Clinical Competencies part 1

Generally Accepted Practices (GAP) For Community-based Midwifery

Characteristics of Clinical Competency associated with
Science-Based* Maternity Care Systems

(**science-based practice includes class I, II and III research published in peer-review journals, statistical analysis, historical documentation, textbooks and authorities in the field consistent with above resources)

1. Background: The ethical foundation for maternity care in a democratic society is to benefit the mother-baby dyad, the family, community and the structure of society without introducing harm to any of these entites. This is consistent with the intent of the Golden Rule and the Hippocratic Oath.

The proper role of maternity care is to preserve the health of already healthy mothers and babies by protecting them from the vagaries of Mother Nature and the excesses of Modern Medicine. Mastery in childbirth services means bringing about a good outcome without introducing any unnecessary harm.

2. Context: World-wide statistics have long testified to the superior outcomes for both mothers and babies of physiological-based maternity services as provided by midwives and physicians, liberal breastfeeding, valuing the parent-child bond, female literacy and obstetrics for complicated pregnancies.

3. Overview: The disciplines of sociology, medical anthropology, nursing, midwifery, lactation, and medicine all hold major pieces of the maternal-child health puzzle. But no single discipline holds all the answers. All must work together to promote the practical well-being of mother and babies. All must share the same body of knowledge. Most important, that shared knowledge must be inclusive of all sides of the public debate -- including the voices of childbearing families, midwives, family-practice physicians, obstetricians, perinatologists, W.H.O officials, and many others who campaign for a simple and common sense approach to maternal-child health

Midwifery and obstetrics are distinct disciplines that deal with the biological events of pregnancy, birth, the neonatal and postpartum period. Midwifery is not the practice of medicine. These two disciplines exist at opposite ends of a continuum which spans from the simplest social and non-medical methods to the most complex high tech medical activities. The areas of expertise of midwifery and obstetrics overlaps in the middle of the spectrum but they are not identical. Classically-speaking, maternity services to healthy mothers experiencing normal pregnancies were provided by midwives in the home of the childbearing parents.

World-wide the standard for maternity care is still midwifery-based, with approximately 60% of all babies delivered by midwives in the home of the family. In those countries with the best pregnancy outcomes 70% (or more) of all births are attended by midwives. In many European jurisdictions the routine involvement of a midwife in all vaginal births is required by law (Germany, Austria, England), even when obstetrical care is being rendered. Culturally-proven ideas such as midwifery are the wealth of the people. This commonwealth, which was rooted for centuries in the oral tradition, has been missing from contemporary life in the United States for several decades.

4. Working Definition of Midwifery: The historical definition of midwifery is the care of healthy childbearing women and their babies during the normal events of pregnancy, physiological childbearing, breastfeeding and the period of early parenting. The term 'midwifery' is correctly applied to the activities of caregivers engaged in providing normal maternity services during the spontaneous events of physiological childbearing, regardless of the educational background or status of the practitioner.

Midwifery is not a practice of medicine but a separate discipline arising in response to the physical, psychological and social needs of healthy childbearing women and their newborns. It is predicated on the expectation of normalcy, a respect for and trust of physiological process, and a non-interventive style which depends on specific skills and social support for the spontaneous biology of birth. This definition is to distinguish the maternity care of normal, healthy mothers -- including palliative treatment of minor deviations and the capacity for emergency-response by the practitioner -- from the hospital-based, high-technology practice of obstetrics which is a surgical specialty that addresses the diseases, dysfunction and disabilities of reproduction and fertility.

5. Maternity Services and Community Values: Ideally midwifery care focuses on the childbearing woman as a whole person with social, mental, and emotional aspects of her personality that need to be taken into account. These non-physical aspects of personality bear greatly on how, when, where or even whether or not the mother-to-be will be able to labor spontaneously and give birth physiologically. The quality of the childbirth experience as defined by the mother extends beyond the moment or manner of delivery and can affect the mother physically and physiologically for months or years, perhaps even becoming a pivotal point in her life.

