(~) Longman Group ' , " UK - " Ltd 1991
Midwifery
EDITORIAL
The Midwife's contribution to the health of w o m e n and children T h e contribution that midwives make to the health of women and babies has been the subject of three previous editorials in this journal (Thomson, 1988; Thomson, 1989; Thomson, 1990). I have been stimulated to address the issue again by the article by Tew and DamstraWijmenga in this issue of Midwifery. T h e authors have analysed some previously unavailable data which demonstrates very convincingly that if a baby is born after 32 weeks' gestation perinatal mortality is lower when care is provided by midwives than when provided by obstetricians. This finding has implications for the provision of facilities for maternity care and should be brought to the attention of all those involved in policy making for maternity services. T h e news that midwives reduce mortality rates is not new (Campbell, 1924; Levy et al, 1971). In 1924 when writing about maternal mortality Dr Janet Campbell stated that ' T h e average death rate a m o n g midwives' cases is certainly lower than that a m o n g doctors' c a s e s . . . ' (MOH, 1924) and this was despite the fact that midwives were caring for women in vastly inferior social circumstances when compared with the social circumstances of the women cared for by doctors. In California in the late 1960s there was a shortage of obstetricians and there was grave concern about the high prematurity and neonatal mortality rates. As recruitment o f obstetricians had failed two nurse-midwives were given licences to practise in the hospital for three years (Levy et al, 1971). By half way through the trial period the nurse-midwives were providing the vast majority of the antenatal care and were responsible for 78% of the deliveries. At the end of the three year p r o g r a m m e there had been a significant decrease in both the prematurity and the neona-
tal mortality rates. Unfortunately the relevant medical licensing authority would not continue the nurse-midwives' licences and there was a subsequent m a r k e d increase in the incidence of p r e t e r m delivery and the incidence.,of death of the baby in the first month of life. Midwives are educated and trained to provide care to women experiencing normal pregnancy and childbirth and to refer women for medical care when abnormalities occur or are expected (WHO, 1966). Those most at risk of maternal and perinatal mortality are those in the lower socio-economic groups. However Chin (1990) has shown that in an area of high socio-economic deprivation in New York women cared for by midwives, who seek medical aid where appropriate, have relatively low mortality rates and low caesarean section and instrumental delivery rates. In the UK community midwives have been shown to enhance the outcome of routine care provided by obstetricians when they, the community midwives, provide extra midwifery care to women living in an area of high socio-economic deprivation (Evans, 1991). For some considerable period of time, and in all parts of the world, the medical profession has claimed that the outcome of childbirth is much safer for both m o t h e r and baby if care is supervised by a medical practitioner and preferably in hospital. In the UK the culmination of the pressure from the medical profession came in the recommendations f r o m the Peel Committee (DHSS, 1970) that there should be provision for 100% hospital confinement. Unfortunately government did not ask the committee for the evidence on which it based this recommendation. In hospital the medical profession control the style of care given and because of the nature of the contracts of employment midwives are allowed very little say in how care will be 53
54
MIDWIFERY
