College Of Midwives Research Articles

Working through adversity in a Midwifery Group Practice

The Logan and Beaudesert Hospital Midwifery Group Practice (MGP) Queensland is an all risk midwifery model of care with a specific objective to care for vulnerable and socially disadvantaged women.Working through adversity has been a challenging journey which has positively influenced midwives practice and professional growth. This journeybeganwithmajor changes inMidwifery management leading to instability in leadership, a decrease inmidwifery autonomy, withdrawal of medical support and attempts to close the service. This caused emotional stress within the MGP and attempts to improve the situation, with support from the Queesland Nurses Union (QNU) were unsuccessful. This led to long term sick leave, work cover claims, discontinued care of women, a reduction in midwives, a change in the remaining midwifery culture, loss of income and emotional distress. Women were affected by withdrawal of their midwifery model of care which also caused them emotional stress. This significantly influenced their decision making processes for their births and affected their outcomes as well as the service statistics. Midwives worked together to challenge the adversity they faced. Professional and consumer bodies such as the Australian College of Midwives, Maternity Coalition, Midwives Australia and the QNU assisted Midwives to negotiate with management. The midwives wrote to and visited Members of Parliament and met with the Health Minister which led to meetings with management, an external review of the service and an improvement in Midwifery leadership. Supporting each other and standing strong helped strengthen the midwives passion for midwifery. It empowered them to return to work and continue promoting professional midwifery practice. Many midwives have improved the workplace culture, supported new graduate positions, gained eligibility, prescribing rights and commenced private practice. These efforts have also led to a Health Minister promise to return birthing to Beaudesert Hospital by 2014. Overcoming adversity has developed stronger more empowered midwives significantly benefiting them and the women in their care.

Colleges pledge to reduce bullying in obstetrics and gynaecology

Two royal colleges have pledged to reduce undermining and bullying behaviour in obstetrics and gynaecology and to foster a respectful working culture. The Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives said that they were acting to tackle problems faced by trainees and fully qualified staff. The colleges said that consultants’ mistreatment of trainees was a long established problem in obstetrics and gynaecology, as shown …

Mastering your profession

British Journal of Midwifery • February 2013 • Vol 21, No 2 As you are all more than aware, the UK is undergoing another baby boom. In a report issued to Parliament last month, the Royal College of Midwives (RCM) highlighted that although there has been a 7% rise in the number of full-time midwives in the UK, there are still too few (about 5000) in relation to the number of births (RCM, 2012). In 2011, there were 688 120 babies born to women in England, the highest number for 40 years (RCM, 2012), and in the UK, of the 808 000 births, 196 000 were to non-UK born women (Office for National Statistics, 2012). Each culture has its own beliefs and challenges and as Britain’s population diversifies, it is more important than ever to understand these differences to help provide high quality, individualised care to women and to promote the normality of birth. One of our remits in BJM, is to encourage the expansion of knowledge and we have always placed emphasis on the importance of continual professional development. Our portfolio of study days throughout the UK provide you with the opportunity to deepen your knowledge of female genital mutilation, stillbirths and complex needs while our study tours to China, run by our partner company Master Travel, give you a unique insight into midwifery practices in a challenging and rapidly expanding nation. The exploration of midwifery in different cultures provides the opportunity to discover a different philosophy of clinical practice, and allows you to broaden your professional and personal horizons. In countries such as China, where almost 50 000 babies are born each day, the rate of caesarean sections performed are well above the World Health Organization’s recommended 10–15% (Feng et al, 2012). Sufang et al (2007) found that the huge demand for the procedure across urban and rural areas of China was linked to the ‘one-child norm’ and women’s demand for the procedure. Furthermore, the cost of a caesarean section is higher than a vaginal birth, so many hospitals encourage the surgery to make more money. However, the Beijing Health Bureau has been promoting normal vaginal birth in order to lower the high caesarean section rate. Stricter supervision will be exerted and hospitals will be punished if they are found to perform unnecessary caesareans. The recent anouncement that 100 hospitals in the UK will share a £25 million fund to improve and upgrade their maternity units is indeed a welcome one and will go far to help promote normal birth in this country. However, would this money be better spent on employing more midwives to cope with the increasing population? I am afraid I am yet another statistic who has added to this baby boom. Set to go off on maternity leave at the end the week, I believe my antenatal care in the last 8 months has given me a great insight into the fantastic work midwives do from the perspective of a service user. My care has been second to none despite the stretched nature of maternity services and I fully intend to make the most of my midwife-led birth unit. BJM

