Midwifery – Reflections on the path ahead

Currently the rates of induction of labour, medical interventions during labour and caesarean sections are rising globally. Mary Brosnan, Director of Midwifery at the National Maternity Hospital in Dublin, reflects on the changes in care in Ireland during her career. She challenges midwives and maternity care providers to consider why this is happening and what is the way forward as midwives.

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Midwifery – Reflections on the path ahead

As I reflect on the 17 years in my role as Director of Midwifery (DOM) at the National Maternity Hospital I am proud of the maternity service developments we have seen and the many ways we have helped to shape our service, such as expansion of the community midwifery service and advanced midwifery roles. In the last decade we have witnessed a worrying rise in the over-medicalisation of childbirth.  The biomedical model has evolved and is an essential part of modern maternity care for so many women and has played a large part in reducing perinatal mortality over the years. However, it becomes problematic when non-medical problems become defined and treated as medical problems (Prosen, & Kranjc, 2019) and some interventions are over-used without clinical justification.

For our profession, it is important that we take stock of where we are at. Our challenge as midwives is to constantly focus on what is best practice and to target interventions appropriately.  We have to improve access to midwifery care pathways, supporting women within our scope of practice, using the framework of the National Maternity Strategy (HSE 2016) to ensure women access the most appropriate pathway of care for their needs.

I have been working in midwifery for the last 36 years and I ask myself constantly- Why is it that we still don’t fully understand the physiology of labour despite decades of research? In the 1960’s men landed on the moon, and yet we still cannot determine when labour will happen or indeed how to stop preterm labour in many cases.

In Ireland there is an overall decline in the national birth rate and a rise in the levels of complexity and acuity (National Women and Infants Health Program, 2022). There has never been more access to information for women, on line via social media or websites, to allow women to be more informed.  There are differences in terms of women’s expectations and choice. Some women wish to have a completely natural birth with no intervention and will wish to attend a midwifery-led service. There are many women who want the biomedical model and wish to have a pain free birth or a planned caesarean section (CS) and many women elect to attend an obstetrician in that case.

How are women receiving the information on pregnancy and childbirth to support them in their choices? Much of the discourse on line can be on the fear around childbirth. This drives some women to choose elective CS as a way of controlling the outcome, removing the uncertainty around labour. Fear can also influence clinicians to offer interventions such as early induction or elective CS, (Panda et al., 2022). There is also a marked difference in the likelihood of induction or CS if a woman attends for private care with an obstetrician: she is twice as likely to have a pre-labour CS and more likely to be induced, (Craven et al., 2020).

The Robson Ten Groups Classification of CS has been adopted by the WHO as an audit tool for maternity care and was first developed at the NMH (Robson, M., 2001). We can now review over fifty years of data and examine trends which reflect the changes in maternity care over time. In the 1970s until recently, active management of labour was offered to all mothers attending the NMH. In recent years, this philosophy has changed and more and more women are opting for a natural approach to labour and on the other hand, many more women opt for pre labour CS.

Robson Group One refers to first time mothers at full term in spontaneous labour and CS rates are generally around 10-11% in this group in our hospital. However, the number of women in this group is consistently decreasing year on year. Why? Because many women are being offered induction or requesting pre- labour CS. While the majority of inductions are clinically indicated for fetal or maternal reasons, there is an increase in non-clinical indications.

It is clear from reviewing our outcomes for 2022, that more first-time mothers will be induced or deliver by pre-labour CS than will present in spontaneous labour, (NMH clinical report, 2022). At the same time our first-time mothers are increasingly aged over 35 years (11% over 40 and 50 % over 35 years). This is a reflection of the changes in the demographics of our population and the fact that risk stratification often becomes the dominant narrative in deciding on management. Last year over 50% of the documented indications for pre-labour CS were for maternal request.

When I commenced working as a midwife at the NMH in 1992, the induction of labour rate was 12%. Thirty years later the rate is now over 38%. The reasons include advanced maternal age (50% of women are now over 35 years old), medical co-morbidities, guidelines for risk management or maternal request. Research such as the Arrive Trial (Grobman et al 2018) has also influenced the practice of offering induction at 39 weeks.

As the Director of Midwifery at the NMH, I am constantly reflecting on the balance between choice and safety, both are essential components of maternity care. I want to support normal or physiological birth and ensure midwives have the option to practice midwifery. On the other hand, I have a duty to ensure that my midwifery team are protected from exposure to excessive risk due to a poor perinatal outcome, which also would result in potentially career ending litigation.