p r o v i d e d , a n d it is p r o b a b l y this fact t h a t is at the b o t t o m o f the i m p r o v e d o u t c o m e o f care p r o v i d e d by midwives. T e w a n d D a m s t r a W i j m e n g a (1991) talk o f t h e n o n - i n t e r v e n t i o n i s t c a r e p r o v i d e d by midwives. A g a i n this i d e a is n o t new. C a m p b e l l ( M O H , 1924) s u g g e s t e d t h a t the r e a s o n why midwives h a d lower m a t e r n a l m o r t a lity rates was because t h e i r role ' p r e c l u d e d o p e r ative i n t e r f e r e n c e ' . O t h e r a u t h o r s w o u l d suggest t h a t the r e a s o n why m i d w i f e r y c a r e is m o r e effective is because midwives c o n s i d e r t h e whole w o m a n , n o t j u s t p a r t o f her. S o m e r e a d e r s m a y have realised t h a t I a m s t i m u l a t e d to write on the topic o f w h a t a m i d w i f e is allowed to d o in the p r o v i s i o n o f m a t e r n i t y c a r e o n an a n n u a l basis. T h o s e r e a d e r s m i g h t be f o r g i v e n f o r t h i n k i n g t h a t in this e d i t o r i a l I a m giving the subject its y e a r l y airing. H o w e v e r , I w o u l d h o p e t h a t those w h o r e a d the T e w a n d D a m s t r a - W i j m e n g a article will realise t h a t this e d i t o r i a l is raising for discussion the issue o f who should p r o v i d e m a t e r n i t y c a r e a n d where. T h e r e is n o t only the issue o f safety, ably d e m o n s t r a t e d by T e w a n d D a m s t r a - W i j m e n g a , b u t w o m e n p r e f e r midwives to c a r e f o r t h e m (Flint, 1991). T h e r e is also the issue o f economics. W o m e n given total a n t e n a t a l c a r e by midwives have fewer days a d m i s s i o n to h o s p i t a l in p r e g n a n c y t h a n w o m e n p r o v i d e d obstetric c o n t r o l l e d a n t e n a t a l care. W o m e n c a r e d f o r by midwives use fewer e p i d u r a l s for a n a l g e s i a in l a b o u r t h a n w o m e n c a r e d f o r u n d e r obstetric c a r e ( R u n n e r s t r o m m , 1969; Flint, 1991). I n a s t u d y of c o n s u m e r views o f m a t e r n a l satisfaction o f m a t e r n i t y services the r e s e a r c h e r s canvassed b o t h health professionals a n d the r e c i p i e n t s o f c a r e as to w h a t s h o u l d be i n c l u d e d in the q u e s t i o n n a i r e (Martin, 1990). A n o b s t e t r i c i a n r e p l i e d that in his o p i n i o n questions s h o u l d be i n c l u d e d o n ' . . . the p a t i e n t ' s u n d e r s t a n d i n g o f t h e risks involved in b e c o m i n g p r e g n a n t a n d
h a v i n g a baby' (Martin, 1990). I d o n o t wish to m a k e light o f the p o t e n t i a l risks o f m a t e r n a l a n d p e r i n a t a l m o r t a l i t y b u t s u g g e s t to obstetricians t h a t the style o f care p r o v i d e d by t h e m d o e s n o t e n h a n c e the o u t c o m e o f c h i l d b i r t h . ANN THOMSON
References Chin M K 1990 The positive impact of midwifery care in an inner city population: NCB experience. Paper presented at 22nd international congress of International Confederation of Midwives, Kobe, Japan DHSS 1970 Domiciliary midwifery and maternity bed needs (the Peel report). HMSO, London Flint C 1991 Continuity of care provided by a team of midwives - the Know Your Midwife scheme in Robinson S, Thomson A M (eds) Midwives, Research and Childbirth, Vol 2. Chapman & Hall, London Evans J 1991 The Newcastle Community midwifery care project - the evaluation of the project in Robinson S, Thomson A M (eds) Midwives, Research and Childbirth, Vol 2. Chapman & Hall, London Levy B S, Wilkinson F S, Marine W M 1971 Reducing neonatal mortality with nurse-midwives. American Journal of Obstetrics & Gynecology 109:50-58 Martin C 1990 How do you count maternal satisfaction? A user-commissioned survey of maternity services in Roberts H (ed) Women's Health Counts. Routledge, London Medical Officer of Health 1924 Reports on public health and medical subjects No 25, Maternal Mortality. HMSO, London Runnerstrom L 1969 The effectiveness of nursemidwifery in a supervised hospital environment. Bulletin of the American College of Nurse-Midwives 14:40-52 Tew M, Damstra-Wijmenga S M I 1991 Safest birth attendants: recent Dutch evidence. Midwifery 7: 55-63 Thomson A M 1988 Control in childbirth. Midwifery 4: 1-2 Thomson A M 1989 The midwife's role under threat? Midwifery 5:1-2 Thomson A M 1990 Medical confusion on care in childbirth and the role of the midwife? Midwifery 6: 57-59 World Health Organization 1966 The midwife in maternity care. Technical Report Series No 331. WHO, Geneva