BJM rewarding excellence

British Journal of Midwifery • January 2013 • Vol 21, No 1 The start of a new year is a time for reflection and new ideas and new possibilities. It is the perfect time to rejuvenate and make a change. 2013 has already started positively for the midwifery profession with the Nursing and Midwifery Council (NMC) releasing its updated Midwife rules and standards on 1 January. The rules have been simplified and clarified and will continue to provide a ‘framework for midwives’ safe and effective practice’. Carmel Lloyd, midwife and standards development manager at the NMC has outlined the revisions on p 65. I hope you will read them with interest. Furthermore, on p 6, Professor Lesley Page looks back on her year as the president of the Royal College of Midwives (RCM) noting that although there are too few midwives, services are usually over stretched and work beyond capacity, midwives have much to be proud of. Midwives around the country are working hard to maintain safe high quality services, and are also leading development in new approaches to care, transforming practice and developing new services. Never is this more apparent than in the number and quality of submissions we receive each month at the British Journal of Midwifery. The British Journal of Midwifery is dedicated to advancing the profession through promoting evidence-based best practice and we believe that good practice needs rewarding. This year will mark the 10th annual British Journal of Midwifery Practice Awards. They will take place on 16th May at Le Meridien Hotel in London, alongside our 2-day national conference on contemporary midwife practice. These awards seek to recognise excellence throughout the profession from students to emeritus professors. Last year, the awards attracted a very high standard of entries in six major categories from enthusiastic individuals and teams highlighting excellent practice for the challenging work that midwives perform. Because of this, we have added two more categories this year—Contribution to Midwifery Award and Educationalist. We at British Journal of Midwifery recognise that multidisciplinary teams help provide the best care to women and their babies, as expertise from all areas can be drawn upon. Thus the contribution to midwifery award will go to a person who has made an outstanding contribution to midwifery. They will have demonstrated dedication and commitment to the caring of the mother and baby. The winner of this category may be an obstetrician, a neonatal nurse or a National Childbirth Trust (NCT) volunteer. The profession would not be what it is today without those of you who train and educate the next generation of midwives. The educationalist award will recognise a committed and influential educator who has contributed to the expansion of midwifery knowledge through the development of new educational strategies. Why not have a think about someone you work closely with who has had a positive impact on the care of mother and baby and nominate them for an award. Other categories include: n Community Midwife of the Year Award n Midwife of the Year n Team of the Year n Excellence in Supervision of Midwives Award n Student Midwife of the Year n Educationalist n Lifetime Achievement Award Nominations open on the 21 January and further details can be found on our awards website: http://awards.britishjournalofmidwifery.com/how-enter. Make 2013 count and nominate a peer. BJM BJM rewarding excellence

Black midwives are punished more harshly than their white colleagues

The Royal College of Midwives has added to the growing evidence of race inequalities in the NHS with research that shows black midwives are more likely to be disciplined than their white colleagues. A Freedom of Information request by the Royal College of Midwives sent to 21 London trusts found that 60 per cent of midwives disciplined between July 2010 and 2011 were black. However, as a group they only make up 32 per cent of the workforce. The research, published to coincide with the RCM annual conference, bears out last week’s investigation by Nursing Standard that found nurses from black and minority ethnic (BME) backgrounds are facing a disproportionate number of disciplinary hearings.