The cumulative effect of the events of childbearing in combination with other influences extend into the mother-child relationship and can profoundly effect the quality and satisfaction in that central and important fact of day to day parenting. Problems within the mother-child relationship can trigger a cascade of difficulties that not only negatively effect the individuals and their family but also the stability of the community and greater societal goals. While there is no immutable evidence that a good-parent-child bond prevents teen delinquency and violence, there is evidence that birth complications in combination with a fractured mother-child bond is a strong contributor to violent behavior in adolescent boys. If only one such shooting can be prevented, it would be worth the extra effort.

Therefore, events that contribute to the fracturing of the mother-father-baby bond are to be avoided and those that protect and promote it are to be pursued and supported by society. Here in lies the concept of "mother-friendly" maternity care.

6. Principles of Mother-Friendly Maternity Care ~ Mother as primary caregiver to her unborn / newborn baby and the ethically-based relationship between the mother/family and the practitioner and the ethical obligation of practitioners to provide informed consent and to obtain voluntary consent before extending treatment in all but "extremely rate and truly exceptional circumstances"*

The autonomy of parents is to be promoted and the mother viewed as the primary caregiver of her baby. The childbearing woman should be respected as a self-directed individual and not viewed as a "patient" in the sense of being infirm or incompetent. Caregivers must recognize that the integrity of the mother-child relationship begins in pregnancy. This mutual integrity is compromised by treatment of mother and baby as if they were separate units with conflicting needs. Both statutory and case law supports the autonomy of adults, including childbearing women, to make healthcare decisions in all but "extremely rare and truly exceptional circumstances".

Parental autonomy extends to circumstances in which the mother (or parents) make medically unpopular decisions which may be considered by others to be an irrational choice. Third parties do not have to concur with a decision for it to be legally valid. Freedom and ability to exercise autonomy are necessary conditions for an individual to be considered a moral agent. Consent is an expression of autonomy and inextricably linked to responsibility -- where autonomous choice is exercised, responsibility inevitably follows.

Permission or voluntary consent is the least standard which is legally acceptable and must be obtained in all but "extremely rare and truly exceptional circumstances". ("Informed Choice" is a higher standard than consent.)

(1) Voluntariness -- choice without coercion, either direct or indirect (example of indirectly coercion is to make care desired by family dependent on acquiescing to unwanted treatments
(2) Information -- Being adequately informed is one aspect of voluntary consent (quality and quantity of information offered by HCPs should not be used to manipulate parents into decisions they otherwise would not make)
(3) Competence -- the foundation for autonomy
(4) Decision -- decision-making is a conscious process, where as to acquiesce is to agree without reflection; consent in which the client actually contracts with the caregiver to do something is far different than expressing a mere preference.

A conscious decision is the last step in consent and also the final point in the process of refusing consent. A valid refusal of consent should be as binding as a valid consent and is equally linked to the responsibility of the parents for the outcome of their decision to decline medical treatment or standardized care.

Proxy decision-making -- those decisions made for the mother (or parents) due to their inability to give timely consent. The mother should identify someone ahead of time to act as a proxy decision maker if she is unable or unavailable to do so. Most often the identified proxy is her husband or other family members. The parental - caregiver contract also contains a measure of assumption that the HCPs will take on proxy decision making role in presence of evident need. This occurs in emergent conditions requiring rapid response and specialized knowledge. It can also be the result of temporary maternal incompetence due to illness, medications, anesthesia or loss of consciences.

Moment-by-moment proxy decision-making by family members and caregivers is qualitatively different that those rare circumstances of a valid judicial process usurping parental rights via a determination of parens patria (court-order directives in place of parental decisions) Proxy decision making by caregivers increases their vulnerability to litigation. If there is client dissatisfaction or an unsatisfactory outcome when the parents did not give voluntary consent or make an informed choice, the client's responsibility for outcome is diminished and the caregiver’s is increased.

