SUMMARY

This chapter provides a closing critique of the public health agenda for midwives, and presents a case for a major focus on keeping birth normal as the key contribution that midwives can make to public health. It provides insight into some of the evidence of the potential short- and long-term consequences of intervention in childbirth with serious public health implications, and argues that an understanding of the importance of keeping birth normal appears to have been largely overlooked in the setting of the public health agenda. Recent research exploring midwives’ perspectives on their preparedness for a public health approach to midwifery is discussed, and recommendations made for a new focus in midwifery education and research.

INTRODUCTION

The preceding chapters have provided insights into how the health agenda of governments in many developed countries has changed. The past focus on preventative health care and individual education for appropriate lifestyle choices has been recognised as limited and largely ineffectual in addressing the poor health of certain population groups. Governments have now embraced a broader understanding of the complex interactions and contribution to health outcomes of not only individual behaviour but also socio-economic inequalities. This has led to a new public health agenda that seeks to engage communities, in concert with a range of health providers including midwives, to improve the health status of those who are currently disadvantaged.

This chapter will add to the previous discussions by exploring three further issues. The first considers midwifery philosophy and the shape of clinical practice. It explores the compelling evidence available to support a focus on keeping birth normal as the primary public health focus for midwives. The second outlines the notion of an enhanced role for midwives and will explore the debate that has begun within the midwifery profession around the issue. It explores the place of the midwife in the multi-disciplinary team, and reveals some of what has been written about educating midwives to fulfil enhanced roles. The final pages focus on the future and discuss the potential barriers to be overcome if we are to fulfil our public health potential.

MIDWIVES’ CONTRIBUTION TO PUBLIC HEALTH

The title of this chapter might suggest to you that putting public health into midwifery practice is part of a new agenda for midwives. Undertaking a review of the many government documents cited in the preceding chapters might lead you to the same conclusion. Midwives are on notice. Authoritative figures in numbers of developed countries have discovered the enormous potential that exists within the midwifery workforce and in midwives’ unique role in relation to practically every child-bearing woman and her family. We need to rejoice because at last, our full potential may be realised.

An increased awareness of the health inequalities experienced by women who endure socio-economic disadvantage has now placed new demands on service providers and challenged current midwifery roles. Midwives are being asked to take on a greater role in community development to improve social capital and reduce health inequalities, as well as providing core maternity services. Governments have suggested many additional services that midwives could provide, and the preceding chapters have examined some of these in detail. Many midwives will regard such lists of ‘additional’ services as integral to their primary health role and something they have been actively pursuing already (Henderson 2002a). Others will see such lists as an unattainable radical change to current maternity services, particularly where new services are called for such as comprehensive sex and relationship education in schools, pre-conceptual care, assessing dental health and assisting with the engineering of community-based social and cultural renewal. What this chapter will argue is that most of the calls for a new public health focus for midwives, no matter how comprehensive, fail to recognise the core role that midwives have in ensuring the health of current and future generations by simply keeping birth normal.

INFLUENCING HEALTH IN LATER LIFE

Every midwife no doubt will be familiar with what has come to be called the Barker hypothesis (Barker 1998, 2003). The story of the epidemiological investigation triggered by the discovery of the meticulous birth records of the people of Hertfordshire makes compelling reading from both a midwifery and a public health perspective. By matching the birth records of 15,000 Hertfordshire men and women born between 1911 and 1930 with the National Health Service Registry, Barker and his colleagues were able to identify a large population cohort and gain their co-operation to provide a range of health data for analysis. This enabled Barker to determine that coronary heart disease (CHD) (and other diseases of later life) has its origin in specific patterns of disproportionate fetal growth that result from fetal under-nutrition in middle to late gestation. When failure to breastfeed, early weaning, and smoking are added to an inadequate maternal diet and low birth-weight, the risk of CHD later in life is increased substantially. Many other studies have found similar associations, thus adding weight to the hypothesis that the prenatal, perinatal and early childhood environment can have a long-term effect on many health outcomes (Howden-Chapman & Cram 1998, Dorling et al 2000, Huffman et al 2001, Robinson 2001, Hypponen et al 2003).

The UK government has recognised the potential for intervention to change this pattern of disease through programmes such as Sure Start, as described in Chapter 10. This programme aims to reduce the incidence of low birth-weight babies by 5%, by targeting women in particularly high-risk areas where there is a high rate of teenage pregnancies, high incidence of domestic violence, high youth unemployment and the highest number of child referrals to health services (Garrod 2002, Hutchings& Henty 2002). It is a significant step to have midwives employed to deliver the maternity component of Sure Start, since this acknowledges the preventative health role midwives can play in not only improving maternal nutrition and birth-weight of infants but also in increasing rates and length of breastfeeding. However, there is also an inherent challenge for midwives working in this way, to keep birth normal.

