Part One ~ Generally Accepted Practices for Community-based Midwifery
Model of Midwifery Practice (Adapted from the College of Midwives, British Columbia)
DEFINITION OF A MIDWIFE
A midwife is a person who, having been regularly admitted to a midwifery educational programme duly recognised in the country in which it is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practise midwifery. International Definition of the Midwife.
SCOPE OF PRACTICE OF THE MIDWIFE
The International Definition of a Midwife goes on to state:
The midwife must be able to give the necessary supervision, care and advice to women prior to and during pregnancy, labor and the postpartum period, to conduct deliveries on her own responsibility and to care for the newborn infant.
This care includes preventative measures, the detection of complications in the mother and child, the procurement of medical assistance when necessary and the execution of emergency measures in the absence of medical help. The midwife has an important task in health counseling and education, not only for the patients but also within the family and the community. The work should involve pre-conceptual and antenatal education and preparation for parenthood and extends to certain areas of gynaecology, family planning and child development. She may practice in hospitals, clinics, health units, domiciliary conditions, or in any other service.This International definition is supported by the International Confederation of Midwives(ICM), the International Federation of Gynaecologists and Obstetricians(FIGO), and the World Health Organization (WHO).
MODEL OF MIDWIFERY PRACTICE
The midwifery model of practice is autonomous, community-based primary care, and incorporates the principles of continuity of care, informed consumer choice, choice of birth setting, collaborative care, accountability and evidence-based practice. Together with the Philosophy of Midwifery Care and the Code of Ethics, these fundamental principles define the midwifery model of practice as embraced by professional midwifery providers in jurisdictions through out North America.
COMMUNITY-BASED PRACTICE
Midwives are primary caregivers in autonomous practice within their communities. Where possible Midwives are encouraged to acquire admitting and discharge privileges at hospital maternity units and, where available, birth centers, enabling them to provide care in all settings. Midwives may offer their services within small group practices, enabling them to share call while providing 24-hour availability to their clients.Antepartal care may be provided in midwifery clinics, offices, or women's homes. Midwifery care for labor, birth and early postpartum will be provided in a setting chosen by the woman. For most women and their newborns, Midwifery care during the early postpartum period is generally best provided in the home.
PRIMARY CARE
A primary caregiver is a practitioner who may be the first point of entry to health services for women seeking pregnancy-related health care. As a primary caregiver, the midwife functions under her own responsibility. For each client, the midwife provides a continuum of midwifery services throughout pregnancy, labor and the postpartum period.
CONTINUITY OF CARE
Continuity of care is midwifery care provided in accordance with the Generally Accepted Practices of of professional midwives and other midwifery providers and available during all trimesters of pregnancy, labor, birth and the postpartum period, on a 24-hour on-call basis. This principle is fundamental to the model of practice. Continuity of care is both a philosophy and a process that is facilitated through a partnership between a woman and her midwife/midwives. It requires a time commitment from each midwife that enables her:
* to develop a relationship with the woman during pregnancy;
* to be able to provide safe, individualized care;
* to support the woman during labor and birth; and
* to provide comprehensive care to the mother and newborn
throughout the postpartum period.
Ideally, midwifery services will be provided by the same principal (i.e., primary or "midwife of record") midwives throughout pregnancy, labor, birth and the first six weeks postpartum. Family planning services may be provided postpartum. The full scope of midwifery care will be provided, including education, counseling, advocacy and emotional support.
Although continuity of care is usually facilitated by a one-to-one or a one-to-two relationship between a woman and her midwife/midwives, continuity of care can be achieved by a small group of midwives (idea is 4 or less), as long as all members of the group share a common philosophy and a consistent approach to practice, and meet together regularly to co-ordinate care. [1] The woman must have the opportunity to establish a relationship with the midwives providing her care. A primary 'midwife of record' who is responsible for co-ordinating the care will be identified. A second midwife should be identified who would normally take over this role if the primary midwife is unavailable. In exceptional circumstances another midwife may attend the birth as the principal midwife.