Midwifery
EDITORIAL
The Midwife's contribution to the health of w o m e n and children T h e contribution that midwives make to the health of women and babies has been the subject of three previous editorials in this journal (Thomson, 1988; Thomson, 1989; Thomson, 1990). I have been stimulated to address the issue again by the article by Tew and DamstraWijmenga in this issue of Midwifery. T h e authors have analysed some previously unavailable data which demonstrates very convincingly that if a baby is born after 32 weeks' gestation perinatal mortality is lower when care is provided by midwives than when provided by obstetricians. This finding has implications for the provision of facilities for maternity care and should be brought to the attention of all those involved in policy making for maternity services. T h e news that midwives reduce mortality rates is not new (Campbell, 1924; Levy et al, 1971). In 1924 when writing about maternal mortality Dr Janet Campbell stated that ' T h e average death rate a m o n g midwives' cases is certainly lower than that a m o n g doctors' c a s e s . . . ' (MOH, 1924) and this was despite the fact that midwives were caring for women in vastly inferior social circumstances when compared with the social circumstances of the women cared for by doctors. In California in the late 1960s there was a shortage of obstetricians and there was grave concern about the high prematurity and neonatal mortality rates. As recruitment o f obstetricians had failed two nurse-midwives were given licences to practise in the hospital for three years (Levy et al, 1971). By half way through the trial period the nurse-midwives were providing the vast majority of the antenatal care and were responsible for 78% of the deliveries. At the end of the three year p r o g r a m m e there had been a significant decrease in both the prematurity and the neona-
tal mortality rates. Unfortunately the relevant medical licensing authority would not continue the nurse-midwives' licences and there was a subsequent m a r k e d increase in the incidence of p r e t e r m delivery and the incidence.,of death of the baby in the first month of life. Midwives are educated and trained to provide care to women experiencing normal pregnancy and childbirth and to refer women for medical care when abnormalities occur or are expected (WHO, 1966). Those most at risk of maternal and perinatal mortality are those in the lower socio-economic groups. However Chin (1990) has shown that in an area of high socio-economic deprivation in New York women cared for by midwives, who seek medical aid where appropriate, have relatively low mortality rates and low caesarean section and instrumental delivery rates. In the UK community midwives have been shown to enhance the outcome of routine care provided by obstetricians when they, the community midwives, provide extra midwifery care to women living in an area of high socio-economic deprivation (Evans, 1991). For some considerable period of time, and in all parts of the world, the medical profession has claimed that the outcome of childbirth is much safer for both m o t h e r and baby if care is supervised by a medical practitioner and preferably in hospital. In the UK the culmination of the pressure from the medical profession came in the recommendations f r o m the Peel Committee (DHSS, 1970) that there should be provision for 100% hospital confinement. Unfortunately government did not ask the committee for the evidence on which it based this recommendation. In hospital the medical profession control the style of care given and because of the nature of the contracts of employment midwives are allowed very little say in how care will be 53
54
MIDWIFERY
