘Midwifery’, ‘Birth’ as well as medicaljournals. There is access to some full textarticles but you need to be a payingsubscriber to have this access.
I have recently found out that Nga Maiahas a web site (www.ngamaia.org.nz). It isa very attractive web site with lovelyphotos. It gives information about the NgaMaia, trustees, membership and links tovarious other pertinent organizations.There is also a discussion forum, whichreally hasn’t got off the ground yet. Myfavourite page is called ‘birthing stories’which deals with creation and birthing.
My summer reading this year was not theusual bosom-heaving Mills and Boon, buta New Zealand magazine called NetGuide(www.netguide.co.nz). I would highlyrecommend it for both established Internetusers and “newbies”. It is a monthlymagazine that deals with hard/softwareproblems, suggests web sites and discussesissues such as safety for children using theInternet. I would especially recommendthe summer edition called “HelpdeskAnnual”, which is a compilation ofproblems people have contacted themagazine’s Help Desk about and theirsolutions. The magazine’s web site is also agreat resource, where readers can downloadsoftware such as games, desktop accessoriesand Internet tools. You can work throughonline tutorials and learn things like howto build your own web site, make the mostof your email program and keep yourPC healthy.
S U R F I N G T H E N E T
New Zealand College of Midwives • Journal 28 • April 200312
R E S E A R C H
IntroductionIt is important to understand the influence thatlegislation and funding structures has had on theway midwives in New Zealand practice and howthese changes have impacted on the continuity ofcare and carer models of midwifery. The 1990Amendments to the relevant Acts that impactedon midwifery practice in effect gave the midwifethe same legal rights as medical practitioners toprovide a comprehensive maternity care servicefor New Zealand women. The legislation changescreated a precedent for midwives making themeligible to provide a full range of maternity careservices. Previous legislation and funding stipu-lated medical involvement in the provision ofmaternity care (New Zealand Statute, 1904, 1925,1945, 1971, 1977). At the time that this researchwas carried out, 60% of low risk New Zealandwomen chose a midwife as their Lead MaternityCarer (Health Benefits Ltd., 1999).
BackgroundThe hospitalisation of women during childbirthfrom the late 1930s onwards changed the scopeof practice of the midwife from that of being in-dependent (Papps & Olssen, 1997), albeit super-vised by the medical profession (New ZealandStatute 1904, 1925, 1945), and primarily com-munity based, to having hospital employee sta-tus. The exception being the small number of in-dependent midwives who continued to serve theneeds of women wishing to have a homebirth(Donley, 1996). The 1971 Nurses Act reclassifiedthe “Midwife” as a “Nurse” thereby further re-ducing the midwife’s scope of practice (New Zea-land Statute, 1971).
Research designThis qualitative study used an eclectic approach
to inform the study design, data collection andthe data analysis. Ethical principles within thisstudy were considered by the researcher and wereadhered to when setting up the study and duringthe course of the research process. Wilson (1985)describes the four rights of research participants:The Right of Privacy, Anonymity and Confiden-tiality; The Right not to be Harmed; The Rightto Self-determination and The Right to Full Dis-closure. Ethical approval was gained from Wel-lington’s Capital and Coast Human Ethics Com-mittee. The method for the data collection was byrecorded narrative of the participants’ experienceof working in a continuity of carer model of mid-wifery. Narrative offers a way of exploring theknowledge and culture of individuals by retainingtheir voice and the context of their lives. Narra-tive has been described as the primary scheme bymeans of which human existence is renderedmeaningful (Polkinghorne, 1988, p.11) and theway in which people organise their experience in,knowledge about, and transactions with, the so-cial world (Bruner, 1990, p.35). The belief thatwomen’s stories are a valuable source of learningwas instrumental in choosing narrative informedby feminist methodology. The reality that mid-wifery is predominantly a female occupation, al-beit that not all midwives share a feminist phi-losophy, and that midwives’ stories have a richcomplexity that should not be excised in the dataanalysis, make this methodology a natural choicefor this research project. Duelli Klein (1983, p.90)explains that research for women is research whichtries to take women’s needs, interests and experi-ences into account and aims at being instrumen-tal in improving women’s lives in one way or theother. The Framework Approach to thematicanalysis was used to analyse the data. As outlinedin Pope, Ziebland and Mays (2000) the Frame-work Approach is a five step analytical process usedmainly in policy research and preserves the origi-nal accounts and observations of the people stud-ied. It is more suited to structured qualitative datacollection but can be usefully adapted to narra-tive. Five midwives from five separate group prac-tices, four of which had a variation in their fund-ing model, took part in the study.
The findings of the research were presented incontextual exemplars. Italicised text represents theparticipants’ words. Pseudonyms have been givento the participants to protect their identity as out-lined in the research recruitment letter. The re-search was undertaken in fulfilment for the de-gree of Master of Arts in Midwifery and furtherdetails are available in Engel (2000).
Findings of the researchFollowing categorisation of key themes and sig-nificant concepts one major conceptually mean-ingful theme and three supporting themesemerged from the data analysis. The three sup-porting themes were:
a) keeping the balanceb) job satisfactionc) setting boundaries on practice.
The major theme was that the balance dependedon the funding model.
A sample of contextual exemplarsfrom the data analysisCiara was the first participant in the study andhas been in independent practice for four years.She is a salaried employee with a Union HealthService and provides midwife led care for all ofher clients. She takes on a maximum of forty-fiveclients per year. She would like to stay in the con-tinuity of carer model of midwifery for anotherthree to five years, beyond that she is not sure whatdirection she will go. The lifestyle is the reasonthat she does not see herself staying in this modelof midwifery any longer. It is the job satisfactionbecause the lifestyle is awful, I think… unless youget extremely high job satisfaction it is not worthdoing, because in too many other ways it is too hardon your life. People who look at our group practice,because we have structured time off and very goodcoverage from each other think we are working inquite a luxurious way but having one week-end inthree off is the only time we are not on call… whenmost people work forty hours a week and the rest ofthe time they are off. We could choose to take moretime off if we wanted to but we don’t actually wantto miss the birth. The relationship with the womendoes mean you are going to be on call for them andvery accessible. So every time you go out or do any-thing personal at all you are likely to be interrupted.I think for many of us it is very easy to get sucked into working day and night and it needs to be checkedand the need to formally pull back sometimes.
The meaningful relationship with the womanseems to be at the heart of job satisfaction for themidwife and yet the most difficult to pull backfrom. Ciara has said that it is quite difficult to ‘letgo’ when so much energy has gone into develop-ing the relationship. I think for many of us we aretrying to pull back a bit from that, but it is hardbecause it is a trade-off between satisfaction in thejob and becoming really aloof from it all and thatwould change the whole relationship… we try andkeep the balance by bringing in a second midwifemore, maybe at the second visit and for othervisits so that there is more contact with thesecond midwife.
Towards a sustainable model of midwifery practicein a continuity of carer setting: the experience of New Zealand midwivesChristina Engel RGON, RM, BA (Education), MA (Midwifery).
Currently employed as a midwifery lecturer atUniversity College Hospital/National Universityof Ireland Galway, Republic of Ireland. Takes asmall homebirth caseload as an independentmidwife in the West of Ireland. Worked inWellington, New Zealand as a midwife from theearly 1980s onwards, later as a midwife lecturerat Massey University, Wellington. During the1990s worked for five years as a self-employedmidwife in Wellington.
Correspondence to: School of Midwifery, University
College Hospital, Galway, Republic of Ireland.
New Zealand College of Midwives • Journal 28 • April 2003 13
The absolute intensity of the relationship mayneed to be diluted a little to help the midwife keepa sense of balance when it comes to ‘letting go’ forregular time off. Ciara goes on to say I think thejob can be quite idealised. There is something ro-mantic about people becoming everything to otherpeople, becoming an important part of their lives.Initially it is very easy to actually lose all of your ownlife and balance and just give everything to the joband doing that is immensely satisfying but I do notthink that is sustainable.
Germaine was the second participant in the study.The practice that she works in has a direct con-tract with the Health Funding Authority wherethe antenatal, labour and birth and postnatalmodules are reasonably evenly split. Germainetakes on approximately forty five clients per yearand provides midwife led care. She has been inindependent practice for seven years and plans onworking in the continuity of carer model untilshe retires. She loves the work, the lifestyle, beingher own boss and professionally finds the job verysatisfying. The clients’ needs are very importantto her but she tries to find a balance so that herown needs are met. Germaine finds it importantto set boundaries with the women she cares forbut she believes it is much more important to havetrust in the woman’s ability to make decisions onwhen to call the midwife. I trust the client to makethe decision and I do not think they will ring meunless they need me. I might have stayed awake ini-tially but I think it is just experience. I am not anuptight person. The guideline is that they can call usany time. We have given them permission to labourwith their support person and that they will call uswhen they need the midwife… the bottom line isthat we will be there for them on the day or whenthey need us. In reality we visit the woman early inlabour, do all the necessary checks, we talk aboutwhat is going on and if everything is well we may say‘right, I will see you in a couple of hours’ or may becalled back sooner than that. If the woman wants togo to the hospital then we do have to stay in attend-ance with her.
Germaine believes that manageable caseloads willavoid the problem of midwives reaching exhaus-tion level. She states I am a little sad to see the fre-quency with which some midwives are in deliverysuite with women and just to hear their commentsaway from the client ‘I’m so tired’ and I just feel forthe woman as some of that type of energy must comethrough to the client and you see how we survivebecause our caseload is not too high.
Valuing the needs of the midwife alongside thatof the woman seems to be a difficult thing formany midwives who have developed a meaning-ful relationship with the woman. The funding al-
location of the labour module in most of the con-tracts for maternity care may contribute to thereluctance by some midwives, who have put somuch into the woman’s care, to hand over the la-bour care to a back-up midwife. Germaine ex-plains in our group the midwife who catches the babyor does most of the care during labour and birth getsthe money. There is no problem in asking your part-ner to come in as we look at it as swings androundabouts. We have met the women at least onceand if they come to the coffee mornings we will havemet them a number of times… I have a responsibil-ity to the woman and also to my partner. I knowthat I can ring her and I do and she knows she canring me and she does. She knows she will get paidand I know that I will get paid.
Germaine believes that the continuity of carermodel of practice is sustainable for her. Yes, I planon continuing in this model of midwifery care untilI retire. I am strict about having structured time off.I could not sustain my practice otherwise. I do notintend to burn out. I enjoy my work and the lifestyleof independent practice… experience has given methe courage to have less time as a midwife and moretime as me.
Sonia was the third participant in the study. Sheis a shareholder with Maternity Project Welling-ton (Matpro) where the funding package gives thelabour and birth module a considerably better al-location of funds than the antenatal and postna-tal modules. Sonia provides midwife led care toher clients and takes on at least sixty clients peryear. She has been in independent practice for nineyears. The job satisfaction is the main reason thatSonia loves working in the continuity of carermodel of midwifery practice. I find it incrediblysatisfying. I love my work, being on call can be verydifficult and we have to have strategies for that butthe actual continuity and satisfaction… and havingwomen coming back baby after baby is lovely.
