Practising midwifery independently: For the majority of midwives?

AUSTRALIAN COLLEGE OF MID'02I\ ES INCORPORATFD

PRACTISING MIDWIFERY INDEPENDENTLY: FOR THE MAJORITY OF MIDWIVES? Jenny Parratt R N RM IBCLC BHSc Independent midwife in private practice

Abstract

Independent: The Meaning

This paper eaplores the proposition that all mMwives can practise independetztly regardless of theirplace o f p r a c t i c e or e m p l o y m e , ~ t s t a t u s . T h a t independence can be defined by the wa), in which the midwife practises is discussed. The theot3' of midwifery as a partnemhip is reviewed a n d its effects on midwifet 3, as a profession will be explored. How this relates to Victoria a n d the absence of regulations will also be discussed. The need for co~ztinuit3, of care a n d women centred practice will be analysed in this" context. Advocao,. as used by mMu'ives. "will be examined, as will midwife empozzerment of the woman a n d the midwife.

The Chambers Dictionary defines independent as not being subordinate to or controlled by others. Similarly, the Australian Concise Oxford Dictionary gives its meaning as not being dependent on authority. Waldenstrom (1996), in discussing whether midwives are independent, uses the Angus & Robertson dictionary definition of independent which includes: that there is no dependence or reliance on anything else for function or support. Waldenstrom goes on to look at the literal meaning of independent, concluding that midwives will always be dependent on collaboration and support from doctors, and on the guidelines of the health facility with which they are involved. Thus, according to WaldenstrOm (1996), it is in no-one's interest to be independent and so 'midwifery will never be i n d e p e n d e n t and autonomous in the literal sense'.

Introduction Following the release of the p r o p o s e d code of practice for Victorian midwives last year (Nurses Board of Victoria 1995), there has been much d e b a t e a b o u t midwives calling t h e m s e l v e s independent, and the role of the midwife in that field. This paper investigates what it means to be independent, and whether this is a possibility for the majority of Australian midwives, nearly all of w h o m are employed by institutions. It has been stated that such ideological arguments must be r e p l a c e d by r e s e a r c h a n d e v i d e n c e - b a s e d knowledge (Waldenstrom 1996), and certainly these are important aspects of midwifery practice. However, it cannot be disputed that a profession needs a sound theoretical foundation, preferably based on practice. The theory of midwifery as a partnership can provide iust such a theoretical foundation. In addition it is very closely aligned with i n d e p e n d e n t practice, and so will be included in this article. The various aspects of practising independently as an employee of an institution will be discussed, and the paper will conclude with a brief summary of the Victorian situation. SEPTEMBER 1906

Using the literal meaning of the word independent can be taken even further. For example, midwives depend on telephones to communicate during their work, they use cars to travel to the w o m a n w h o requires their services, and many midwives rely on baby sitters or creches for their own children while working. Thus, midwives are dependent on a great variety of social systems to allow them to function. Now we could carry this literal meaning of independent to the extreme and point out h o w we are dependent on the air we breath and the food we eat to continue to live. It makes one wonder w h y such a word exists at all if it is so impossible to be 'independent'! The reason, of course, is that it exists because it is not meant to be used literally. Use of the word independent with reference to an individual's thoughts, actions or decisions is a common occurrence, and its use with reference to professional groups is not at all unusual. The medical profession certainly see themselves as independent, as do Obstetricians & Gynaecologists. Indeed, the Chairman of the National Association of Specialist Obstetricians & Gynaecologists believes that it is in everyone's interest to have a strong independent medical specialty (Molloy 1995). This group also uses the term 'Independent

ACMI JOITRNAL

PAGE 23

AUSTRALIAN COLLEGE OF MIDWIVES INCORPORATED

Midwifery' throughout the June 1995 issue of their Newsletter (NASOG 1995). The international midwifery literature abounds with papers on independent midwifery practice (for example Evans (1994), Waters & Steele (1992) and Leap (1991)). Indeed our o w n Australian College of Midwives (ACMI) have devised an accreditation program for independently practising midwives (Brown 1994), and the D e c e m b e r 1994 issue of the ACMI J o u r n a l (vol 7 n o 4) f o c u s s e d o n independent midwifery. So the word is in c o m m o n usage with regard to midwives, and no doubt it will continue to be used despite some concern about its use by some sections of the community.