In many circumstances in our hospitals, women who could be cared for within midwifery care pathways are offered obstetric care pathways because of strict guidelines around maternal age or BMI. Our focus on risk identification in pregnancy is extremely important.  As I mentioned, more than half of the women attending us are now having their first baby at aged 35 or older. One in six couples have had IVF treatment, often with donor eggs. More women have co- morbidities requiring higher levels of surveillance in maternal medicine clinics. However, the recent highly publicised failings in maternity care, such as Morecambe Bay, Shrewsbury and Telford, East Kent, MLUs in Northern Ireland, have all seriously damaged public confidence in midwifery care and have also eroded the confidence of midwives to practice to the full scope of their expertise in many circumstances.

The lack of dynamic risk assessment is criticised in several recent publications reviewing failures in maternity services in the UK by Ockenden, (2022). The HSIB maternity investigations identified repeated examples of insufficient robust continuous risk assessments in the maternity pathways, (HSIB Learning Report 2023). Given the devastation that can occur from a sentinel event, is it any wonder that midwives are fearful of making a mistake?  At times the focus on risk management results in a ‘too much, too soon’ approach, due to the fear of missing an opportunity to intervene, in an effort to offer safe midwifery care.

There are many implications for midwifery practice in this changing environment. In recent years the vast majority of women ask for an ultrasound at each antenatal visit and are very disappointed if it is not offered. This can limit recruitment of clients to community midwives clinics as they don’t perform scans. Midwives need enhanced knowledge of antenatal and postnatal morbidity, wound care and perinatal mental health, in order to support women requiring additional interventions. But we also need to support junior midwives in particular. They have to be supported in order to have renewed confidence in their ability to assist women to birth naturally, in first time mothers particularly. Midwives also have to be in a position to support women who could opt for VBAC safely in a subsequent pregnancy.

As midwives we have to focus on the elements that are within our control. Pre- pregnancy and antenatal education can have an impact on women’s decision making in terms of seeking induction or elective CS for non-clinical reasons. Continuity of midwifery care in clinics and in community midwifery teams can improve the confidence of women to trust in their bodies with affirmations and support for physiological birth or VBAC if circumstances allow. There are many tools available to us, such as the use of the ‘Labour Hopscotch’ (Carroll, & Thompson, 2022) which was developed in our hospital by midwife Sinead Thompson, or for instance other workshops to support empowerment of midwives and women.

Surely all of us as maternity care providers need to be asking ourselves, is it acceptable that if trends towards increasing CS rate continue to rise, then half of our daughters will be giving birth by surgery, not the way our mothers and grandmothers gave birth?

References:

Carroll, L., Thompson, S., Coughlan, B., McCreery, T., Murphy, A., Doherty, J., Sheehy, L., Cronin, M., Brosnan, M., and O’Brien, D. (2022). ‘Labour Hopscotch’: Women’s evaluation of using the steps during labor’. European Journal of Midwifery, 6(September), pp.1-10.

https://doi.org/10.18332/ejm/152492

Craven S. et al. (2020) ‘Do you pay to go private?: a single centre comparison of induction of labour and caesarean section rates in private versus public patients’. BMC Pregnancy and Childbirth 20:746 https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-020-03443-4

 

Grobman, W.A. et al (2018) Labour Induction versus Expectant Management in Low-Risk Nulliparous Women. New England Journal Medicine, 379:513-523

HSE (2016) The National Maternity Strategy: Creating a Better Future together 2016-2026. Health Services Executive, Ireland. https://www.gov.ie/en/publication/0ac5a8-national-maternity-strategy-creating-a-better-future-together-2016-2/#

HSIB Learning Report (2023) https://www.hsib.org.uk/investigations-and-reports/assessment-risk-during-maternity-pathway/

The National Maternity Hospital (2022), NMH clinical report 2022, The National Maternity Hospital Dublin, D02 YH21.

National Women and Infants Health Program (2022) Irish Maternity Indicator System (IMIS) Annual Report 2021 https://www.hse.ie/eng/about/who/acute-hospitals-division/woman-infants/national-reports-on-womens-health/national-women-and-infants-health-programme-report-2021.pdf

Ockenden D (2022). Ockenden report – Final: Findings, conclusions, and essential actions from the independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust (HC 1219). Crown. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1064302/Final-Ockenden-Report-web-accessible.pdf

Panda S, Begley C, Daly D (2022). Clinicians views of factors influencing decision making for CS for first time mothers. A qualitative descriptive study. Plos One 17(12): e0279403 https://doi.org./10.1371/journal.pone 0279403.

Prosen, M., Krajnc, M. (2019) Perspectives and experiences of healthcare professionals regarding the medicalisation of pregnancy and childbirth. Women and Birth 32 e 173-e 181. https://www.sciencedirect.com/science/article/abs/pii/S187151921730505X

Robson, M, (2001) Classification of CS. Fetal and Maternal Medicine Review, 12 (1). 23-39.

 

Mary Brosnan

Director of Midwifery and Nursing, The National Maternity Hospital, Dublin

April 2023.