Paternalism is when someone’s capacity to make their own decisions is ignored. This takes the form of overriding an actual decision, not bothering to get a decision in the first place, or deliberately manipulating a decision by misleading the parents through information given or withheld. Employing these techniques invalidates consent and renders the procedure concerned involuntary (i.e.. shifts responsibility to caregiver, with its associated increase in vulnerability to litigation). Paternalism arises out of an honest but misguided opinion that the caregiver knows better than the subject as to where the subject’s best interest lies. Paternalism correctly describes actions or omissions based on a benevolent but arguably misguided motive-- is of a different nature than usurping parental autonomy for reasons growing out of a hidden agenda concerned with caregiver gain (convenience, added profit, prejudice against racial, ethnic group or religious affiliation, etc)

Informed consent is a safeguard for the mother’s best interests and a protection from paternalism, practitioner preference, prejudice, ignorance or hidden agendas. Mother’s informed choice consent or informed decline of standard midwifery/ medical interventions must be honored in all but those emergent circumstances in which there is a clear and present danger of death or permanent disability to either mother or baby (the principle of health caregiver as proxy decision-maker) and for which medical, obstetrical or neonatal care offers a dependable treatment of acceptable risk to the individuals and society. *The above material is excerpted from "Midwifery Ethics", published in the United Kingdom, 1996.

The Maternity Center Association's publication "Your Guide to Safe and Effective Care During Labor and Birth" is an up-to-date, authoritative overview of the safety and effectiveness of many maternity care practices. It describes evidenced-based maternity care, that is, maternity care which is consistent with the best current research. Pertinent guiding principles identified by the Maternity Center Association come from "A Guide to Effective Care in Pregnancy and Childbirth". They are:

~ Practices that limit a women's autonomy, freedom of choice and access to her baby should only be use if there is clear evidence that they do more good than harm

~ Practices that interfere with the natural process of pregnancy and childbirth should only be used if there is clear evidence that they do more more good that harm

~ We encourage you to honor and experience your body's remarkable capabilities for childbearing and to guard your autonomy, freedom of choice and relations with your baby @2000MCA

These foundational principles are also recognized as a central tenant and ethical obligation for practitioners of independent, community-based midwifery and hereby incorporated in the principle of Characteristics of Clinical Competency associated with science-based maternity care system as adopted by the American College of Domiciliary Midwives and the California College of Midwives, a state chapter of the ACDM.

The Gap Between the Evidence and Maternity Care Practice

Healthy, low-risk women in the United States often receive maternity care that is not consistent with the best research. Many people are not aware of the following major areas of concern:

~ The under-use of certain practices that are safe and effective

~ The widespread use of certain practices that are ineffective or harmful

~ The widespread use of certain practices that have both benefits and risks without enough awareness and consideration of the risks

~ The widespread use of certain practices that have not been adequately evaluated for safety and effectiveness @2000MCA

8. Non-erotic sexual nature of childbirth: Acknowledgement of the non-erotic but none-the-less sexual nature of childbearing which involves the same biological structures and psychologically includes many of the same principles necessary for physiological function in both sexual and excretory biology. These principles include acknowledgement of the mother’s physiological need for privacy and her right to voluntariness in participation of persons and procedures that transgress the boundaries of her body or sexual psyche. It also includes freedom from performance pressure and arbitrary time constraints. Spontaneous biology is heavily influenced by psychological factors (both mental & emotional states) which are themselves an extension of normal reproductive sexuality. The childbearing woman has a right to that quality of care from her companions and her caregivers that does not disturb or interfere with normal physiology of spontaneous progress in labor & birth (such as the "fetal ejection reflex"). [(or definition of "Fetal Ejection Reflex, see section on the expulsive Stage/ Perineal Phase)

In the absence of this quality of support, which is the core of the traditional midwifery model of care, the mother will frequently need narcotic medication and secondarily the use of oxitocin to overcome the labor retarding effects of narcotics. Additional surgical interventions of episiotomy, forceps, vacuum extraction, cesarean section often represent the failure of the maternity care system (or individuals within it) to account for the influence of the mother’s psyche in regard to the events of labor and birth. [Safety of Alternative Approaches to Childbirth; Peter Schlenzka, 1999]

A socially appropriate environment in which the mother feels unobserved and yet secure, with emotional support as necessary, is the purposeful mechanism of midwifery care which addresses the mother’s pain, her fears and privacy needs so that labor can unfold naturally. It is also necessary to take into account the positive influence of gravity on the stimulation of labor, dilatation of the cervix and decent of the baby through the bony pelvis. Maternal mobility not only helps this process along but also diminishes the mother’s perception of pain (perhaps by stimulating endorphins).