Cord clamping guidance

British Journal of Midwifery • September 2012 • Vol 20, No 9 New guidance by the Royal College of Midwives (RCM) on the timing of cord clamping is expected to be unveiled at the RCM conference in November. The new guidance will recommend delaying clamping the cord until after it has stopped pulsating—sometime between 3 and 5 minutes. Delaying cord clamping is thought to protect babies against iron deficiency and anaemia, and allows vital stem cells to be transferred. Currently, midwives are advised to clamp the cord within 30 seconds of birth (National Institute for Health and Clinical Excellence (NICE), 2007). It was previously thought that cutting the cord within 30 seconds protects babies from exposure to hormones given to speed up labour and deliver the placenta and could also prevent jaundice. The change in guidance follows a growing number of studies highlighting the benefits of delayed cord clamping. For example, in a Swedish study that looked at the outcomes of 400 babies born after a low-risk pregnancy, where some had their umbilical cords clamped after at least 3 minutes and others were clamped in less than 10 seconds after delivery, Andersson et al (2011) found that babies with delayed clamping had better iron levels at 4 months of age and were far less likely to suffer newborn anaemia. Hutton and Hassan (2007) compared the potential benefits and harms of late vs early cord clamping in term infants. They found that delaying cord clamping by 2 minutes could half the risk of anaemia. The benefits of delayed cord clamping have been known for sometime—Hutton and Hassan’s meta-analysis was over 5 years ago. The World Health Organization (WHO) dropped early clamping from its guidelines some years ago as anaemia is a big problem in the developing world (WHO, 2009). The Royal College of Obstetricians and Gynaecologists (RCOG) also updated its guidelines in 2009 to state that: ‘the cord should not be clamped earlier than is necessary, based on clinical assessment of the situation. Evidence suggests that delayed cord clamping (more than 30 seconds) may benefit the neonate in reducing anaemia, and particularly the preterm neonate by allowing time for transfusion of placental blood to the newborn infant,which can provide an additional 30% blood volume. In the preterm infant (less than 37+0 weeks of gestation), this may reduce the need for transfusion and reduce intraventricular haemorrhage. Delayed cord clamping does not appear to increase the risk of postpartum haemorrhage’ (RCOG, 2009). The change in guidelines is definitely welcome, but the question has to be asked why has it taken so long for us to catch up? BJM

Centralising midwifery care

British Journal of Midwifery • august 2012 • Vol 20, No 8 In a controversial bid to provide higher levels of care for women and babies—especially those with complications, Dr Tony Falconer, president of the Royal College of Obstetricians and Gynaecologists, has proposed that almost a third of NHS maternity units should be closed and replaced with a smaller number of large facilities where consultants are available around the clock. He believes that under the existing maternity care structure, there are too few consultants to guarantee high quality care for everyone. Under the rationalisation programme, a fewer number of units would handle 5000 to 6000 births a year. Having a baby is an extremely personal milestone in a woman’s life and there is a concern that these larger units will lose the human touch and will be more concerned with turning beds around. However, as approximately 94% of births currently take place at hospitals, this may encourage more low-risk women to attend midwifery-led birthing units or to have home-births. But will this have a knock-on effect on the already strained workload of midwives? Additionally, while centralising maternity care may be feasible in larger cities such as London where there are a large number of obstetric units, women from less densely populated areas would have to travel further for their care. The cost implication is not the only thing that should be considered here, what happens to those women who have a precipitous birth and cannot reach a hospital in time? Cathy Warwick, General Secretary of the Royal College of Midwives said: ‘We do need to rationalise because, in future, smaller obstetric units won’t be affordable if they are too small. For units delivering 2500 to 3500 babies a year, their future is a bit gloomy. Units of that size are going to struggle to survive. It’s going to be very hard to justify them, unless there’s a justification based on geography.’ As we are all aware, maternal obesity and the prevalence of older mothers is on the rise. It is well known that these can lead to complications during pregnancy. For example, maternal obesity can increase the risk of caesarean section, postpartum haemorrhage, maternal hypertension and gestational diabetes as well as fetal death (Arrowsmith et al, 2011). There is no doubt that around the clock access to consultants may help improve the outcomes for known high-risk births and surely it is better to go further afield if you will receive higher-quality care. However, this suggestion of centralising services, further from people’s homes, does seem to run contrary to the coalition government’s broader drive to devolve power to local communities, to develop local services, based in community settings, tailored to local needs and demographics (Department of Health, 2010). When weighing up the cost between geography and care, it is vital that everyone works together to ensure care always comes first. BJM

News update.

The RCN, Royal College of Midwives, Unite and Unison are joining together to survey their members about changes in pay and conditions.

Is midwifery still a labour of love?