Sonia sees it as important to have good collegialrelationships and a shared philosophy of midwiferywith her colleagues. My colleague and I are bothcomfortable with each other’s philosophy of care.I like the way she works, so that is extremely impor-tant… if you can find someone who is philosophi-cally compatible to work with, to back you andyou back them, that is the absolute key to keepingyour sanity.
The financial side of Sonia’s midwifery practice iskept strictly business like. She has a clear under-standing with her colleague and other midwiveswho are within her support system on how fi-nances are shared for work done on her behalf. Ithink I have to keep it business like otherwise resent-ments build up. My colleague does much more of my
visits than I do for her as I have a much biggercaseload. We have a very good friendship… but wekeep all the money side of things very business like, sothat it does not cause problems between us, becausewe do not want problems. We reciprocate a lot of thetime or we bill each other depending on the indi-vidual midwife. We may work it out loosely some-times but because we work so closely we try and keepeverything so that there is no disagreement. We workwell together and we do not want to blow it.
Sonia provides midwife led care and works with amodular system of funding that also lends itselfto shared care with a medical practitioner. Shebelieves the total funding is inadequate for sharedcare arrangements. I know it is swings androundabouts but when you have to share it… I ac-tually think plumbers can make a lot more money, ifyou compare the hours that midwives work… if youthink of the hours and hours that a midwife spendswith a woman in labour, sometimes.
Sonia’s long-term plan is to continue working inthe continuity of carer model of midwifery. Shesees this model as sustainable for her. I look aroundand see midwives burning out in all directions andhere I am… it is nine year’s now since I started andI actually feel just as good about the job as when Istarted. In some ways I am unique… I think theimportant thing is not to dwell on the responsibility.It’s like when you have children if you think too hardabout all the things that could happen to them youwould never have children. You would be paranoid.It is like that with midwifery. I think you do the bestthat you can with the knowledge that you have. Ifyou are in doubt you refer to a specialist or you ringa colleague and talk about it. Have a mentor if youcan possibly get one. I didn’t have a mentor. I amgoing to do this job until I retire.
Libby was the fourth participant in the study. Sheclaims set fees direct from Health Benefits Lim-ited. The labour and birth fees through this gov-ernment agency allow considerably more for thelabour and birth module. Libby had taken in ex-cess of sixty clients per year and provided bothshared care and midwife care. Libby stayed in in-dependent practice for eight years. She has nowleft the practice to take up another position withregular hours. Libby explains how the unstruc-tured nature of the continuity of carer model wasfor her initially. A major change. I found it moredemanding than anything I had ever done previ-ously, more tiring, hardest part being the long peri-ods of being on call. I developed strategies to copewith this. I think if you want to work on a one toone basis you have to accept an unstructured timeta-ble. If the midwifery group want a team approach itis probably a bit better as you may get week-endsand regular time off… I have no problem with un-
continued over...
New Zealand College of Midwives • Journal 28 • April 200314
structured hours as it makes it easier to care for thewomen, easier to detect if things are beginning to gowrong. You become more aware of the woman as aperson, so in that way it is a positive thing. As far asgetting called out that was not a problem.
Libby realised that she had to set boundaries withthe women she provided care for otherwise shecould not have continued in the continuity of carermodel of midwifery for so long. The demands ofwomen changed over theyears, very much so, whereasat the start continuity ofcarer was something new tothem and something theythought ‘I will give it a go’.They enjoyed the experienceof continuity, so they cameback and started to demandmore, or had higher expectations. An attitude of ‘Ican clap my hands’ and you would come wheneverthey wanted. I would have to say ‘I am sorry but I dothat type of care within regular hours’. When I spoketo women initially or when they contacted me I wouldlet them know that a booking visit and regular ante-natal visits were done during daytime hours… Iwould say I am not coming out at 8pm for non-urgent visits. When I first started in practice I woulddo late evening visits and I soon realised that I hadno time for myself… people were very understand-ing if I had to cancel… the women always hadaccess to me.
Funding of any service ultimately has a majorimpact on how that service is delivered. Libbybelieves that the modular system may have nega-tive financial implications for midwives workingin shared care arrangements. It is very difficult withthe modular system when you want to take regulartime off or emergency calls, as there is no extra pay-ment available. I think the government have optedout of making the decision on things like that be-cause of the general practitioners wanting to stay inobstetrics. I really do, the power the medical profes-sion have has influenced decisions that are affectingmidwifery practice. It is the midwife who is calledout in the shared care situations… funding definitelydirects the way one practices, as in any business. Itfocuses attention on how much you give regardingyour time. Having regular bills to pay such as taxand other expenses certainly focuses one on the amountof work you take on.
Libby decided that after working in independentpractice for eight years it was time for a change ofdirection. She explains why she came to that de-cision. My reason for choosing another career wasnot motivated by money. I left independent practicebecause of burnout due to the demands made uponme. Phone ringing all the time, on call twenty-four
hors a day for long periods of time. I had my owncaseload. I had good back-up. Gradually I lost mostof my social contacts that I had built up over theyears’ as I had to keep turning down invitations.When I invited people to my place I sometimes hadto leave in the middle of entertaining… I graduallycut back over a period of six months and now aftereight years of being self-employed I have given up mypractice completely. I am happy with my decisionand have another position that gives me regular hours
and plenty of stimulation…I feel more in control.
Angela was the fifth par-ticipant in the study. Shehas been in independentpractice for eight years.Angela is a shareholderwith Maternity Project
Wellington (Matpro) and does a mixture of sharedcare and midwife led care. Angela takes on ap-proximately sixty clients per year. She enjoys thelevel of professional autonomy that being in in-dependent practice brings mainly because I can stilluse all my knowledge and skills… a midwife needsto be able to use all the knowledge she has gainedduring her training and experience. The outcome ofyour training should be to be a professional educa-tor. That is where I get my job satisfaction. Yes, it isquite good and satisfying professionally.
Angela sees having regular time off work as a pri-ority. There should be some ground rules in the groupin which you work. We are aware in our practicethat we all get time off, that we need time off. Defi-nitely we encourage one day a week and then week-ends when we can. If things are quiet we try andshare having some of that particular weekend off,other than our planned weekends. The longer thatwe have been practising the more aware we are, themore aware we have become, of the importance ofregular time off. Because we can burnout so quickly,if you have a lot of births in one go and a lot of visitsto catch up with you sometimes feel… I think thereis an awareness that the job can be draining espe-cially if you have young children, it can be quite stress-ful. We have a good working relationship. We lookafter each other. I see this as being very important. Isee midwives with poor back-up or no structuredgroup. Not fair on the women. I have regular holi-days… I find my back-up midwife very supportive.It makes a huge difference. The women don’t mind.I have explained to them beforehand, I make it clear.If two women are in labour at the same time theyknow my back-up will come.
Angela believes it is important to set boundariesaround one’s practice and realises it can be a sourceof stress for women and the midwife concernedwhen a guarantee can not be given that you will
be there for the birth. It is an issue and also you feelthe pressure from the woman for you to be there. Youwill have seen the woman for most of the nine monthsand just when she needs you most you are not there,so you have all this conflict going on in your head,but that is made easier if she has met your back-upmidwife as well. Once you overcome that hurdle of‘letting go’ it gets easier. There may be the odd womanwhere I felt I was better with than my colleague andI would then say to my colleague that if she goes intolabour while I am off I will come in, than my col-league would come and do the fourth stage and makeit the shortest possible time for me.
Having a manageable caseload is integral to main-taining a balanced lifestyle for Angela and she isnot easily swayed to take on more than five or sixwomen each month. Yes, I will say ‘I’m sorry but Icannot take any more this month’. I might have takenmore at the beginning or up to a year or two ago butnot now. You do feel for the women when they say‘you are the third or fourth midwife I have phoned’and I say ‘have you got any more to ring’ and then Iwill give them some other midwives’ phone numbers.The workload, it can be variable on whether theyare primips or multips.
The modular system of funding of maternity caredoes not pose much of a problem for Angela andher colleagues as they have reciprocal arrangementswithin the group practice. I mostly reciprocate timewith my back-up midwife... the only time moneychanges hands is when I have covered for someonewho is not associated with my group or when I men-tor a midwife. I see it as straightforward, time recip-rocation is easiest but we pay each other if appropri-ate. No, I don’t see the funding directing practice,it may do for some midwives, I think midwives wouldtake more holidays and time off if the fundingwas different.
Angela plans on working in the continuity of carermodel until retirement. I may take less clients eachmonth. I can see myself doing that. When I look atmyself I manage fine.
DiscussionThe central aim of this research was to discoverthe extent to which a variety of factors contrib-uted or detracted from a sustainable model ofmidwifery practice in a continuity of carer set-ting. The influence of the funding model on thesustainability of self-employed midwives practicewas incorporated as a central aspect of this re-search. Personal circumstances may influence howlong a midwife continues to work in the continu-ity of carer model of midwifery but when mid-wives reach exhaustion and burnout levels it canbe said that that particular model of practice isunsustainable for them.
Towards a sustainable model of midwifery practicein a continuity of carer setting: the experience of New Zealand midwives
continued...
Keeping the balance between job satisfaction
and setting boundaries around one’s practice
was seen as integral to the sustainability
of practice by each of the participants
in the study.
New Zealand College of Midwives • Journal 28 • April 2003 15
Remuneration did not emerge in the data analy-sis as the driving force behind the participants’decision to become self-employed initially. How-ever, the findings indicate that the funding modelof maternity care became a very important con-sideration in the size of self-employed participantspersonal caseloads and in how participants viewedthe labour and birth module of funding as centralto the overall funding package. Self employedparticipants indicated that the loss of this moduleof payment on a number of occasions meant thattheir projected monthly income was reduced con-siderably. This had the potential for serious cashflow problems from a business perspective. Lossof clientele could impact on the financial stabilityof the participant’s midwifery practice when allassociated costs of being a self-employed midwifewere taken into account. It was stated by someparticipants that there were financial implicationswhere a second midwife was involved in the wom-an’s care. Some of the participants did not viewthis as a financial loss as back-up was done on areciprocal basis and was not viewed as a financialloss if the participants had a comparable numberof clients.
It was evident in the findings in the theme jobsatisfaction that professional autonomy and per-sonal accomplishment contributed to a sustain-able model of midwifery practice. All participantsexpressed the view that they experienced high lev-els of job satisfaction and personal accomplish-ment in providing continuity of midwifery care.Sandall (1996) found that professional autonomyand personal accomplishment were linked to con-trol over work. Self employed midwives in NewZealand have control over work to a large extentbut working in a business model of midwifery mayencourage large personal caseloads, for examplein excess of fifty to sixty clients per annum, wherecontrol over work may be difficult to achieve. Flint(1993) and Leap (1996) stress the need to developstrategies for self-care when working in the conti-nuity of care models of midwifery. All participantsin the research elaborated on the need for goodback-up midwifery support in order to sustainpractice. Research by Brody (1996), Sandall(1997), and McCourt and Page (1996) shows thatcollegial support and good back-up facilities areas equally important to the woman as to the mid-wife concerned.