Practising Midwifery Independently I propose that as midwives we have developed and can continue to develop our o w n explanation of the term independent with respect to midwifery. Overwhelmingly the references in the literature to independent midwives either describe them as being homebirth midwives, or assume them to be self employed (for example Evans 1994, Hobbs 1993, Wilkes 1994). The word independent is used to refer to independence from an employment body, that is the midwife is self employed or in private practice. Such characteristics of the self employed midwife include: •

ability to choose working hours;

•

ability to fit work around other commitments.

These are characteristics of a self e m p l o y e d midwife, not n e c e s s a r i l y an i n d e p e n d e n t l y practising one. Certainly it seems that all privately practising midwives will be practising independently, but does it follow that all midwives w h o practise independently will be doing so in a private capacity? Some of the characteristics of the independent midwife are: •

experience

•

diverse reasons for entering midwifery practice

•

sees birth as a social event

•

believes birth is usually a normal event, that is, a trust in women's bodies that they can give birth without intervention

PAGE 24

•

provides continuity of care

•

provides real choice in options for place of birth

•

promotes the w o m a n and the midwife having equal but complementary responsibilities

•

promotes a relationship of trust and mutual respect with the w o m a n

•

adopting their own style and way of practice

(Adapted from Leap 1991 & Crowe et al. 1994). When w e look at this list of attributes of the independent midwife, we see that none absolutely require that the midwife is self employed, nor are they influenced by the planned place of birth. Independence is actually defined by the way the midwife practises rather than birth place or employment status. This concept is supported by Guilliland & Pairman (1994).

The Theory of Midwifery as Partnership

a

The set of characteristics of the independent midwife, referred to above, is congruent with the theory of partnership which underpins midwifery in New Zealand (NZCOM 1993). Guilliland & Pairman (1994) actually define midwifery as 'the partnership between the w o m a n and the midwife'. The underlying philosophy of this theory is shown in Figure One, and its theoretical principles are s h o w n in Figure Two. As this theory has b e e n developed from actual midwifery practice, the similarity to the list of characteristics of the independent midwife is not surprising.

Underlying philosophy The four concepts of the underlying philosophy (Figure One), cover birth as a normal life event, continuity of care, independence and w o m a n centred care (Guilliland & Pairman 1994). Each item is linked with the other, so that all are necessary for the practice of midwifery as a partnership. Thus, having the w o m a n (rather than the midwife or medicine) at the centre of midwifery practice, the normality (or h o p e d for normality) of the e x p e r i e n c e is a c k n o w l e d g e d , as is the importance of childbirth in the life of each woman. This, then, will also include the social and cultural aspects for each individual w o m a n during her personal experience of the total childbirth event

ACMI JOURNAL

SEPTEMBER 1996

AUSTRALIANCOLLEGEOF MIDWIVES INCORPORATED

T H E T H E O R Y O F M I D W I F E R Y AS A P A R T N E R S H I P The Underlying P h i l o s o p h y

(Modified from Guilhland & Pairman (1994)

---...... Midwifery is women centred

Birth seen as a normal life event Viewing birth in the social and cultural context.

\

Woman's focu~l i~eOr~aheirlyelf,her baby Midwife's focus is on the woman.

The midwife is the guardian of the normal.

Midwifery provides care during the total childbirth experience

Midwifery is a profession in its own right

Provides total service during pregnancy, labour, birth and postnatal period on midwife's own responsibility.

Professional autonomy/independent midwifery.

(continuity of care)

Equal status and responsibility with other professions involved in maternity care.

Figure o n e : Midwifery as a partnership: Underlying Philosophy, Modified from Guilliland & Pairman (1994) T H E T H E O R Y O F M I D W I F E R Y AS A P A R T N E R S H I P Theoretical Principles

(Modified from G m l l i l a n d & Palrman (1994)

Individual Negotiation

Continuity of Care & Caregiver

Between woman and miwife with recognition of the essential contribution of each partner.

Provides time and opportunity to develop a trusting relationship. Small teams with smaller caseloads will provide continuity caregiver as well as continuity of care.

Discuss issues of choice, consent, decision-making, power sharing, mutual rights and responsibilities.

Woman centred care rather than midwife centred care must be ensured in team midwifery.

Equality, shared responsibility and empowerment

Midwife and woman have equal status; knowledge and power are shared. The partnership is dynamic and can be balanced through negotiation, reflecting the changing needs of the partners. Decision-making is shared although the woman has the primary role. Both the midwife and the woman are accountable for their decisions. A successful partnership will empower the woman and so empower the midwife.