Sitting next to a woman on the tube recently, I noticed she was engrossed in an article entitled ‘Women hire own midwives after trauma of NHS births’ (Goodchild, 2012)’. At my next stop, I got the paper and perused it over the obligatory latte. It stated that London mothers are resorting to private midwives because they fear giving birth on the NHS, the reasons they gave were the rising birth rate and the shortfalls in midwives. The story also provided private midwives views on why hers and similar services are being increasingly used. She highlighted that reality shows such as ‘One Born Every Minute’ showing women being left by the midwife for long periods of time or not seeing the same midwife twice were partly to blame. I think we all understand that a women’s previous experiences can affect subsequent pregnancies and choice place of birth as well as service provider. So what is being done? Many NHS trusts provide services to support women who have had difficult or traumatic births. These services include debriefing interventions to help reduce psychological problems in the postnatal period or VBAC (vaginal birth after caesarean section) clinics to offer information and support for women who have had previous caesarean sections and who want a vaginal birth. These obviously do not go far enough to meet the needs of all women. What we may now see is a group of women in their first pregnancy who have a dread of childbirth because of other people’s experiences via reality shows. True, women have often relayed scary birth stories to me from friends and relatives giving rise to concern but they were just that, ‘stories’ which often become embellished over time. As a midwife it was usually easy to discuss these anxieties and offer appropriate support. However, women are now ‘living through’ the ups and downs of a number of births via the media, which are edited for entertainment value, and do little to allay the fears of pregnant women. A quick scan of the programme’s forum postings shows that women are shocked by some of the content, which leaves them stressed and anxious. It is clear that midwives need to be aware of the impact of these shows, rather than avoiding watching them (as a lot of us do). We should be in a position to try to explain what has happened if women ask. I hope every midwife watches these reality shows with a critical eye, again we can learn from observing care from a different perspective. Although private and NHS provision might differ, all midwives want to offer the best service they can. In the NHS, it might not be one-to-one care that midwives wish for, but women need to be able to feel they have access to a midwife whenever they need one. Better communication is fundamental, informing women about what they can expect from the NHS so they can make a decision to engage private services in light of this information. Lawrence (2012) reported that women are paying independent midwives to support them during hospital birth providing information, arguing their case and being a constant presence during labour. This raises the question of advocacy. Why might NHS midwives have lost this skill? Is it that they lack the resources, the ability to promote normal birth or fail to listen to women’s needs? Even in light of limited resources there is still a lot of good will in the NHS, only last week I heard that midwives who are experts in home birth are providing voluntary support for inexperienced midwives in an attempt to increase the service. This echoes the feelings of Cathy Warwick CBE, General Secretary of the Royal College of Midwives, who stated that great work is being done by midwives in relation to increasing home and water birth figures (Dabrowski, 2011). Has midwifery changed so much that the NHS cannot provide women with the care and support they need or have women’s expectations changed? Either way the service needs modernising to meet these needs and this can only be done if there are adequate midwives available. It appears that women want the traditional role of the midwife back, to communicate effectively and encourage them to make their own choices. Let us make sure these are in our everyday practice and remember that midwifery will always be a labour of love regardless of who provides the service. BJM

Maternity and mental health services working collaboratively for women

Through the collaboration and partnership working of key professionals within maternity services, Child and Adolescent Mental Health Services (CAMHS), health visiting, GP services and Oxford Primary Care Trust (PCT), an innovative new service has been established which addresses the needs of women with mild to moderate mental health problems in pregnancy and the perinatal period—the Infant Parent Perinatal Service (IPPS). The partnership model of working has created firm pathways across service providers and has resulted in a forum for ongoing opportunity and creativity which continues to seek and develop new ways of improving mental health care for vulnerable women in pregnancy and the perinatal period. It is now well recognized that not only the physical but also the mental and emotional health of a woman while pregnant and in her infant’s early years will have a lifelong effect ( Department of Health, 2011 : 10). The IPPS project has been recognized nationally, receiving second place in the 2009 British Journal of Midwifery awards for ‘team of the year’ and a highly commended second place in the Royal College of Midwives 2010 awards for excellence in partnership working.

Promoting normality and providing a cost-effective service

I have recently returned from Royal College of Midwives (RCM) conference and, as always, it was a mixture of inspiring speakers, new evidence, great ideas from practice and a chance to network and meet up with old friends. What I have reflected on since my return is the enduring problem of the rising caesarean section rate, which does not fit well with the rhetoric of midwives as experts and guardians of normal birth. There is little doubt that the increase in caesarean sections is a result of the culture of medical dominance, fear of litigation and women's fear of the pain of childbirth, to name just three factors. However, as midwives we have been complicit in this; midwives are just as present as obstetricians on our labour wards.

Midwife shortage is at its most acute in inner cities.