In the theme setting boundaries on practice partici-pants found that it was important to set bounda-ries around their practice by giving guidelines totheir clients on the role of the midwife in the con-text of continuity of carer. Participants had dif-ferent strategies on setting boundaries but the gen-eral consensus was that it was important to haveeffective communication and to give the woman
appropriate information on the midwifery serv-ice and when to call the midwife. After long ex-posure to the demanding nature of an unstruc-tured work environment one participant in thestudy had decided to cease practising midwiferycompletely.
Keeping the balance between job satisfaction andsetting boundaries around one’s practice was seenas integral to the sustainability of practice by eachof the participants in the study. For the self-em-ployed participants this appeared to be under-pinned by the structure of the funding model.‘Letting go’ at crucial times such as during thewoman’s labour and birth was difficult for themajority of participants in the study when so mucheffort had gone into developing the meaningfulrelationship with the woman.
The limitations of the studyThe limitation of the study was the small numberof participants in the research project. The factthat all five participants practised in one large geo-graphical area and were known to me, the re-searcher, may also have influenced the narratives.At the time of my research I was not working inthe same practice as any of the participants and Ibelieve the participants spoke with integrity andclarity on their experience of working in the con-tinuity of midwifery care model. Despite the smallnumber of research participants I believe that theresearch findings can be generalised to a muchlarger population of midwives working in thismodel of midwifery care. Issues such as the de-manding nature of the work, being on call forlengthy periods of time, similarity of the mater-nity care funding models nationally are all com-mon features for midwives working in this modelof midwifery. For self-employed midwives the rel-evant issues discussed in the narratives would beof a similar nature to issues of concern to themajority of midwives who operate financially vi-able midwifery practices in New Zealand.
ConclusionsThe structure of the maternity care funding modeldid appear to influence the size of participants’personal caseloads. However the participants’ per-sonal and midwifery philosophy appeared to bemore influential in the organisational aspects ofindividual midwifery practices.
Recommendations• A flexible funding model that leans towards easy
remuneration of back-up midwifery services andtakes into account the on-call nature of the work.
• Capitation funding that would have the poten-tial to create financial stability for independentmidwives. This could be adjusted up or downin order that variables were accounted for.
• Inclusion of pre-conception care, family plan-ning and lactation consultancy as additionallyfunded modules. This would enable midwivesto offer a wider range of women’s health serv-ices and in turn create a more secure financialbase for self-employed midwives.
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S T U D E N T C O R N E R
IntroductionBreastfeeding has been described as the most in-timate form of communication a woman mayhave with her child (Kitzinger, 1998). It is an ex-pression of love (Kitzinger, 1998), a precious gift(Spangler, 2000), and an act that nurtures thematernal-infant bond (Lauwers & Shinskie, 2000;Rose-Neil, 1984; Spangler, 2000). Kitzinger(1998) places emphasis on the relationshipbreastfeeding affords the infant, describing thisfirst relationship as the foundation for all otherrelationships in life. The La Leche League con-siders breastfeeding as the optimal way to feed ababy. Benefits to the mother and baby are welldocumented and include nutritional and immunebenefits to the baby, and physical and health ben-efits to the mother (e.g. Beasley & Trlin, 1998).Both mother and baby profit from the emotion-ally enriching experience (Kitzinger, 1998;Lauwers & Shinskie, 2000; Mohrbacher & Stock,1991; Spangler, 2000).
This article describes my experience ofbreastfeeding my first born son, Michael. He wasborn in 1990, in Bangkok, Thailand. Significantfactors such as family, friends, hospital profession-als, and the cultural influences that impacted onmy breastfeeding experience, are discussed. Fac-tors that contributed to my breastfeeding experi-ence, and to the difficulties I encountered, areidentified and explored.
Initial decisions to breastfeedEven prior to my pregnancy I had already decidedthat, should I ever have a baby, I would definitelybreastfeed. Due to fertility problems my pregnancywas very unexpected, but very much wanted, andour baby was very precious. I saw breastfeeding asthe best way to feed my baby. I never questioned mydecision to breastfeed; likewise I never really ques-tioned the validity of the information on which Ibased this decision. Thinking back, I guess I basedmy decision to breastfeed on information from a va-riety of sources - the media, my nursing experiences,family, friends and perhaps, most importantly, a verystrong gut feeling that it was the right thing to do.My husband was happy to leave feeding decisions tome, though I do wonder what his reaction wouldhave been, had I decided not to breastfeed fromthe outset.
Up to 65% of women decide on infant feedingintentions before pregnancy, and the majority ofall women have decided before birth (Earle, 2000;Huang, Chen & Wang, 2000; Lauwers &Shinskie, 2000; McLeod, Pullon & Basire, 1998).A strong belief in the value of breastfeeding, anda positive attitude, are powerful motivating fac-tors for women choosing to breastfeed (Huang,Chen & Wang, 2000; Lauwers & Shinskie, 2000).The New Zealand College of Midwives(NZCOM) (1992) suggests that a woman’sbreastfeeding success corresponds to her level ofmotivation. However, this can be influencedgreatly by others. Health professionals, significantothers, and the woman’s partner, all play crucialroles influencing the breastfeeding decisions madeby the woman (Huang, Chen & Wang, 2000;Kessler, Gielen, Diener-West & Paige, 1995;Lauwers & Shinskie, 2000; NZCOM, 1992; Raj& Plichta, 1998). Women who choose tobreastfeed often have strong breastfeeding rolemodels within their network of family and friends(Hoddinott & Pill, 1999; Kessler, Gielen, Diener-West & Paige, 1995). Women who receive sup-port from their significant others and from laysupport groups, are more likely to breastfeed(Ryan, 1997). Factors that have negativebreastfeeding associations for women include;young maternal age, lower socio economic class,low educational levels (Hoddinott & Pill, 1999),lack of social support (Raj & Plichta, 1998), smok-ing (McInnes, Love & Stone, 2001) and a desirefor paternal involvement (Earle, 2000).
Reasons for breastfeeding are both maternal andinfant focused, and also reflect a sphere of widerinfluences. These include pregnancy related issuessuch as uterine tone, control of bleeding (Spangler,2000), weight loss and body image. Non preg-
nancy maternal health concerns include beliefsabout; breast cancer (McLeod, Pullon & Basire,1998; Lauwers & Shinskie, 2000; NZCOM,1992; Spangler, 2000), empowerment, osteoporo-sis and maternal – infant bonding (Lauwers &Shinskie, 2000; Spangler, 2000). Infant relatedbenefits include optimal nutritive values ofbreastmilk, immune benefits, increased bondingand health benefits including lower rates of Sud-den Infant Death Syndrome (Spangler, 2000).
My decision to breastfeed was reinforced during mypregnancy by the steadfast belief that it was as na-ture intended, and more importantly, thatbreastfeeding was better for the baby. No baby of minewould have a bottle!
Antenatal preparationI had little prior exposure to breastfeeding. As a childand young woman in New Zealand, I had had verylittle interaction with pregnant mothers, infants, orbreastfeeding. It seemed that breastfeeding was some-thing that was done in the privacy of the home andcertainly not in front of others. While living over-seas, most of my expatriate friends in Indonesia andThailand, returned to England or Australia to havetheir babies, again limiting my exposure of earlybreastfeeding. The antenatal classes I attended inIndonesia and Thailand did address breastfeeding.But, unfortunately, due to moving countries and thenthe premature arrival of my son, I was unable toattend these particular sessions. Thus, most of my priorbreastfeeding learning experience was based on sev-eral weeks’ clinical experience on a postnatal ward atNational Women’s Hospital in the early 1980s. Myrecollection of this experience was of bottles, fourhourly feeds, breastfeeding for increasing minutes perday, starting at one minute per side per feed, babiesbeing kept in the nursery and taken to their mothersat feeding time.
Women who associate with breastfeeding womenare more likely to breastfeed and are more likelyto show confidence in their mothering abilities(Hoddinott & Pill, 1999; Lauwers & Shinskie,
2000). However, Hoddinott and Pill (1999), docaution that exposure to unfamiliar womenbreastfeeding can be a negative experience.Kitzinger (1998) suggests that a woman, who hashad little exposure to breastfeeding, may harbourdoubts about her ability to breastfeed and to pro-duce sufficient milk. A society that fails to recog-nize breastfeeding as the optimal way to feed ababy sends conflicting messages to women andcan act as a deterrent to breastfeeding (Lauwers& Shinskie, 2000).
This article formed an assignment in theHuman Lactation and BreastfeedingModule within the BHSc degree atAuckland University of Technology.
It was written in 2001 during Tracey’s firstsemester of study. The assignment brief
was to relate knowledge and understandingof breastfeeding and lactation,
to a woman’s experience.
Biography: I became interested in midwiferywhen I was pregnant with my first son. Howeverit was to be 10 years, three sons and threecountries later before I was to commence myformal midwifery training at AUT, in 2001.I am currently working as a staff midwife atNational Women’s Hospital, Auckland.Future plans include study towards a MHSc.Contact: [email protected]
A breastfeedingjourney revisitedTracey Rountree BHSc (Midwifery), NZRM, NZRCpN.
New Zealand College of Midwives • Journal 28 • April 2003 17New Zealand College of Midwives • Journal 28 • April 2003 17
During my pregnancy, my Thai and Indonesianobstetricians were my only health care providers. Un-fortunately they had neither the time, nor the incli-nation, to discuss my feeding plans. I was unawareof any alternative health professionals who could of-fer care to a pregnant woman. However in Thai-land I did join an expatriate organisation, BangkokMothers and Babies International. This organiza-tion provided antenatal classes and offered support,friendship and companionship to pregnant womenand mothers.
The NZCOM (1992, p.17) recommend pregnantwomen are “counselled” about breastfeeding. Thisenables the midwife to ap-preciate the woman’s his-tory, breastfeeding knowl-edge, feeding plans and thelevel of available supportavailable. The mechanics ofbreastfeeding and any pos-sible problems can also be
discussed. Benn (1998,p.111) writes, “education is the cornerstone support-ing the entire framework of lactation andbreastfeeding” (p.111). Lauwers and Shinskie(2000) agree, commenting that the earlier awoman receives advice and information onbreastfeeding then the more likely she will
breastfeed for a substantial period of time. Awoman who understands what breastfeeding en-tails is more likely to persevere through any diffi-cult early patches (Rose-Neil, 1984). Prior knowl-edge of potential breastfeeding problems enablesmothers to cope better and to preservebreastfeeding (McLeod, Pullon & Basire, 1998).
Breastfeeding literatureDuring my pregnancy I endeavoured to be well readon pregnancy and birth. Not easy in Indonesia wherebooks were censored and every picture or outline ofthe female form was blacked out in accordance withgovernment policy. Of the four pregnancy books Ihad, three were published in England.– “Baby andChild”, by Penelope Leach (1989), “Pregnancy andChildbirth”, by Sheila Kitzinger (1986) and “TheComplete Handbook of Pregnancy”, edited by WendyRose-Neil (1984). “Pregnancy”, by Dr Teoh Eng Soonand D.E. Lam (1988), was written and publishedin Singapore. As I was having my baby in Asia, thislast book was significant, especially in regard to prac-tices I would come across in Asian hospitals.