The primary and second-call midwives would normally be responsible for providing the majority of prenatal and postnatal care, and for attending the birth, assisted if necessary by other midwives in the group. The midwifery practice will ensure there is 24-hour on-call availability, preferably with of one of the midwives already known to the woman.
In situations where transfer of care to a physician is required during labor, the midwife is expected to continue providing supportive care after transfer and may resume primary care if appropriate. Supportive care involves education, counseling and advocacy throughout the course of care and also includes labor support and postpartum assistance and instructions to the mother about infant feeding and newborn developmental needs.
INFORMED CHOICE
The Philosophy of Midwifery Care states:"Midwifery promotes decision-making as a shared responsibility between the woman, her chosen family and her caregivers. Midwives recognize women as primary decision makers."
Midwives respect the right of women to make informed choices and facilitate this process by providing complete, relevant, objective information in a non- authoritarian, supportive manner. Having adequate time for discussion in the prenatal period is necessary to the successful facilitation of informed choice. Normally, antenatal and postnatal visits last approximately 45 minutes or more.
Midwives support the principle of informed choice by:
* promoting shared responsibility between the woman, her family and her caregivers and recognizing and supporting the woman as the primary decision maker;
* encouraging women to participate actively in their care and to make choices about the services they will receive and the manner in which their care is provided;
* discussing the scope and limitations of midwifery care with the women in their care; and
* allowing adequate time for discussion in the prenatal period.
CHOICE OF BIRTH SETTING
Midwives respect the right of the woman to make an informed choice about the setting for birth. Midwives must be competent and willing to provide care in a variety of settings, including homes, hospitals and birth centers, where available. Midwives are encouraged to have hospital privileges and be able to function within their full scope of practice in both the home and hospital setting. The ability to attend the woman in her choice of birth place is an essential aspect of continuity of care and informed choice. Midwives provide the information required to make an informed choice about appropriate settings in which to give birth. The birth setting is chosen by the woman in consultation with the midwife.
Establishing choice of birth setting as a fundamental component of midwifery practice is essential to providing women with equitable access to care in their chosen place of birth. This is particularly important in rural and remote communities where it is unlikely that women will have access to a choice of midwives.
SECOND MIDWIFE OR QUALIFIED BIRTH ATTENDANT
The generally-accepted standard of care is to have two skilled attendants at every birth. The safest care can be provided when there are two qualified persons present at a birth, each skilled in neonatal resuscitation and in managing maternal emergencies. Each birth, particularly those occurring in an out-of-hospital setting, should be planned with the understanding that two midwives will be in attendance if time permits.
When it is not possible to have a second midwife in attendance, reasonable efforts must be made by the primary midwife to secure the assistance of a suitably qualified second attendant prior to the birth. The second birth attendant must be skilled in neonatal resuscitation and in handling maternal emergencies.
Qualified second birth attendants may include nurses, physicians, or other health care practitioners who have the knowledge and skills required to assist the midwife with the birth, in accordance with the midwifery model of care.COLLABORATIVE CARE
Midwives collaborate with other professionals to ensure their clients receive the best possible care. Collaborative care involves co-operation and consultation with other health care professionals in the provision of care. Collaboration with other health care providers occurs with informed choice and in the best interests of the woman and her newborn.
ACCOUNTABILITY AND EVIDENCE-BASED PRACTICE
Midwives' fundamental accountability is to the women in their care. They are also accountable to their peers, their regulatory body, the health agencies where they practice and to the public, for safe, competent, ethical practice. Midwifery practice will incorporate evaluation that includes ongoing community input and participation in current mortality reporting standards and review processes. Results of these evaluations must be widely distributed to influence policy, education, and practice. Midwives will continue to develop and share midwifery knowledge, promoting and participating in research regarding midwifery outcomes.1. The standard for continuity of care does not restrict the number of midwives who may work together in a practice.
to continue to next in series ~ Philosophy of Care