Further to Christian Duffin's interview with Cathy Warwick, general secretary of the Royal College of Midwives (career development September 8), I fear for the future of maternity services.

Termination of the Albany Practice contract: unanswered questions

As Yiannouzis (2010) comments in the previous issue of the British Journal of Midwifery, King's College Hospital management's decision to terminate its contract with the Albany Midwifery Practice (AMP) has caused significant concern among midwives. More importantly the decision, which was taken with no public consultation, has caused a huge amount of distress to the families served by the AMP. Shortly afterwards, a support group ‘Albany Mums’ was set up on Facebook and has attracted 690 supporters. The Albany Action Group (supported by members of Royal College of Midwives (RCM), Association for Improvements in Maternity Services (AIMS), National Childbirth Trust (NCT), Association of Radical Midwives (ARM), Independent Midwives UK (IMUK) organized a rally in London which attracted 2000 people voicing their support and a desire for the caseload model of care to be rolled out across the UK. A petition with 4000 signatures has been handed in to the Department of Health.

Fighting talk from midwives.

The Royal College of Midwives (RCM) will hold any future Labour government to account about commitments made to the profession.

Midwifery in the spotlight as politicians vie for votes.

The 850 midwives and students who gathered in Manchester last month for the Royal College of Midwives' (RCM) annual conference shared a vision for the future: a passion for supporting normal births where possible.

Investment, recruitment and support: initiatives to tackle the midwifery crisis.

When the Royal College of Midwives (RCM) responded to the prime minister's Commission on the Future of Nursing and Midwifery, the comment from one midwife was so resonant it was printed in full in the submission.

Effects of valsalva manoeuvre on maternal and fetal wellbeing

The aim of this article is to relate basic findings from research papers to identify the effects that valsalva manoeuvre (‘purple pushing’) has upon maternal and fetal wellbeing. Analysis of 16 papers revealed four main consequences from purple pushing. These include: an increase in fetal distress; maternal distress; and perineal trauma, when compared with spontaneous pushing. Valsalva manoeuvre also makes little difference to length of second stage. Key conclusions from this literature review are that women should be encouraged to push instinctively, which often embraces natural vocalization. Restrictions of time should not be imposed when mother and fetus are well. Awaiting instinctive behaviour reduces the incidence of urinary system, pelvic floor and perineal trauma. These findings should facilitate midwives to critically understand research that underpins the Royal College of Midwives (2007) second stage of labour guidelines.

A demographic snapshot of midwives in Victoria

Midwifery in Victoria has experienced significant change over the last twenty years. Over more recent years, midwifery workforce issues have become prominent with studies highlighting an ageing midwifery population and a high proportion of part time employment. During a study conducted in 2005 that explored midwives’ attitudes to online and computer based learning the demographic data proved to warrant more detailed analysis. This paper presents a discussion on that data. Participants for the study were drawn from the membership of the Australian College of Midwives (ACM)Victorian branch.However, while the sample was small (n=169), the findings presented in the paper add to the existing body of knowledge around the midwifery workforce in Victoria. They reinforce that the midwifery workforce remained an ageing one, predominantly female, and a significant percentage were employed on part time or casual bases. With graduates emerging from recently introduced undergraduate midwifery programs, it is argued that it is timely for larger studies of the midwifery workforce to be conducted. Studies should seek to explore a range of factors such as reasons why midwives are choosing not to work in full time employment.

ICM Congress: a forum for new ideas

This month midwives from all over the world will be flocking to Glasgow to attend the International Confederation of Midwives 28th Triennial Congress, hosted by the Royal College of Midwives. The UK location will allow many more UK midwives to attend this special event, which spans five days from 1st June. This is a celebration of midwifery where midwives from many countries join together to share practice and learn from one another. Woman-centred care and evidence based practice are goals common to midwives all over the globe and hundreds of them will be presenting their findings to a wide audience at the conference on many subjects. They will cover the whole spectrum of the midwife's role, from normal birth, infant feeding and public health to risk management, stillbirth and mental health. Whatever your specialist area of practice, there will be plenty on offer to stimulate the mind and generate new ideas.

International Confederation of Midwives 28th Triennial Congress

The Royal College of Midwives invites midwives from all over the world to attend the ICM Congress held in Glasgow, beginning on 1 June. This is an international event and the opening ceremony is not to be missed. It includes performances from those all over the UK and the presentation of national flags.