In three books, the authors are somewhat ambiva-lent towards breastfeeding. Leach (1989, p.51)describes breastmilk as “physically better for babies”,
but then adds “but modern baby formula can bevery nearly as good” . She then goes on to say “breastor bottle, or even both will do… as long as feeding ishappiness” (p.131). Kitzinger (1986) devotes just5 pages of her 350-page book to breastfeeding.She describes the mechanics of breastfeeding well;but ignores the maternal and infant benefits ofbreastfeeding, the nutritional superiority ofbreastmilk over artificial formula, and the impor-tance of breastfeeding in the maternal-infant rela-tionship. Soon and Lam (1988) were even moreambivalent towards breastfeeding arguing that“there is actually no harm in giving baby the bot-tle… formula is as nutritious as milk from the moth-
er’s breasts” (p.270). In thefourth book, Rose-Neil(1984) details both infantand maternal benefits ofbreastfeeding. These in-cluded superiority ofbreastmilk, nutrients, andantibodies for the infant,
combined with maternalbenefits such as assisting with uterine tone andpostnatal recovery, and the shared benefits of ma-ternal-infant bonding.
With literature displaying such ambivalence towardsbreastfeeding and the lack of professional support, itwas a wonder that I decided to breastfeed at all. Itwas only my steadfast belief that my baby would ben-efit most from breastfeeding, that kept me determinedto breastfeed.
After the birthMy son was born by emergency caesarean section at34 weeks gestation following a large antepartum bleedas a result of an undiagnosed anterior placentapraevia. After the birth I struggled through the grog-giness that a general anaesthetic leaves and the paininadequate analgesia fails to mask. My son was criti-cally ill for several days. My only concern was whethermy baby would live or die. My son was too ill to befed and, in the ensuing flurry of activity, my breastswere somewhat neglected. It never occurred to me thatI should express, and it was never suggested that Ishould.
When a premature baby is unable to breastfeed, itis imperative that the mother begins expressing assoon as possible in order to initiate, and main-tain, a milk supply (Bartle, 2000; Gotsch, 1990;Spangler, 2000). Kitzinger (1998) adds that thebreastmilk a mother produces after a preterm de-livery has a higher protein content than usual, andoffers valuable protection to the infant from
necrotising enterocolitis. However, Soon and Lam(1988) belittle the value of colostrum. Whilst sug-gesting that a determined mother could beginbreastfeeding within the first 24 hours after deliv-ery, the text notes that feeding immediately afterbirth was “not always advisable nor convenient”(p. 267).
Colostrum is often withheld in Thailand (Lefeber& Voorhoeve, 1999). In Thailand there is a beliefthat colostrum is bad for the infant and that in-fants are incapable of sucking (Kotchabhakdi,1988). This leads to a delay in breastfeeding, whichin turn causes problems in the initiation and main-tenance of breastfeeding. According to the UnitedNations Children’s Fund (1996), the exclusivebreastfeeding rate in Thailand (1986-1995) at fourmonths of age was only 4 %.
These culturally based beliefs clearly influenced mybreastfeeding experience. Especially with regard tonon-expression of milk in the first few days, the with-holding of colostrum and the lack of any promotionof, or assistance with, breastfeeding.
Early feedsThree days post delivery I woke up to very painfulengorged breasts. I can remember very clearly boththe pain and the boiling hot compresses applied tomy engorged breasts. My milk had “come in”, andsince Michael now had a naso-gastric tube in situ itwas suggested I express. Expressing was fiddly, timeconsuming, and no substitute for a baby; but it washelping Michael, so I was pleased to do it. I hadplenty of milk, far more than Michael would need,so I ended up donating the excess to the hospital’smilk bank. Up to this point Michael had been givenformula but no colostrum. Michael’s condition wasstable, but I had yet to hold him in my arms, letalone give him a breastfeed.
The staff were keen for him to feed orally, but in-sisted that bottle feeding was easier for him. Once hewas feeding well from a bottle he would then be ableto breastfeed. In order to encourage Michael to suck,he was given a pacifier. Another complication wasthat Michael was finding it difficult to maintain hisbody temperature and could not be removed, albeitbriefly, from the incubator.
For most babies, breastfeeding is easier and lessstressful than bottle-feeding, with sucking, swal-lowing and breathing more easily coordinated at
the breast (Bartle, 2000; Gotsch, 1990; NZCOM,1992; Spangler, 2000). Introducing bottle feeds
continued over...
Health professionals, significant others, and
the woman’s partner,
all play crucial roles influencing the
breastfeeding decisions made by the woman
New Zealand College of Midwives • Journal 28 • April 200318 New Zealand College of Midwives • Journal 28 • April 200318
before breastfeeding, is liable to cause problemssuch as; exacerbation of suck-swallow-breathe co-ordination problems, loss of confidence for themother, interference with supply and demand ofbreastmilk, an increase in bottle feeds as opposedto breastfeeds (Bartle, 2000; NZCOM, 1992) andnipple confusion (Gotsch, 1990; NZCOM, 1992).
Feeding via a nasogastric tube during transitionto breastfeeding increases the likelihood of suc-cessful breastfeeding (Kliethermes, Cross, Lanese,Johnson & Simon, 1999). The use of pacifiers isgenerally discouraged (Lauwers & Shinskie, 2000;Spangler, 2000; Weatherly, 2000). HoweverLauwers and Shinskie (2000) do concede benefitsfor preterm infants using pacifiers, though onlyduring nasogastric feeds.
I was able to hold Michael for the first time when hewas seven days old. I’m sure he would have preferredto nestle up to me, skin-to-skin, listening to my reas-suring heartbeat and to smell me. Instead he wasbundled up in multiple layers of blankets. Michaelhad his first breastfeed when he was ten days old. Itwas in Intensive Care, with little privacy or helpfrom the nurses. It was a wonderfully satisfying ex-perience. It meant more to me than just the act ofbreastfeeding; it was an intimate form of closenessand a real indication that Michael was getting bet-ter. I found breastfeeding very easy, despite all theobstacles that prematurity brings and despite the lackof assistance. Breastfeeding times were moments ofjoy, where everything seemed to be just so right.
Bartle (2000) and Weatherly (2000) suggest in-fants be afforded the opportunity of kangaroo
care, offering the infant the chance to be warmedby the mother’s breasts, and have the chance tosmell and taste her breasts.
The next week was a juggling of nasogastric feeds,bottle feeds, and breastfeeds complicated by Michael’sinability to maintain his temperature. Howeverthings did improve and by seventeen days of age hefinally had his nasogastric tube out and he was in acot in my room. At this stage Michael was havingalternate breastfeeds. How he must have looked for-ward to my soft warm breasts!
Breastfeeding at homeMy son and I finally went home three weeks afterhis birth. Michael was breastfeeding on demand. Hewas a slow feeder, and would take up to an hour tofeed, waking just one hour later for anotherbreastfeed.
On the day of discharge Michael had loose stools. Staffdismissed these, but the loose, green stools continuedand Michael started to lose weight. Tests were nega-tive for any infectious causes, but positive for reduc-ing substances and a diagnosis of lactose intolerancewas made. I was advised Michael would not be ableto breastfeed due to the lactose content in breastmilkand soy formula was recommended. The intolerancehad probably occurred as a result of antibiotic therapy,and was not unexpected given his circumstances andprematurity. I was devastated! I firmly believed thatMichael’s health was of the utmost importance and,as a result, somewhat reluctantly I commencedMichael on the recommended soy formula.
However, I was not deterred from breastfeeding atsome further point in time. I continued to expressand discard at every feed time. It was a very tryingand exhausting time, but I wanted to keep my op-tions open and be able to breastfeed Michael whenthings improved. Every week or so I would giveMichael one breastfeed, but the diarrhoea would re-appear, and the breastfeeding would cease.
I returned to New Zealand when Michael was 2 1/2
months old. At this stage I was able to breastfeedMichael just once every day, and even though thisproduced slightly loose stools, Michael was happy andgaining weight. Feeding more frequently would in-variably result in profuse diarrhoea.
I consulted a paediatrician, who diagnosed a rela-tive lactase deficiency, but was very hopeful that thesituation would improve and that I would be able tobreastfeed more frequently. I continued to breastfeedMichael once a day; expressing and discarding theother feeds. Unfortunately things did not improve,and after one further month, I gave up trying tobreastfeed. I didn’t feel sad, angry or upset. I knew Ihad tried my hardest, and it just hadn’t worked out.My husband and family had all been very supportiveof me but were relieved when I decided to stopbreastfeeding, as it seemed so futile to continue.
Infants, who have had antibiotic therapy, mayexperience lactose overload (Hull & Johnston,1993; Lauwers & Shinskie, 2000). This results in
green frothy loose and frequent stools. Lauwersand Shinskie (2000) suggest this may be a tempo-rary problem and can be simply managed bybreastfeeding only on one breast per feed, allow-ing the baby to receive the low lactose and highfat hindmilk. (I nearly cried when I read this. Per-haps the answer had been this simple all along!)
Wattie Whittlestone (1967, cited in NZCOMMidwives News, 2000), argues for newborns to
have only colostrum. Colostrum is especially highin the bifidus factor, which is thought to promotethe activity of lactase. Therefore a deficiency ofcolostrum and hence the bifidus factor can resultin lactose malabsorption. Whittlestone believedthat a baby’s ability to digest lactose was depend-ent on receiving nothing but colostrum from birth.
The breastfeeding culture in Thailand had influencedmy breastfeeding, and hence the outcome of mybreastfeeding experience. Had Michael been born inNew Zealand, he would undoubtedly have been givencolostrum, and perhaps his intolerance to lactosewould not have occurred.
Cultural influences on breastfeedingGiving birth in a foreign country did make me feelvery vulnerable. My husband and I felt almost over-whelmed by the events, lack of family support, thechange in culture and language difficulties. I felt Ihad little say in our care or in the decisions made. Itwas difficult to be assertive in the early days after myson was born. I had been in Thailand for only onemonth, and had met my doctor just once. My Thaidoctors had very good command of the English lan-guage. However, breastfeeding was very much thedomain of the obstetric nurse. The nurses were allThai, and unfortunately most did not speak Eng-lish. We did however muddle through, using my Thai,the nurses’ limited English and a lot of gesticulation.Unfortunately, I did not receive a lot of breastfeedingsupport from the staff. However, at the time ofMichael’s birth most mothers left the hospital withfree samples of formula, which is indicative of thevalue placed on breastfeeding.
Lauwers and Shinskie (2000) suggest that culturalinfluences and barriers play a very important partin breastfeeding decisions. Language difficultiescan serve to increase cultural barriers (Lauwers &Shinskie, 2000) and women who have problemscommunicating with their caregivers generallyhave less positive experiences (Small & Rice,1999).
For the period 1990-1998, the Population Refer-ence Bureau (1999) cites Thailand as only taking“some action”, with regard to the implementationof the International Code of Marketing BreastmilkSubstitutes. James (1994, cited in Lauwers &Shinskie, 2000) notes a correlation between de-creased breastfeeding rates and the availability offree formula samples.
In Thailand I do not ever remember seeing a womanbreastfeed. Breastfeeding in public was an absolute
A breastfeeding journey revisitedcontinued...