Figure two: Midwife~ as a partnership.. Theoretical Principles, Mod~'ed from Guilliland & Pairman (1994) SEPTEMBER 1996

ACMIJOURNAL

PAGE 25

AUSTRALIAN COLLEGE OF MIDWIVES INCORPORATED

(that is pregnancy, labour, birth and the postnatal p e r i o d ) . It t h e n f o l l o w s t h a t h a v i n g t h e responsibility for provision of care during the total childbirth experience, with the w o m a n as the primary decision maker, the midwife is acting as an autonomous or independent practitioner. Theoretical principles The three theoretical principles (Figure Two) of individual negotiation; equality, with shared responsibility and empowerment; and continuity of care and caregiver (Guilliland & Paimmn 1994) are all linked with each other, and are all necessary for a successful partnership. For e x a m p l e , the relationship, developed while providing continuity of care and caregiver, promotes respect by each partner for each other. This respect nurtures the negotiation process and facilitates the sharing of knowledge and of power. Each partner will also respect the other's opinions, and decisions and make allowances for them in their own decision making. R e l a t i o n s h i p to o t h e r m o d e l s o f c a r e a n d other professions Now we can see the development of the midwifery model of care as o p p o s e d to the medical model. In the midwifery model, fragmented care is no longer possible, and the w o m a n and the midwife are in an equal partnership, though with different roles within that partnership. Midwives are no longer practitioners dependent on various aspects within the medical model as, in the midwifery model of care, they are independent practitioners taking full responsibility for their own actions (Guilliland & Pairman 1994). The midwifery model does not exclude working with the medical profession or other disciplines as required. O t h e r disciplines w o r k i n g in the maternity field may work in a parallel way, but they will have different underlying philosophical and theoretical principles with which to guide them. Midwifery's relationship to the other professions, such as nursing, physiotherapy, medicine and obstetrics, must be as a profession with equal status and responsibility, though with a different role to play. It is because the midwifery model includes true continuity of care and carer, and because its focus is primarily on the w o m a n rather than on her baby or family, that make the midwifery profession different from other professions in this field. PAGE 20

H o w e v e r , b e c a u s e i n d e p e n d e n t practice is intimately linked with the other aspects of midwifery's underlying philosophy, the majority of midwives must endeavour to work independently to realise midwifery as a profession in its own right. For example, as Guilliland & Pairman (1994) point out, w h e n providing fragmented care the midwives may act as midwives, but unless they are acting independently then they will not be practising midwifery.

Midwives Employed by Institutions Practising Independently The theory of midwifery as a partnership will be familiar to m a n y midwives reading this paper. Many midwives in Australia are currently using this model of care. However, there are m a n y more midwives w h o are not working in a partnership with the w o m a n but who, I believe, given the chance, would wish to. With the increasing possibility of non midwives working in maternity care, it is in midwifery's best interest to strengthen and further establish itself as a profession in its own right. This will be possible by facilitating the majority of midwives in working according to the theory of midwifery as a partnership. Woman c e n t r e d c a r e To achieve the majority of midwives working in the midwifery model would require, by definition, these midwives to be working independently. This seems an impossible aim w h e n such a large proportion of hospitals are providing fragmentary care under the medical model. Furthermore, Clarke (1995) argues that providing continuity of care within the medical model is a conflict of loyalties to w h o m do midwives' allegiance lie: to women: to midwifery: to doctors; or to institutions, their employers? Perhaps i n d e p e n d e n t midwifery has evolved closely with private practice and homebirth because of the need of midwives to escape from this dilenuna. Practising self employment, and out of hospital birth, certainly do not follow the medical model, and it is likely that this form of midwifery practice allowed the rediscovery of the theory of midwifery as partnership. However, with a defined theory to use as a model for practice, it is probable that more midwives will be able to practise this m o d e l within the confines of institutionalised employment. So the question of

ACblI JOURNAL

SEPTEblBER 1990

AUSTRALIAN COLLEGE OF MID~(qVES INCORPORATED

allegiances can be answered by providing an accepted model which requires woman-centred care.