p r o v i d e d , a n d it is p r o b a b l y this fact t h a t is at the b o t t o m o f the i m p r o v e d o u t c o m e o f care p r o v i d e d by midwives. T e w a n d D a m s t r a W i j m e n g a (1991) talk o f t h e n o n - i n t e r v e n t i o n i s t c a r e p r o v i d e d by midwives. A g a i n this i d e a is n o t new. C a m p b e l l ( M O H , 1924) s u g g e s t e d t h a t the r e a s o n why midwives h a d lower m a t e r n a l m o r t a lity rates was because t h e i r role ' p r e c l u d e d o p e r ative i n t e r f e r e n c e ' . O t h e r a u t h o r s w o u l d suggest t h a t the r e a s o n why m i d w i f e r y c a r e is m o r e effective is because midwives c o n s i d e r t h e whole w o m a n , n o t j u s t p a r t o f her. S o m e r e a d e r s m a y have realised t h a t I a m s t i m u l a t e d to write on the topic o f w h a t a m i d w i f e is allowed to d o in the p r o v i s i o n o f m a t e r n i t y c a r e o n an a n n u a l basis. T h o s e r e a d e r s m i g h t be f o r g i v e n f o r t h i n k i n g t h a t in this e d i t o r i a l I a m giving the subject its y e a r l y airing. H o w e v e r , I w o u l d h o p e t h a t those w h o r e a d the T e w a n d D a m s t r a - W i j m e n g a article will realise t h a t this e d i t o r i a l is raising for discussion the issue o f who should p r o v i d e m a t e r n i t y c a r e a n d where. T h e r e is n o t only the issue o f safety, ably d e m o n s t r a t e d by T e w a n d D a m s t r a - W i j m e n g a , b u t w o m e n p r e f e r midwives to c a r e f o r t h e m (Flint, 1991). T h e r e is also the issue o f economics. W o m e n given total a n t e n a t a l c a r e by midwives have fewer days a d m i s s i o n to h o s p i t a l in p r e g n a n c y t h a n w o m e n p r o v i d e d obstetric c o n t r o l l e d a n t e n a t a l care. W o m e n c a r e d f o r by midwives use fewer e p i d u r a l s for a n a l g e s i a in l a b o u r t h a n w o m e n c a r e d f o r u n d e r obstetric c a r e ( R u n n e r s t r o m m , 1969; Flint, 1991). I n a s t u d y of c o n s u m e r views o f m a t e r n a l satisfaction o f m a t e r n i t y services the r e s e a r c h e r s canvassed b o t h health professionals a n d the r e c i p i e n t s o f c a r e as to w h a t s h o u l d be i n c l u d e d in the q u e s t i o n n a i r e (Martin, 1990). A n o b s t e t r i c i a n r e p l i e d that in his o p i n i o n questions s h o u l d be i n c l u d e d o n ' . . . the p a t i e n t ' s u n d e r s t a n d i n g o f t h e risks involved in b e c o m i n g p r e g n a n t a n d
h a v i n g a baby' (Martin, 1990). I d o n o t wish to m a k e light o f the p o t e n t i a l risks o f m a t e r n a l a n d p e r i n a t a l m o r t a l i t y b u t s u g g e s t to obstetricians t h a t the style o f care p r o v i d e d by t h e m d o e s n o t e n h a n c e the o u t c o m e o f c h i l d b i r t h . ANN THOMSON
References Chin M K 1990 The positive impact of midwifery care in an inner city population: NCB experience. Paper presented at 22nd international congress of International Confederation of Midwives, Kobe, Japan DHSS 1970 Domiciliary midwifery and maternity bed needs (the Peel report). HMSO, London Flint C 1991 Continuity of care provided by a team of midwives - the Know Your Midwife scheme in Robinson S, Thomson A M (eds) Midwives, Research and Childbirth, Vol 2. Chapman & Hall, London Evans J 1991 The Newcastle Community midwifery care project - the evaluation of the project in Robinson S, Thomson A M (eds) Midwives, Research and Childbirth, Vol 2. Chapman & Hall, London Levy B S, Wilkinson F S, Marine W M 1971 Reducing neonatal mortality with nurse-midwives. American Journal of Obstetrics & Gynecology 109:50-58 Martin C 1990 How do you count maternal satisfaction? A user-commissioned survey of maternity services in Roberts H (ed) Women's Health Counts. Routledge, London Medical Officer of Health 1924 Reports on public health and medical subjects No 25, Maternal Mortality. HMSO, London Runnerstrom L 1969 The effectiveness of nursemidwifery in a supervised hospital environment. Bulletin of the American College of Nurse-Midwives 14:40-52 Tew M, Damstra-Wijmenga S M I 1991 Safest birth attendants: recent Dutch evidence. Midwifery 7: 55-63 Thomson A M 1988 Control in childbirth. Midwifery 4: 1-2 Thomson A M 1989 The midwife's role under threat? Midwifery 5:1-2 Thomson A M 1990 Medical confusion on care in childbirth and the role of the midwife? Midwifery 6: 57-59 World Health Organization 1966 The midwife in maternity care. Technical Report Series No 331. WHO, Geneva