New Zealand College of Midwives • Journal 28 • April 2003 19New Zealand College of Midwives • Journal 28 • April 2003 19
social taboo and something that was actively discour-aged in antenatal classes and in hospital.
As Lauwers and Shinskie (2000, p.161) suggest“lack of breastfeeding as the cultural norm can leavenew mothers with little confidence in their abilityto breastfeed or little understanding of how theprocess works”.
ConclusionIt seems that everything was against me in terms ofbreastfeeding. I was in a country that had abreastfeeding culture different to that of my own.Antenatally, I had little breastfeeding preparation orcounselling. After the birth of a sick preterm baby, Ihad little encouragement to breastfeed, and no fam-ily, friends or specialist professionals to help me. Myson did not benefit from colostrum or early skin-to-skin contact, and he had adequate opportunity torefuse the breast in favour of bottle-feeding. Despiteall these obstacles, we somehow made it, and I wasable to fully breastfeed my son, albeit briefly. For methe one thing that kept me going, especially in thoseearly days, was my belief that breastfeeding was theright thing to do.
Clearly, successful breastfeeding is inextricablylinked to a woman’s motivation to breastfeed(Hoddinott & Pill, 1999; Huang, Chen & Wang,
2000; Lauwers & Shinskie, 2000; NZCOM,1992; Papinczak & Turner, 2000). From before awoman is pregnant, factors influence many of herbreastfeeding decisions and will continue to im-pact on her breastfeeding experience (Lauwers &Shinskie, 2000; McLeod, Pullon & Basire, 1998).
Cultural beliefs are often more important to awoman than rational and valid practices, and mayhave a negative impact on the breastfeeding expe-rience for some women and their babies(Mohrbacher & Stock, 1991). Obstacles to suc-cessful breastfeeding can be overcome, but thisis often dependent on the determination ofthe woman and the support and encouragementshe receives.
FootnoteMichael remained intolerant to lactose until he waseighteen months old. I subsequently went on tobreastfeed my next son, born at 32 weeks gestation,for fifteen months. My third son, born at term,was breastfed for eight months when he decided towean himself.
References
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Benn, C. (1998). Education: The cornerstone of breastfeeding. InA. Beasley & A. Trlin (Eds.), Breastfeeding in New Zealand:Practice, problems and policy (pp. 111-126). PalmerstonNorth, NZ: The Dunmore Press.
Earle, S. (2000). Why some women do not breastfeed: bottlefeeding and father’s role. Midwifery, 16 (4), 323-330.
Gotsch, G. (1990). Breastfeeding your premature baby. Illinois:La Leche League International.
Hoddinott, P., & Pill, R. (1999). Qualitative study of decisionsabout infant feeding among women in East End of London.British Medical Journal, 318, 30-4.
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Accepted for publication: August 2002
Rountree, T. (2003). A breastfeeding journeyrevisited. New Zealand of College of MidwivesJournal, 28 (1), 16-19.
New Zealand College of Midwives • Journal 28 • April 200320
Place of birth in the Number 1999 1999South Island (SI) of facilities (% of all South
Island Births)
Births in tertiary obstetric units 2 5462 51.31
Births in secondary maternity hospital 7 4246 39.89
Births in primary and rural facilities* 21 937 8.8
Total births 30 10645 100
Births in rural primary facilities** 16 468 50% of SIprimary births
Births in the study group facilities 9 313 66.9% of SIrural facility births
Table 1 Place of birth in the South Island of New Zealand 1999 (MoH, 2001)
* One of the services in the study was omitted in the MoH ‘1999 Report on Maternity’ their 33 births for 1999have been included in this total.
** Primary facilities 60 minutes or more from a secondary or tertiary obstetric facility.
Papers presented at the 7th Biennial New Zealand College of MidwivesConference in Dunedin, July 2002.
In the October 2002 issue we printed several papers presented at the conference. In this issue we include afurther two papers. We regret that we are unable to print all of the papers but hope that this selection willhighlight interesting issues for midwives. The papers have not gone through a peer review process but havebeen prepared by the presenters in a form for publication in the Journal.
BackgroundAt the time of this study (September 2001) therewere twenty-one rural maternity facilities (mean-ing hospitals or birthing units) in the South Is-land of New Zealand, located within rural towns.None of these facilities provide for caesarean sec-tions. Sixteen of the facilities were located morethan 60 minutes from a secondary or tertiarymaternity facility (HFA, 2000). The nine ruralfacilities scanned for this study accounted forabout a third of the primary facility births and66.9% of rural facility births in the South Island.See Table One for the types of maternity facilities,excluding homebirth, in New Zealand in 1999.
The scan was carried out as part of a midwiferydoctoral study into the organisation of maternityservices in rural localities by midwives.
MethodologyIn August 2001 midwives providing servicesaround nine rural maternity facilities from threeDistrict Health Boards (DHBs) in the South Is-land of New Zealand, contributed informationfor a contextual scan of maternity service provi-sion within each of their localities. The contex-tual scans were based on the concept of environ-mental scanning (Correia & Wilson, 2001). Thefindings from these scans were then amalgamatedto provide an indication of the issues facing ma-ternity service provision by midwives within thecontext of the rural South Island. First, a scanquestionnaire was sent out, and then the researchervisited each facility to meet the midwives and com-plete the questionnaire with them.
The four main componentsof the scan process included:• the development of a broad description of the
maternity services provided within the locality• a profile of the community in which the facil-
ity and service was located• a profile of the local health services provision
issues• identification of threats and opportunities im-
pacting on the future of the maternity services.
Following the researcher’s visit, the individual scanresults were returned to the informants who re-viewed and corrected the findings and contrib-uted to a set of draft strategies for the further de-velopment of their service. The scan profiles ofeach service locality and its context were then usedto collectively identify key issues that seemed tohave the potential to influence the survival andenhancement of the rural maternity services.
Ethical approval for the research was obtainedfrom the Ethics Committee of the University ofTechnology Sydney. A copy of this was thenlodged, as requested, with the New Zealand Min-istry of Health Ethics Committee.
Scan findings: rural maternity servicesService locationsAll of the birthing facilities were located withinprovincial towns with catchment populations of5000 - 20000 people. All the facilities were lo-cated 1 to 1.5 hours road travelling time from asecondary or tertiary maternity facility. Transferprocesses increased the distance by at least 30minutes. Most were spaced at least 60 minutesfrom another rural maternity facility.
Maternity facilitiesSeven of the maternity services were located within10-15 bed community hospitals in maternity‘wings’ consisting of 3-4 postnatal beds and 1-2birthing rooms. One of the facilities was identi-fied as a Birthing Unit that was midwifery ownedand managed. The other service was located withina rural hospital that had reduced its beds to pro-vide only maternity services. Two of the facilitieswere owned and managed by a base maternityhospital, while six were owned by a CommunityTrust and one by a midwife. Three of the trust-owned community hospitals were in need of con-siderable upgrading. All the facilities employedmidwives and nurses to staff their maternity serv-ice. Employed midwives in five facilities had wellestablished midwifery Lead Maternity Carer(LMC) services (where the midwife takes totalresponsibility for the clinical management of thewoman’s pregnancy, birth and postnatal care).
The organisation of maternity services by midwivesin rural localities within the South Island of New ZealandChris Hendry RGON, RM, BA, Master Public Health, Cand. Professional
Doctorate in Midwifery
Currently working part-time as a lecturer in thePostgraduate Midwifery Programmes at OtagoPolytechnic, based in Christchurch with studentsthroughout the South Island, of whom 50% workin rural localities. Part-time Executive Director ofMidwifery and Maternity Provider Organisation.
New Zealand College of Midwives • Journal 28 • April 2003 21
Volume of maternity activitiesThe total births per facility ranged from 13 to 90per year, with an average annual birth rate of 35births per facility. The combined total births ofthe three DHBs1 within the scan area was esti-mated at 4697 for the 1999 year (Ministry ofHealth, 2001). The total births in rural facilitieswere estimated at 426, indicating that the averagerate of rural births for these DHBs was 9%. Thebirths with the facilities scanned (313) representedabout 83% of all the rural births in these DHBs.See Table Two for further details.
Midwifery Lead Maternity Carer(LMC) ServicesOverall about 60% of all births within these fa-cilities had midwifery LMCs, three facilities had100% midwifery LMCs. By January 2003 themidwives estimate that all but one facility will have100% LMC midwife births. Up until July 2001employed midwives in four facilities did not pro-vide midwifery LMC services but provided mid-wifery care for General Practitioner (GP) LMCs.
Home birth services were mainly provided by self-employed midwives within the catchment area offive of the facilities. These midwives also accessedthese facilities to birth women. Four facilities weretotally reliant on employed midwives to provideall the community midwifery services. Only threefacilities had employed midwives who offered
home birth as an option. All the employed mid-wife informants expressed a conflict between try-ing to maintain viability of their facility and offer-ing home birth.
Medical LMC ServicesOver the 12 months prior to the scan, GP LMCsattended an average of 40% of births in the facili-ties under study. Midwives reported that GP LMCswere choosing to exit provision of maternity serv-ices in the rural facilities by December 2001. Fivefacilities provided a location for regular obstetricclinics. The obstetricians and ‘their midwives’ vis-ited up to fortnightly, from two base maternityhospitals and one private obstetric service. Mid-wives reported that these clinics enlisted ‘low risk’women to birth away from the local maternity fa-cility. Most of these obstetricians relied on localGPs to provide some of the antenatal care and lo-cal independent midwives to provide the postna-tal care.
Pregnancy and parenting programmesSeven facilities provided these services. Plunket andParents Centre also offered programmes. Thereseemed to be little collaboration between the localmidwives and these providers.
Postnatal transfer back to the rural facilityAn average of 33% (range 14% to 60%) of admis-sions to the facilities were women needing post-
natal care following birth elsewhere. These womentended to stay about a day longer than womenwho birthed in the facility.
Midwifery co-ordination of facilitiesThree of the facilities had an established midwifeco-ordinator or a midwife manager role; two fa-cilities had some hours per week allocated for thefunctions. Within the six months prior to the scan,three facilities had allocated a midwifery-LMCestablishment role to an employed midwife. Twoof these roles were 12-month contracts. The re-maining three facilities did not have a designatedmidwife co-ordinator and the service managementwas informally taken on by one of the midwives.Two of these latter services had hospital managerssupporting their employed midwives to establishmidwifery LMC services.
Management and monitoringof maternity servicesOnly one of the facilities had a formalised processin place to monitor the activities of the maternityfacility, other than the ‘birth book’, which recordedeach specific admission. No overview summarywas developed and few facilities had formalised‘booking’ processes that enabled them to forecasttheir workload. The activity data for the scan wasprovided after the scan visit on a form created bythe researcher specifically for the facilities.
Only two facilities appeared to have systems inplace for monitoring midwifery activities, includ-ing individual midwives’ caseloads. Because somefacilities were just establishing their midwiferyLMC services with employed midwives there waspoor forecasting data on which to estimate theactual number of midwives required. Only onefacility had an arranged caseload limit for em-ployed midwives.