To ignore the well-known relationship of gravity to spontaneous progress is to do so at the peril of mother and baby. The complex interplay of the physical and the psychological are such a biological verity of childbearing that women have an undeniable right to have the maternity care provided to them be structured to address gravitational influences and the quasi-sexual nature of spontaneous labor and physiological birth. [Safety of Alternative Approaches to Childbirth; Peter Schlenzka, 1999]

9. Mother’s right to special considerations: Mentally competent adults have certain inalienable rights. Pregnancy does not usurp those rights except for "rare and unusual circumstances", which would normally only occur by a court order after a formal inquiry. Midwives support the right of women to choose obstetrician-only care, pain medications, anesthesia and/or elective surgical delivery even though medical and surgical procedures carry with them additional risks to her and her fetus / neonate.

Special considerations and accommodation should be extended to childbearing women with a history of physical or sexual abuse or other unique psychological factors. Other examples of special circumstances are considerations based on ethnic, cultural or gender-identity, a recognition of spiritual values and those asking for care under a religious exemption clause.

10. Limitation of Domiciliary midwifery care: Non-medical maternity care provided in a non-medical setting is restricted to healthy mothers with normal pregnancies who do not desire or require induction of labor, or anticipate the need or desire for narcotic pain medications or anesthesia during labor and birth.

11. In the Midwifery Model of Care, the professional midwife must live up to the following responsibilities and duties:

            A.) Safeguard the physical health and psychological well being of the mother
            B). Safeguard the physical health and psychological well being of the baby
            C). Safeguard the personal and professional well being of the midwife
            D). Safeguard the reputation of midwifery

1. Have up-to-date knowledge of the standards of practice of her profession
(see www.collegeofmidwives.org web site for a definition of standard midwifery practice)

2. Have the education, skills and equipment needed to provide standard midwifery care

3. Communicate those standards to the client and negotiate an informed consent contract for community-based non-medical midwifery care

4. Provide full information to the client/family in the context of the midwifery care being offered and obtain the mother�s/or other parent�s voluntary consent before implementing the various discrete observations, actions, and interventions associated with standard midwifery care in a non-institutional setting

5. Document the informed decline of standardized care and memorialize in writing the circumstances and associated conversations with parents and others leading to this choice

6. Provide �first-responder� and emergent care to mother or baby when necessary

7. Initiate access to appropriate emergency services in the presence of an evident need � a clear and present danger of death or disability

a) offering such midwifery care as is appropriate to the mother or baby�s situation

b) performing such observations/actions/treatments/protocols with due diligence and in a timely manner (including recommendations for medical evaluation or transfer of care and/or institution of emergency measures pending transport)

c) documenting all pertinent facts, including a chronology of the specifics of care provided, the content of patient education and instructions given by the midwife and informed consent conversations

d) when applicable obtaining written consent/decline of care and memorializing in writing any formal discussions or consultation with other professionals relative to making decisions on care and medical interface.

These aspects of care make up the appropriate �standard� of care for professional midwives. The professional midwife who conforms to this standard is judged to be competent.

The membership of the ACDM/California College of Midwives has developed a comprehensive set of practice guidelines recorded in a document entitled Characteristics of Clinical Competency. These standardized guidelines were adopted by the 55 professional midwives -- both CMNs and LMs � who were members of the malpractice consortium covered by professional liability insurances as provided under a group policy through the American College of Domiciliary Midwives.

The Generally Accepted Practices ~ Characteristics of Clinical Competency includes:

1. The international definition of a midwife
            2. A definition of the midwifery model of care
            3. Standards of practice for community midwives
            4. Philosophy of care
            5. Code of ethics
            6. Informed consent policy
            7. Educational competencies
            8. Criteria for client selection and preliminary consultation
            9. Indications for discussion, consultation and transfer of care during the antepartum,
                intrapartum, neonatal and postpartum periods
            10. Special circumstances informed consent / decline of standard procedures and provision
                 of care under the �Good Samaritan principle�

These standards and guidelines are supplemented by technical bulletins for:

            Intermittent auscultation
            Episodic electronic fetal monitoring
            Guidelines for postnatal management following birth at home
            Presence of meconium in a vigorous term newborn.

ACDM	California College of Midwives
2004	Principles of Mother-Friendly Childbearing Services