Advocacy The various allegiances a midwife may have are also seen to effect that midwife's ability to be an e f f e c t i v e a d v o c a t e ( K e y s e r 1985). I n d e e d , Guilliland & Pairman (1994) argue that this is an i n a p p r o p r i a t e role for the m i d w i f e / w o m a n partnership. Others also criticise the concept of advocacy within the hospital setting, seeing it as basically paternalistic (Sawyer 1988). Advocacy has been a role traditionally espoused by midwives as a way of supporting the w o m a n in the institutionalised setting, and this is recognised in the Standards for the Practice of Midwife O, (ACMI 1987 p. 4 & 6). It does not have to be a dependent relationship, and there are various methods of practicing advocacy (for example, Nicholls & Andrew 1990, Curtin 1986, Bramlett et al 1990). The dictionary definition of advocate implies a verbal action of pleading for another (Australian Concise Oxford Dictionary 1987). Yet advocate's Latin meaning, 'to be called to stand beside' (Nicholls & Andrew 1990), implies more of a quiet presence. Thus the action of the advocate does not necessarily require a vocal pleading for another but may be a strong, silent, support. Consequently, the midwife in partnership with the w o m a n may work toward supporting and encouraging that w o m a n to vocalise her own needs. As long as the ultimate decisions regarding the w o m a n are made by the woman, then advocacy is not paternalistic. All midwives, regardless of employment status, will have various allegiances which could be seen to effect their relationship with the woman. Although the midwife working in partnership with the w o m a n will give her primary allegiance to that woman, this will also be influenced b y the midwife's duty to be professionally, personally, socially and legally accountable. However, if the midwife is aware of these influences and is honest with the w o m a n about them, it is still possible to be an effective advocate.

Continuity of Care and Caregiver Woman-centred care allows a respectful, honest relationship to form between the midwife and woman, but time and opportunity are also essential ingredients in the formation of this relationship SEPTEMBER 1996

(Guilliland & Pairman 1994). This is one reason for the importance of continuity of care and caret. It is an essential aspect of the theory of midwifery as a partnership, and can be provided by either one midwife with a covering midwife, or by a team of midwives. There has b e e n m u c h interest in developing this type of care within institutions both in Australia and internationally (Biro & Lumley 1991, Flint et al. 1989, Rowley et al. 1995) However, the importance of keeping the numbers of team m e m b e r s low, so that continuity of caregiver can be a reality, must be emphasised. Guilliland & Pairman (1994) note that rather than increasing the number of team members, their case loads should be decreased. They also remind us that teams must be organised in a woman-centred rather than midwife-centred style.

Empowerment The outcome of the shared decision making, and respect involved w h e n midwives act in partnership with the woman, is that the w o m a n ' s self-esteem is maintained or even boosted, because she is e m p o w e r e d to retain control of what happens to her. The w o m a n generally feels very satisfied with the experiences she has had, even if she also feels disappointed because the experiences were not her ideal. One of the reasons she is able to feel positive is because she has taken responsibility for the decisions she has made. Such a beneficial effect on the w o m a n also positively effects her family and her friends, and ultimately her midwife. So, e m p o w e r m e n t of the w o m a n constructively b e n e f i t s m i d w i f e r y p r a c t i c e itself, b y also empowering the midwife.

The Victorian Situation In victoria the abolition of the Midwifery Regulations (1985) along with the issuing of the Code of Practice for Midwives (Nurses Board of Victoria 1996) has instigated m a n y questions and comments about what this means for midwifery and for w o m e n (Tattam 1996). The old regulations, at best, made independent practice difficult for midwives w h o were in private practice, and, at worst, restricted midwifery practice in general to one of d e p e n d e n c y on the medical model of care. With the removal of these restrictions, Victorian midwives, in line with other Australian midwives, n o w have the o p p o r t u n i t y to p r o v i d e true independent care, including woman-centred care and continuity of care and caregiver.

ACMI JOURNAL

PAGE 27

AUSTRALIAN COLLEGE O F MIDWIVES INCORPORATED

There has also been much enthusiasm from midwives in looking at what post regulation midwifery will be like. The new Code of Practice (Nurses Board of Victoria 1996) states that it is the responsibility of the midwife to practise in partnership with the woman. A n u m b e r of seminars on the t h e m e of post regulation midwifery have reflected on midwifery care, and a future vision has begun to develop. Along with this has been a list of proposed actions (Hall 1996), and many of these proposed actions also support the theory of partnership. So it appears that midwives are gradually moving towards putting into action the four concepts (which include independence) of the underlying philosophy of midwifery as a parmership.

Conclusion This paper presents a future vision of an independent midwifery profession with independent midwives, both employed by i n s t i t u t i o n s a n d s e l f e m p l o y e d . T h e s e m i d w i v e s will b e w o r k i n g in p a r t n e r s h i p w i t h w o m e n , a n d b e respected by other professions, and by the administrators of the institutions within which they work, for practising in the way that they do. This vision may take many years to come to fruition. H o w e v e r , its b e g i n n i n g s a r e s e e n w i t h i n c r e a s i n g numbers of midwives providing woman-centred care and continuity of care within the institutions. I n d e p e n d e n c e is n o t s o m e t h i n g t h a t c a n just b e g i v e n t o m i d w i v e s , it is s o m e t h i n g t h a t m i d w i v e s must decide that they have. The aim of the m i d w i f e r y p r o f e s s i o n at t h e m o m e n t m u s t b e t o provide the right environment for midwives to be able to come to this conclusion themselves. The b e s t w a y o f d o i n g t h i s is b y e m p o w e r i n g w o m e n w h o will t h e n e m p o w e r m i d w i v e s .

