Introduction

The first chapter of this book states ‘It is midwives who make their profession, what it is today and what it will be tomorrow, globally.’ This final chapter will briefly address challenges that may face midwives in the 21^st century in order to maintain their roles within the midwifery profession and maternity service. (Supporting information is on the website, which, therefore, is not referred to within the chapter.)

The Future

If midwives wish to have their role recognized, they must be clear of their role and its professional boundaries. Where overlaps in responsibilities occur in caring for women and families when working within the multi-professional environment, agreeing distinct pathways for the role of the midwife is essential. Where multiple providers are offering support and care in health and social care, then, ideally, a choice should be made for a key worker from one group who can build the best relationship. The essential element, here, is to ensure good channels of communication between all healthcare providers. In many cases, the midwife is most likely to provide continuity to the woman during the pregnancy and childbirth period.

In responding to new disease patterns, changes in society and public expectations, it is opportune to consider how midwives may work flexibly and broaden their remit within the public health agenda to meet the needs of society (DH 1999, 2001b, UN 2001). Altering economic climates will also demand new ways of working to provide an effective and efficient midwifery service that utilizes support where necessary.

Though many resources for this book and the website have drawn upon midwifery in UK literature, messages for midwives working with women throughout the world are similar. In countries where the midwifery profession is established, women have optimum opportunity to birth in ways that suit them. The aim must be to provide trained midwives for all women all over the world, as this is proven to impact on quality of maternity care, and reduction in mortality and morbidity (WHO 2004).

Clinical care

Providing women with choices and enabling families to make decisions in their care is government policy in the UK (DH 2007a). A recent review of women’s maternity care experiences demonstrates diversity in experiences that women receive in the UK; however, the report notes that midwives are in a powerful position to influence the care that women receive (Redshaw et al 2007). Women’s voices and views need to be heard antenatally, in labour, and during the postnatal and neonatal care periods, so that clinical care takes place in non-threatening spaces, and always with the ability to respond to emergencies.

Features of practice environments will include:

• provision of unbiased information that meets the needs of individuals

• ensuring mutuality through knowledge-sharing in partnership through communication with women as a way forward to promoting women’s decision-making (NHS Scotland 2009) and their feelings of their own control

• promotion of normality in all processes of birth and its environment with the option of working with women to accomplish as normal a birth as possible (RCM 2009a)

• direct communication with, and referral between, medical and midwifery teams

• pathways for rapid access to emergency care, to medical facilities and other interventions as necessary

• ensuring communication in complex cases (RCOG RCA RCM RCP 2007) and, as professionals and women may not share the same language and knowledge base, to review ways of mediating understandings

• development for all midwives of their leadership qualities to articulate for women in their care, recognizing their individual wishes

• education and training of midwives to develop knowledge and skills to practise with autonomy and recognize when to liaise with other agencies (Reid 2007). All midwives need to continuously develop their knowledge and skills.

Clinical care may need to be offered flexibly to ensure that women’s societal and cultural needs are accommodated within provision of best evidence for practice. With increasing medical advances midwives need to balance sound knowledge of normalization of birthing processes with appropriate use of science and technology in clinical care. Advances are increasingly enabling women with complex medical conditions to become fertile and give birth. This brings higher levels of complexity in caring. The aim is to ensure optimum health outcomes for mother and baby with reduction of morbidity and mortality.

Working with women

Women want clear unbiased advice, offered in simple lay terms, that does not indicate a professional’s individual view, but gives the options and implications of a choice of action to tailor this to their individual circumstances. This is not an easy task for each professional who has a mantle of their own prejudices and biases that need to be set aside. The Darzi report (DH 2007b) indicates that professionals must provide a personalized service that gives control to women and families.

Women may find advice contradictory and confusing, therefore, current information could be improved (Healthcare Commission 2008). This often means listening to women and confirming that they understand the implications of advice (Redshaw et al 2007). Building partnerships with women and working with their organizations, such as the Association for Improvement of the Maternity Services (AIMS; http://www.aims.org.uk/) and the National Childbirth Trust (NCT), and local groups, will assist in providing a service where their needs are met.

If women do not like what is offered, they may take their own decision for their birth, as shown by the movement for free birthing (Cooper & Clarke 2008). Care must be equitable for all women and families regardless of their individual circumstances (DH 2007a).

The influence of a trained midwife present at birth has been shown to effect a reduced morbidity and mortality rate for both mother and baby (WHO 2004). In this century, an aim would be to see education, training and registration for midwives in all countries of the world. The caveat is that as midwives become qualified, the costs of midwifery service may rise, thus there may be those who work in affiliation with midwives. Clear parameters and boundaries will be necessary to ensure that it is midwives who provide skilled care to women through the pregnancy and childbirth continuum. Their responsibility is to be knowledgeable, know their limitations and how to harness appropriate multi-professional help when needed. This would be the aim to ensure safer birth. To see a fulfilment of this aim for safer birth and to reduce inequalities in birth means continuing training and lifelong learning for all midwives, including professional updating that recognizes the value of normalization of birth where possible. This includes changing behaviours and attitudes that have become reliant on interventions, however minor.