There appeared to be 22.5 full time equivalentemployed2 (FTE) midwives between all the fa-cilities (2 FTE were planning to leave in the fol-lowing 3 months). The existing FTE level wouldcalculate at 1 FTE employed midwife per 20 birthsin these facilities. With postnatal women includedin the total, each FTE midwife would care for anaverage of 34 women per year. These employedmidwives cared for about 774 inpatient admis-sions per year, with an average day stay of 3.5 daysor 2709 bed days (according to the scan inform-ants). This type of data does not appear to be col-lected or analysed by the midwives or their man-agers to project and manage the midwifery andmaternity workforce in these settings. The distri-
Table 2 Volume of maternity activities and outcomes for the nine rural services in 1999,compared with national volumes. (MoH, 2001)
Facility Normal Breech Forceps Vacuum Induction Episiotomy StillBirths extraction births
* This does not include the 261 primary births wrongly coded as caesarean sections (MoH, 2001:32)
continued over...
New Zealand College of Midwives • Journal 28 • April 200322
bution rather than the volume of midwives seemedto be more of a problem.
Facility maternity back up servicesKaritane nurses, obstetric nurses, enrolled nurses,registered nurses and hospital aids were available‘on call’ in seven of the facilities to support themidwives to provide 24-hour cover when a womanwas in the facility. Two of the facilities relied onthe midwife to carry out routine cleaning and pro-vide meals. The midwives in four of the facilitieswere transferring from a ‘core’ facility role to anLMC role, which means they will become moreinvolved in the co-ordination of the whole ma-ternity service than previously. They were awarethat they needed to shift their focus from facilityto community maternity service provision. Thiswould include managing the logistics of midwiferycoverage of the facility for independent midwives(who all require facility midwives as back up),midwifery care for GP LMCs and midwifery backup for each other.
Self employed midwivesThe informants indicated that there were in total10 self-employed midwives providing serviceswithin the catchment area of five of the facilities.Four facilities had no self-employed midwivesworking in the locality. The self-employed mid-wives provided most of the home birth and somefacility births. The FTE status of these midwivescould not be calculated, but many appeared totake a heavy caseload because they also providedantenatal and postnatal home based care forwomen birthing out of the locality. This work wasbuilding as GPs were withdrawing, recommend-ing women birth at the base hospital ‘just in case’.
Medical servicesThree facilities did not have GP LMC services.Most of the GPs providing LMC services in an-other four facilities had chosen to cease providingthis service within the 6-12 months following thescan. This was the key reason that the employedmidwives were beginning to offer local womenLMC services to birth in their facilities. Whileobstetricians regularly visited four facilities to carryout their clinics, none would provide services di-rectly to the facility. Over the previous 12 monthsonly one facility had a forceps delivery and noneoffered epidurals or caesarean sections. Inductionswere rarely carried out.
Referral and support servicesFive of the facilities are located within 2 hours ofan obstetric referral hospital and the other fourare within 60 minutes road travelling time. Sixfacilities had weather dependent road transfer fa-
cilities and needed to rely on air transfer at timesin winter. Because of the lack of proximity to anambulance, some facilities needed to add up toan extra hour to transfer times to the secondaryfacility. All the facility midwives indicated that theyhad excellent relationships with obstetricians atthe secondary facilities. Strategies they had devel-oped to enhance this included attending studydays on-site and visiting the base hospital whenin town.
Eight facilities had regular ultrasound and labo-ratory services. The midwives had a good relation-ship with the district andPlunket nurses. The rela-tionships with practicenurses and GPs were lesswell developed. This wasmainly due to the histori-cal preference of thesepractitioners for referringall pregnant women to thesecondary maternity serv-ice via the visiting obstetric clinics. This enabledthe GP to retain the antenatal and postnatal LMCfunding. Facilities with the best relationships withGPs were those where the GPs did not practiceobstetrics and referred women to the midwivesfor their initial assessment and birth options.
The communitiesEight of the facilities were located within the lowerhalf of the South Island. The other facility waslocated in the top part of the Island. All the com-munities were rural with high tourist populationsand associated service industries. All but three hadseasonal population fluctuations. All the south-ern communities were experiencing populationgrowth with the new dairy industry which hadled to an increase in maternity service requirementsbecause this industry brought new, young fami-lies into the area.
Geographic featuresThe maternity services provided from most of thefacilities covered a radius of 1-1.5 hours. Midwivestravelled great distances for home visiting. In win-ter the roads around seven of the facility catch-ments were affected by ice and snow. Generallythe roads to the base facility, for all but one serv-ice, were straight and well maintained. Publictransport was infrequent and costly. Women hadto find their own transport if they need to travelto the facilities. Therefore, the midwives believedthey did more home visiting, unless the woman wereregularly coming to town for shopping.
Sociocultural profileMidwife informants consistently described thepopulation as consisting of two distinct socio-eco-nomic groups. There were the service workers andsocial welfare beneficiaries who lived in transient,low cost accommodation and most had youngfamilies. Then there were the farming families andbusiness owners who were older with childrenaway at school or tertiary institutions. Midwivesnoticed an increase in women with complex so-cial problems particularly associated with drug andalcohol abuse. Many midwives felt ill equippedto support these women. Many new families mov-
ing into the southern fa-cility areas with the dairyindustry had no familysupport.
Consumer support forthe servicesAll informants indicatedthat word of mouth wasthe main means women
had of learning about the local maternity facilityservice. All facilities had developed brochures andone also had a website. One facility (the midwiferyowned birthing unit) actively involved women indeveloping and directly promoting the service.
Political environment around maternity serv-ice provisionIn all but two localities most rural women trav-elled to the secondary hospital to birth. Midwifeinformants believed that competition for the LMCrole antenatally between doctors and midwivescontributed to this. While the doctors were with-drawing from birthing women locally, they ap-peared to be continuing to provide antenatal andpostnatal LMC services whilst referring womento the secondary facility to birth. Women whowanted continuity of midwifery care, had to seekout a midwife themselves. The perception of riskassociated with a local birth was believed to beperpetuated by the information given to womenon confirmation of their pregnancy test by thepractice nurse and/or GP.
Four facilities were at risk of closure if the volumeof births had not increased. The two facilities thathave a steady volume of births engage in commu-nity information and publicity about their serv-ice. The midwives had become personally recog-nisable in their communities. They had establishedclear relationships with the GPs which identifiedmidwives and their facility as the prime mater-nity service providers in the locality.
The organisation of maternity services by midwivesin rural localities within the South Island of New Zealand
continued...
Closure of rural maternity facilities willprobably result in midwives leaving thedistrict because the volume of antenatal
and postnatal care services they will be leftto provide, for women forced to birth
in the cities, will be insufficientto provide them with a livelihood.
New Zealand College of Midwives • Journal 28 • April 2003 23
difficult. Relationships between practice nurses andmidwives did not appear to be well developed.
While seven facilities formed a network of mater-nity services that bordered on each other, the mid-wives had little contact with each other. Most hadnot visited the other facilities. There was not aneffective rural midwifery network other than thatdeveloped when midwives attended midwiferyupdates at either the base facility or the tertiaryfacility, which seemed to occur on an annual basis.
Midwifery professional developmentAll of the midwives in the facilities scanned weremembers of the New Zealand College of Mid-wives and indicated that they relied heavily uponthe College for advice and support. The midwivesworking in the community trust facilities weremost reliant on the College and were increasinglyusing the Midwifery and Maternity Provider Or-ganisation (an independent provider organisationlinked to the College of Midwives) for claimingLMC payments and providing practice manage-ment advice.
Continuing educationAll facility midwives undertook annual updatesin infant resuscitation, cannulation, pharmacol-ogy, emergency care and other clinically based top-ics. Most were run by the secondary facilities orthe local polytechnic.
Postgraduate studyOnly three facilities had a midwife involved inpostgraduate study. Midwives cited cost as themain factor inhibiting pursuit of further educa-tion.3 These costs included:• long distance travel to the venue (few live within
daily commuting distance from a polytechnicor a centrally located venue)
• accommodation during the seminar/course• loss of earnings for independent midwives and
cost of replacement staffing for employed mid-wives
• childcare/family care arrangements while away.Midwives indicated an interest in a postgraduateprogramme that encouraged networking, knowl-edge sharing and opportunities for rural midwivesto develop their services.
Strategies for strengtheningmaternity services in rural locationsFindings from this scan have led to the develop-ment of strategies for enhancing and strengthen-ing maternity services run by midwives located inrural and isolated settings. The maintenance ofthese rural primary facilities appears to be contin-
gent upon support for the development of the lo-cal midwifery LMC services.
The following recommendations have emergedfrom the scan process and have been agreed to bythe midwifery participants of the scan.
1. Encourage and enable women to use their local maternity service• Develop local support networks for rural ma-
ternity services• Encourage women to actively support their lo-
cal maternity service• Provide information on local maternity services• Inform local medical practitioners and practice
nurses of the midwifery LMC role
2. Professional development for rural midwives• Provide regular midwifery practice updates• Develop a postgraduate midwifery programme
for rural midwives
3. Support the transition to provision of LMC services
• Identify ways to manage maternity facilityworkforce
4. Development of locum service• Identify practitioners willing to locum in rural
areas, e.g. midwifery lecturers• Co-ordinate leave to match locum availability
5. Analysis of maternity workforce• Scan the workforce profile and projected re-
quirements over the next 5 years
6. Development of a rural midwifery network• Set up a formal process for linking rural mid-
wifery providers in the South Island• Enable the network to have a tangible influence
on the development and maintenance of ma-ternity and midwifery services within the ruralsetting
Risks of not supporting midwivesproviding local rural maternity servicesThe scan indicated that midwives were attempt-ing to strengthen and develop the services theyoffer to rural women within their localities.Most were hopeful of increasing the birthing vol-umes once the GPs left maternity services to mid-wives. However, it would seem likely that with-out immediate support for these midwives andthe service they provide, a number of these rural
Rural maternity service developmentFacility designSix of the maternity services were located withinnew or refurbished facilities. Two of the new fa-cilities had been poorly designed, without recog-nising the implications of providing a midwiferyLMC service from the facility. Four of the facili-ties had the maternity beds close to other serv-ices, which enabled the midwife to access nursingsupport or cover when a woman was staying post-natally. Two facilities had their maternity beds iso-lated a distance from the rest of the hospital whichnecessitated a staff member staying close by whena woman was in over night. Five facilities had al-tered their postnatal room furniture to encouragethe partner and/or family to stay overnight.
All the facilities, other than the birthing unit, hadbirthing rooms separate from the postnatal rooms.Some of the facilities retained the original obstet-ric delivery theatres, in which women were ex-pected to birth. Two facilities had water birthingand another offered a labouring pool. The otherfacilities had conventional baths that women usedin labour.
TechnologyNone of the facilities had a maternity dedicatedcomputer to store data or access the internet. Onlytwo facilities had access to a computer for themidwives’ use.
Interprofessional co-operationAll midwives clearly viewed themselves as beingpart of the community’s maternity service eventhough seven facilities were located within com-munity hospitals that also have aged care and re-habilitation beds. None of the midwives in thesefacilities were expected to undertake nursing roles,but nurses were expected to back up the mater-nity service when women were staying over night.The midwives indicated that they had a harmo-nious relationship with the facility nurses, butexperienced tension at times with hospital man-agers who had little understanding of the com-plexity of providing midwifery LMC services whileproviding back up midwifery care in the facility.