References Australian College of Midwives Inc. (1987) Standards for the Practice of Midwifery. Australian College of Midwives Inc, Sydney. Blro, M & Lumley, J. (1991) The safety of team midwifery: the first decade of the Monash Birth Centre, Medical Journal of Australia 155, 478 - 480. Bramlett M, Gueldner S & Sowell R (1990) 'Consumer-Centric Advocacy: Its Connection to Nursing Frameworks'. Nursing Science Quarterly, v. 3, no 4, pp. 156-161. Brown, J (1994) The Accreditation of Independently Practicing Midwives A Brief History, Australian College of Midwives Journal 7 (4)p. 5-6. PAGE 28

Clarke, R (1995) Strength through unity. Modern Midwife, 5(1): 32-3 Curtin, L. (1986) The Nurse as Advocate. A Philosophical Foundation for Nursing. In China, P. (Ed) Ethical Issues in Nursing. Aspen, Maryville Evans, J. (1994) Independent midwifery - - why do we do it? . real choice for mothers and midwives. Midwives Chromcle & Nursing Notes 107 (1278). 239-40 Flint C, Poulengeris P, Grant A. (1989) The 'Know Your Midwife' scheme - a randomised trial of continuity of care by a team of midwives. Midwifery 5 (1) p. 11-16. Guilhland, K & Pairman, S (1994) The Midwifery Partnership A Model for Practice New Zealand College of Midwives Journal, October pp. 5 - 9 Hall, J. (1996) Midwifery and the Future. Open Line 4 (2) p. 7 8 Hobbs, L (1993) Going Independent. Nursing Times 89 (20) p.68 - 69. Keyser, P. (1985) 'Ethics of Nurse-Patient Relationships m the Self Care Model, The Science and Art of Self-Care ed. J. RiehlSlsca. Appleton-Century-Crofis, Connecticut, p 14-19 Leap, N (1991) RCM Professional Day Paper: independent midwifery--fllhng the gaps and picking up the pieces. Midwives Chronicle, 104 (1237). 34-8 Midwives Regulations (1985) 1985 Statutory Rule No 256, Nurses Act 1995 Molloy, D. (1995) From the Chairman, National Association of Speclahst Obstetricians & Gynaecologlsts News 2 (3) p. 1- 2. National Association of Specialist O b s t e t r i c i a n s & Gynaecologlsts (1995) National Association of Specialist Obstemcians & Gynaecologists News 2 (3) New Zealand College of Midwives(1993) Midwives Handbook for Practice. New Zealand College of Midwives, Dunedm. NlchoUs, R & Andrew, R. (1990) %' Stands for Advocacy The Report of the Advocacy Prolect. Wesley Central Mission & Office of the Public Advocate, Melbourne Nurses Board of Victoria (1995) Proposed Code of Practice for Midwives m VlCtonan Nurses Board of Victoria, Melbourne Nurses Board of Victoria (1996) Code of Pracnce for Midwives in Victorian Nurses Board of Victoria, Melbourne. Tat*am, A. (1996) Midwifery practice revolunon or evolution~ Australian Nurses Journal 3 (10) p. 13-14. The Angus and Robertson Dictionary and Thesaurus in one volume (1992). Harper Colhns, Sydney The Australian Concise Oxford Dictionary of Current English (1987) 7th ed. Oxford University Press Melbourne The Chambers Dictionary (1993), Chambers Harrap, Edinburgh Rowley M, Hensley M, Bnnsmead M, Wlodarczyk J (1995) Continuity of care by a midwife team versus routine care during pregnancy and birth: a randomised trial, Medical Journal of Australia 163 (6) p 289-293. Sawyer, J. (1988) 'Panent Advocacy on Behalf of the Patient' Nursing Times v.84, no. 41, p 27-30. Waldenstrom, U. (1996) Midwives In Current Debate and in the Future Australian College of Midwives Joumal 9 (1) pp 3-9. Waters, R & Steele E. (1992) The independent midwife: has she a role to play in our society? Midwives Chronicle, 105 (1254): 1827 Wilkes, V. (1994) Independent Midwifery Australian College of Midwives Journal 7 (4) p.25-26.

ACMI JOURNAL

SEPTEMBER 1996