Facilities with exclusive midwifery LMC servicesappeared to have more harmonious relationshipswith local GPs. The localities where GPs contin-ued to take an LMC role experienced most diffi-culties in maintaining constructive relationships.Communication difficulties appeared to centre onexpectations that GPs had of facility midwives.Poor quality booking information and late con-tact with the midwife made co-ordination of care
continued over...
New Zealand College of Midwives • Journal 28 • April 200324
facilities risk closure by the DHBs within the next12 – 18 months.
Closure of rural maternity facilities will probablyresult in midwives leaving the district because thevolume of antenatal and postnatal care servicesthey will be left to provide, for women forced tobirth in the cities, will be insufficient to providethem with a livelihood. Midwifery will again be-come invisible in rural settings without the smallfacilities as a focal point for birth. Midwives haveindicated a desire to provide continuity of mid-wifery care for rural women within their own lo-cality, the only way to achieve this is to supportthe development of midwifery LMC services inthese settings.
References
Correia, Z., & Wilson, T. (1997). Scanning the businessenvironment for information: a grounded theory approach.Information Research, 2 (4). Retrieved August 30, 2002 fromhttp://InformationR.net/ir/2-4/paper21.html.
Health Funding Authority. (2000). Maternity services: areference document. Wellington, NZ: Health FundingAuthority.
Ministry of Health. (2001). Report on maternity 1999.Wellington, NZ: Ministry of Health.
Hendry, C. (2003). The organization of maternityservices by midwives in rural localities within theSouth Island of New Zealand. New ZealandCollege of Midwives Journal, 28 (1), 20-24.
1 The accuracy of the specific birth numbers other than
those within the facilities has been difficult to determine.
Therefore, they are given to indicate a trend that should
be more fully investigated. One of the facilities scanned,
which had 33 births in the 1999 year, was omitted from
the MOH Report on Maternity 1999 published in 2001.
These births have been included in this total.
2 The actual FTE status was difficult to determine. Some
midwives claimed overtime for excess hours while others
saw themselves as full-time when sharing a position with
a colleague.
3 Following the scan Otago Polytechnic introduced a rural
paper in its midwifery masters programme. A number of
from these facilities are now enrolled in postgraduate
study. A proposal to the Clinical Training Agency to fund
this was declined. Other sources of funding continue to
be investigated.
continued...
The organisation ofmaternity services bymidwives in rural locali-ties within the SouthIsland of New Zealand
The Otaki Birthing Centre is a very small, mid-wife owned and operated public primary birthingfacility in a small rural town. It is probably thesmallest of the three midwife owned and managedbirthing facilities in New Zealand. Funded forbetween 20 – 30 births annually, it provides a fa-cility for labour, birth, assessment of women, an-tenatal education and midwife ‘gatherings’.Birthing families go home when ready after thebirth, commonly 2 to 4 hours postpartum. Thecentre is not funded to provide midwifery care –the contract is purely for the provision and man-agement of the facility.
The woman’s lead maternity carer (LMC) providesthe midwifery care within the facility and the fol-low-up at home. As LMCs we also have our ownclients who elect to birth in other facilities or athome. In keeping with the principles of informedchoice we try very hard not to influence women’sdecisions regarding birth–place. We acknowledgethat there is difficulty in presenting unbiased in-formation when one is committed and enthusias-tic about a particular course of action.
To provide some context to the situation of thebirthing centre, it is useful to consider the historyof the maternity services in this area.
HistoryOtaki played an important role historically in theKapiti-Horowhenua region because of the largeand important Maori population of NgatiRaukawa and consequently it gained importanceas a base for early missionaries. Chinese marketgardeners, farmers, flax workers and timbermillersincreased Otaki’s population in the early years. Thepopulation now stands at just under 6,000.
In the early twentieth century midwifery was prac-tised privately by handywomen and possiblytrained midwives. We know of at least one housein the town that was known to have been a mater-nity ‘home’. A cottage hospital had been built in1899 and a tuberculosis sanatorium was estab-lished. Later one of the first Children’s HealthCamps was also established in Otaki. Around theearly 1930s the cottage hospital became the firstmaternity hospital in the area serving the KapitiCoast and the Horowhenua. Although a mater-
nity hospital was built in Levin (1953) and thenin Paraparaumu, the Otaki maternity hospitalsurvived until 1995.
Maternity care in OtakiThe Otaki Maternity Hospital was a sunny 6 bedwooden building on the top of the hill in centralOtaki. It is quite isolated, surrounded by trees andlawns. The extensive grounds it was built on weregifted by the local iwi for health purposes. It hada Matron’s flat – which now houses the OtakiWomen’s Health Centre. It also had Nurses’ bed-rooms where (in the 1990s) the lone midwife onduty slept ‘on call’. It was managed by the Ma-tron (Gloria Johnston) and utilised for antenatalchecks and births by the local women under thecare of general practitioners.
The maternity home staff supported the labour-ing women using the old deep clawfoot bath,massage and lots of ambulation and whanau sup-port. Pethidine and nitrous oxide were also usedbut it seemed to us that far less narcotic andinhalational analgesia were necessary than wereused in the busy, more impersonal large city hos-pitals. We felt that this was because the womenwere more at home in the hospital, more relaxed,freer to move around and enjoyed more privacy.However, women were still expected to follow theinstitutional ideas of position for birth and activethird stage management required by the doctorsand the mostly ‘medical model’ midwifery preva-lent at the time.
It was not unusual before 1995 to see a labouringwoman quietly walking up and down the hall andout into the gardens or into the kitchen to makesome toast or a cup of tea. Her family and friendswould be supporting her or playing cards or watch-ing TV, enjoying the relaxed and private environ-ment. Often that woman was the only woman inthe hospital but at other times we were sometimesoverflowing with patients. It was not unusual tosee a woman lying on the benches near the lemontree sunning her caesarean section wound or nip-ples in the privacy of the garden. For midwivesused to the rush and bustle of large city hospitalsit taught us a lot that we had not known aboutthe normality of labour and birth in a relaxed andfriendly environment.
We accompanied women who required transferto Palmerston North Hospital by ambulance; thecare was handed over to the base hospital staff.Otaki Maternity hospital was enjoyed and sup-ported by the Otaki community... but... it was
A paper presented at the 7th Biennial New ZealandCollege of Midwives Conference in Dunedin, July 2002.
Otaki Birthing Centre - He Whare Kohanga OraJane Stojanovic RM RGON ADN
Midwife at Otaki Birthing Centre -He Whare Kohanga Ora
New Zealand College of Midwives • Journal 28 • April 2003 25
expensive and often empty. Sometimes three weekswould go by with no women being admitted. Theplace lost its ‘soul’ when the hospital was alteredto try to save money. The old delivery area wasturned into a ‘birthing unit’ and the rest of thehospital adapted to accommodate District Nurs-ing, Public Health and a play centre. The postna-tal inpatient care was reduced to 48 hours withsome follow-up care from the Crown Health En-terprise (CHE) midwives.
There were drawbacks such as loss of privacy forthe women and the unit remained an expense forthe CHE because the main cost was the midwives’salaries. The building was one hundred years oldand needing upgrading with some expensive roof-ing and plumbing.
Changes to maternity care in the 1990sIn 1995 the MidCentral CHE decided to closethe Otaki Maternity Hospital and provide theOtaki women with services based in Levin 15 to20 minutes north of Otaki. The Central RegionalHealth Authority approached Elizabeth Jull andmyself to ask if we would contract to them to pro-vide a birthing facility. They wanted us to use theold delivery area as a birthing unit in the old ma-ternity hospital, (now being converted to a ‘HealthCentre’), but without the postnatal stay which wasavailable in Levin or Paraparaumu. We agreed anda contract was signed. From November 1995 toJune 1996 we cared for our clients at the old ma-ternity hospital. We found this to be unsatisfac-tory, most importantly, because of security issuesand lack of privacy for the women in the build-ing, which was now housing other health groupsand services.
The concept of a newbirthing service for OtakiWe discovered that there was transitional fund-ing available for a limited time. This was for newcontracts as the government’s political agendaopened up the health arena to competition in thename of efficiency. One of the criteria for fund-ing to set up a new service was that the old servicehad been withdrawn by the CHE controlling it.We applied for a grant.
Vision - A ‘stand-alone’ birthing unit to providemaximum privacy and choice of birthing optionsfor Otaki Women.A ‘stand-alone’ birthing unit would providemuch more privacy, freedom of movement and ahomelike atmosphere for the women who use itand their families.
A suitable house was found and set up as ‘non-clinically’ as possible. This included a nice cornerspa bath, deep and roomy enough to accommo-date active birth positions comfortably and witha firm double bed in the birthing room. No doc-tors have practised maternity care in Otaki since1995. There are no criteria for admission and nobarriers to any woman using the facility. Thereare no other policies; no protocols. As for anypublicly funded facilityany woman is welcome touse the facility as long asher LMC has an accessagreement with us. EveryLMC has a duty to con-sider the safety of thewoman and her baby and,as facility managers, it isnot our responsibility todictate in clinical matters.
Experience at the Otaki Birthing Centre– He Whare Kohanga OraThe babies born at the centre since 1996 haveranged in weight from 2200gm to 4700gm.The 2200gm baby was 37 weeks gestation andsmall for dates. Her mother arrived fully dilatedon the doorstep having been seen only once inpregnancy. Mother and baby were transferredpostnatally as the baby needed observation althoughshe was breastfeeding well. Several weeks later thebaby was found to have a ventricular septal defect.
The largest baby was born at term in the centre.One of the advantages of the centre environmentis the ability of mothers to choose positions thataccommodate their needs. This woman, in sec-ond stage ‘crept’ her foot up the wall until herlegs were as wide apart as she could make them. Itwas fascinating to watch and wonder why she wasdoing that. When the baby arrived we could seewhy! The baby fed well and needed no interven-tion, he was just a normal big baby. We are con-vinced that in a hospital where she may not havebeen able to use her instincts freely this baby wouldnot have been born without intervention.
We often have quite ‘high risk’ women who birthwith us either ‘by choice’ or ‘by chance’. Womenwho come ‘by choice’ make the decision aftermuch discussion and often specialist referral sowe are quite sure they understand the risk factorsinvolved in using the birthing centre. Such womenmay have had previous caesarean sections or evenbe susceptible to malignant hyperthermia. Womenwho come ‘by chance’ often arrive on the door-step fully dilated. They are usually booked else-
where but by accident, or design, do not have timeto travel. One woman who was passing in a housetruck went into labour and enjoyed staying to haveher baby with us. Some women may have hadprevious caesarean sections or are giving birthslightly too early. One such woman had a haemo-globin of 83. Some of these women can make usvery anxious but we cultivate a carefully confi-dent and relaxed manner because we know that
anxiety, more than anyother factor, is likely tocause a labouring womanto have problems.
We have only just begunto keep statistics regardingthe management of thirdstage. Many of the womenusing the centre seem tochoose physiological man-agement of third stage. We
try to give informed choice but maybe it is theway we communicate the options that makes somany choose it, maybe it is because women ‘want-ing to do things naturally’ tend to choose eitherhomebirth or the birthing centre. Maybe beingin the birthing centre with its focus on normalityreinforces to them that they want to keep thephilosophy of normality and non-interferencethroughout the process.
When practising physiological management wetry to help the woman to keep the focus on herbaby rather than third stage – not usually diffi-cult! We tend to encourage the woman to sit upso that she is not lying flat, gravity helps us tokeep an eye on blood loss and probably helps theplacenta to separate and move into the lower uter-ine segment/vagina more easily. Sometimes thewoman kneels or sits cross-legged on the doublebed; if she is in the spa then she sits up againstthe side of the spa. We make a cup of tea, checkthe baby, and while keeping a quiet and unobtru-sive eye on the blood loss, scarcely mention theword “placenta”.
We try not to handle the umbilical cord and donot usually clamp the cord at all. If we do need tocut it, usually because it is awkward for the mother,we wait until the cord is empty of blood. We donot normally take the cord blood until after theplacenta is delivered. Then we take it from thesurface of the placenta near the insertion of thecord. We have never had a problem getting theblood. This way the baby gets the cord blood, richin stem cells, that nature intended. We do notworry about the mother’s position relative to the
continued over...
How can we compare care in a relaxed,comforting environment, such as ours, wherethere is a known and trusted midwife, with abusy, bustling hospital where the attendants
may not be known to the woman and may notbe comfortable with physiological third stage?
Apples and pears!
New Zealand College of Midwives • Journal 28 • April 200326
baby and we have not had a large number of jaun-diced babies, despite some paediatricians’ concerns.
Often the placenta delivers spontaneously whenthe mother moves. If it is taking a long time andthe mother wants to get on, we may ask thewoman to give a push and put very slight pres-sure on the cord – after checking the fundus forsigns of separation. If the placenta is not obvi-ously separated and the baby has been sucklingwe will offer the woman the opportunity to sit onthe toilet with a bowl in the toilet to catch theplacenta. This is usually effective. Women, as forsecond stage, find it easier to ‘let go’ on the toilet.If there is noticeably heavy bleeding (heavier thanthe normal separation bleed), after discussion withthe woman we will give intramuscular syntocinonand deliver the third stage without waiting.
We also use ergometrine (usually a half dose), ifwe are worried about ongoing heavy lochia. Par-ticularly if we think there are risk factors for post-partum haemorrhage present, remembering thatthese women are going home after the birth. Ahalf dose of ergometrine does not give the womanthe side effects of a full dose but does help to keepthe uterus well contracted. If we have a true haem-orrhage we use the full dose. We discuss all thiswith the woman during birth planning during thepregnancy. Despite probably a 50 - 75% use ofphysiological third stage we have only had twopostpartum haemorrhages, both under 1,000 ml.
Barbara Katz-Rothman (1989, p.178) wrote:
I have come to see that it is not that birth is“managed” the way it is because of what weknow about birth. Rather, what we know aboutbirth has been determined by the way it ismanaged. And the way childbirth has beenmanaged has been based on the underlyingassumptions, beliefs and ideologies that informmedicine as a profession.
How can we compare care in a relaxed, comfort-ing environment, such as ours, where there is aknown and trusted midwife, with a busy, bustlinghospital where the attendants may not be knownto the woman and may not be comfortable withphysiological third stage? Apples and pears! It fol-lows then that we must be critical of research donein a totally different environment from the waymany of us practise. It becomes ever more neces-sary that we have our own perinatal data-base sothat we can truly compare like with like and getsome research data which really is relevant to ourown situations.
The Otaki Birthing Centre is small and statisti-cally insignificant, but it provides us with a centre
where women can access us each Tuesday morn-ing, when we have an open coffee morning. Ithelps us to liaise with other midwives, well-childnurses and healthcare workers who often drop infor coffee. It has been used by new mother groupsand provides us with a venue for antenatal classesand midwifery workshops.
We are grateful for the chance that we have hadto work in this very autonomous way. We see thatthe centre is useful in providing an option forbirthing women in an environment that is con-ducive to normal birth and family involvementand that allows midwives to develop confidencein their own abilities. We particularly notice thedifference in the behaviour of women and the dif-ference in our own practice when we have to workin hospital environments. This has reinforced ourbelief that environment has a huge effect on theprogress of labour. An environment that reinforcesthe normality of birth and that is relaxed and cul-turally appropriate makes a huge difference towomen’s ability to birth well.
Otaki Birthing Centre - He Whare Kohanga Oracontinued...
Developing and working in the centre has been aremarkable experience. Although running the cen-tre is a responsibility and sometimes even a bur-den, it has given us great freedom to practise thecraft of midwifery. We continue to strive to keepwomen in control of their birthing. We do notalways get it right but the experience of being ableto practice with true midwifery autonomy is onewe will never regret.
Reference
Katz Rothman, B. (1989). Recreating motherhood: Ideology andtechnology in a patriarchal society. New York:W W Norton &Company.
Stojanovic, J. (2003). Otaki Birthing Centre - HeWhare Kohanga Ora. New Zealand College ofMidwives Journal, 28 (1), 24-26.
Kate Spenceley presented this poem at the National Conference in 2002 and we were delightedto print her work in the October 2002 issue. However, in the typesetting process the layout ofthe poem was altered. As Kate noted, this disrupted the intended meaning and was akin todisplaying a photograph in several parts. The Editorial Board apologises for this disruption andhas taken the opportunity to reprint the poem for readers to enjoy.
When Kate presented the poem at the conference session she explained her choice of title. Herwords were “that the title was partly out of my respect for the Maori people and partly out of my awefor the marvellous organ that grows the babe.”
WhenuaAt the beginning of your world, I was part of you.
Made of the same luminous fabric, flesh of your flesh, of our father and
mother’s being.
As we grew, we were separated but united. I fed you, breathed for you,
became a pathway for the flushing currents of our mother’s blood.
As you slept, I was your cradle and your guard; when you awoke I was
your companion.
Together for that last day I leashed you to the very limits of our linking line
before releasing you to the touch of others—lovers, yes—but surely none will
hold you as nearly, as sweetly or as softly as I did.
As our connection was severed you cried aloud, then were gone.
Carry me deep in your heart as you bury me in the soil of our home, for I am
the earth of your making.
New Zealand College of Midwives • Journal 28 • April 2003 27
THE NEW ZEALAND COLLEGE OF MIDWIVES DOES NOT ENDORSE THE SOFTWARE IN THIS ADVERTISMENT
New Zealand College of Midwives • Journal 28 • April 200328
Recruitment
Education
New Zealand College of Midwives • Journal 28 • April 2003 29
New Zealand College of Midwives • Journal 28 • April 200330
J O U R N A L g u i d e l i n e s f o r c o n t r i b u t o r s
The NZCOM journal is published in April and Octobereach year. It focuses on midwifery issues and has a readershipof midwives and other people involved in pregnancy andchildbearing, both in New Zealand and overseas. Thejournal welcomes original articles which have not previouslybeen published in any form. In general, articles should bebetween 500-4000 words.
FormatArticles should be typed on one side of white A4 paperwith double spacing and a left margin of 3 cm. Authorsshould use section headings and label any diagrams or tableswhich are included. Diagrams, tables or photographs shouldbe supplied as computer generated items. The word countfor the a rticle should be stated. If supplied as hard copythen three copies of the article should be supplied. If sup-plied as an electronic copy then a WORD document orRTF file for PC is required.In addition, authors are requested to provide the followingdetails on a separate sheet which is not sent to the reviewers.Name, occupation (current area of practice/expertise), quali-fications, address for correspondence during the reviewprocess including day time phone number, contact detailssuch as email address which can be published if the journalaccepts the article . Where the article is co-authored, thesedetails should be provi ded for all authors. ALL authors ofthe article should sign an accompanying letter stating that theywish to submit it for publication.
ContentAny article which reports a piece of research needs to notethe processes undertaken for ethical approval.
ReferencesAuthors are responsible for providing accurate and com-plete references. The journal uses the American Psycho-
logical Association (APA) format. Some details of this formatare available on the APA website at www.apastyle.org. The 5th
edition of the APA Publication Manual was published in 2001.In the text, authors’ names are followed by the date of publicationsuch as “Bain (1999) noted …..” or “this was an issue in Irishmidwifery practice (Mary, 2000)”. Where there are three or moreauthors, all the names should appear in the first citation such as“(Stoddart, Mews, Neill and Finn, 2001)” and then the abbre-viation “(Stoddart et al., 2000)” can be used. Where there aremore than 6 authors then “et al.” can be used throughout.The reference list at the end of the article should contain acomplete alphabetical list of all citations in the article. It is theresponsibility of the author to ensure that the reference list iscomplete. A comprehensive range of examples are provided onthe APA website. Two examples are included here.Journal articlePairman, S. (1999). Partnership revisited: Towards amidwifery theory. New Zealand College of MidwivesJournal, 21 (4), 6-12.BookPage, L. (Ed.). (2000). The new midwifery. London:Churchill Livingstone.
CopyrightIt is the responsibility of authors to ensure that any necessarypermission is sought for copyright material. This relates to articleswhich include substantial quotations, diagrams, artwork andother items which are owned by other authors. Further detailsand examples are included in the APA Publication Manual.Written evidence of copyright permission must be sent to thejournal if the article is accepted for publication. Please contactthe Editorial Board if you wish to have clarification of copy-right material.
Review processAll articles are sent out for external review by two reviewers whohave expertise relevant to the article content. In addition, amember of the Editorial Board acts as a reviewer and collatesfeedback from the two external reviewers. The process of reviewis outlined in the October 2001 issue.
Other items for publication
Items other than articles are welcomed for publication. Theseinclude:• Exemplars/ stories of practice• Book reviews• Abstracts of Masters or doctoral theses• Letters to the editor.The expectation regarding publication of any of these itemsis that they preserve confidentiality where necessary (e.g. inexemplars) and seek any necessary copyright permission ofquoted materials (see earlier section on copyright). Itemsother than articles are not generally sent out for a review.Instead the Editorial Board reserve the right to make a finaldecision regarding inclusion in a journal issue. Such decisionstake into account the length of the journal and the nature ofother articles.
AcceptanceOn acceptance of an article or other item for publicationauthors will be requested to submit the material with anynecessary amendments by a specified date as either a Worddocument or a RTF file for a PC. Articles which are acceptedand published become the copyright of the journal. In thefuture this may include placing articles as part of an on-linepublication of the journal. As part of the electronic processof printing the journal, the Editorial board reserves the rightto modify any article which is accepted with regard toformatting and layout.
Contacts for the Editorial BoardAlison Stewart, Board Convenor,[email protected] Davis, Manager of Review Processc/o School of Midwifery, Otago Polytechnic,Private Bag 191 0, Dunedin. [email protected]
Reference: American Psychological Association. (2001).Publication manual of the American PsychologicalAssociation (5th ed.). Washington, DC: American PsychologicalAssociation.
New Zealand College of Midwives • Journal 28 • April 2003 31