KEEPING BIRTH NORMAL

Midwives are, and always have been, primary health care providers with a public health agenda. Unfortunately the last 100 years of midwifery practice has seen our focus diverted from our primary role by the move to a hospital-centred, medicalised approach to childbirth. Midwives’ ability to assist women to give birth naturally, which is our primary task, has been gradually eroded until some estimates suggest fewer than 25% of women will give birth without some form of medical intervention (Downe 2001). The rhetoric has been that the increase in scientific medicine and subsequent rising intervention rates in childbirth are to make childbirth safe. However, far from being pleased, women’s sense of well-being has deteriorated to the point where most women are fearful of childbirth and are afraid of the pain of labour and of losing control. Childbirth is seen as risky and fraught with complications, and some women are shocked and emotionally scarred by the experience (Walsh 2002). The idea that birth is only normal in retrospect has been finally assimilated into the body and mind of society (Bates 1999) as the medicalisation of childbirth has gone too far (Johanson et al 2002). This situation is the first challenge that individual midwives and the midwifery profession must address if we are to realise our potential contribution to public health.

There are compelling reasons why we need to keep birth normal. There are numerous unintentional and serious consequences of unnecessary intervention in childbirth that have public health implications. There are short- and long-term effects in both mother and baby, revealed in studies ranging from basic science research in individuals (animals and humans) to large epidemiological investigations of population groups. An examination of two of the most common events which child-bearing women experience will provide insights into this proposition.

LABOURING UNDISTURBED

The potential public health effects of perinatal environmental disturbance were investigated over 30 years ago by psychologist Niles Newton. In a series of elegant experiments conducted with mice, Newton established that supporting the mother to labour undisturbed is crucial not only for ensuring labour progresses normally but also for the health of the infant (Newton et al 1966, 1968). Placing the labouring mother in a hostile environment, or simply moving her from one place to another during labour, resulted in both a significant slowing of labour and the death of some of the pups.

While we assume that human behaviour is much more complex than that of animals, it is reasonable to extrapolate from studies of parturient animals. Comparative obstetrics has demonstrated that ‘… different species have made specific adaptations to the ecology of which they form a part … and … common mechanisms which have a fundamental value, are observed in all mammals. This is just as true for the behavioural as for the physiological, endocrinological, anatomical (and many other) aspects of parturition’ (Naagteboren 1989:796). Therefore while the results of research in mammals is not directly transferable, it does need to be given due attention. Newton asked (1990:37), ‘… are mammals with more highly developed nervous systems than the mouse equally sensitive to perinatal environmental disturbance… what effect if any do variations between home and hospital environments have on the course of labour and on perinatal mortality?’

How often are women disturbed during the course of their labour in your unit? Why should we be surprised that the two main reasons for all operative intervention in childbirth are uterine inertia and fetal distress? Where is the call for labouring undisturbed placed on the public health agenda?

LABOUR ANALGESIA: SHORT- AND LONG-TERM HEALTH IMPACT

A growing body of evidence is available to describe how early breastfeeding behaviour is disturbed by labour analgesia, but few policy documents have made links between labour analgesia, breastfeeding and the public health implications of failure to breastfeed (Ransjo-Arvidson et al 2001, Righard 2001, Stafford 2002, Torrance et al 2003). Many resources are currently being allocated to the Baby Friendly Hospital Initiative in order to change the behaviour of health care professionals and clients to increase the uptake and success of breastfeeding (UNICEF 2003). However, fewer resources have been invested in enabling midwives to provide continuity of care, which has been demonstrated in numerous evaluations to be associated with both less use of analgesia and higher rates of successful breastfeeding. In so doing we are arguably focusing on a downstream effect modifier, rather than a potentially more positive preventative health intervention (Fowler 2000).

Labour analgesia administered to the mother has also been implicated in increased susceptibility to drugs in later life for her offspring, due to an imprinting process when the neonate is exposed to drugs in utero (Nyberg et al 1992). Research by Kerstin Uvnas-Moberg and her colleagues has revealed the crucial role that oxytocin plays in human attachment and relationship behaviour and how this can be blocked or inhibited, by epidural analgesia in particular (Uvnas-Moberg 1997, 1998). Further studies by Swedish researchers also found the mother’s labour analgesia and other obstetric procedures were implicated in an increased risk of suicidal tendencies and anti-social behaviour for their offspring (Jacobson et al 1987, 1990, Jacobson & Bygdeman 1998). How can we ignore the public health implications of these findings?

Ensuring that well women remain well is the first priority of midwifery practice and maternity care. We must continue to address this issue, at the same time as focusing on disadvantaged groups of women in our communities. Midwives’ perspective is long term and preventative, and the foundation of our philosophical approach is that childbirth is a normal (albeit stressful and life-changing) event in women’s lives. Supporting and encouraging women in holistic and respectful ways in order to keep birth normal must be our primary function. We have much work to do in order to fulfil just that key component of our role.

CONTINUITY OF CARE: A MEANS TO AN END, NOT AN END IN ITSELF

The potential health gains from midwifery care, especially that provided in a continuity of care model, are well established, having been explored in 19 randomised controlled trials, 15 prospective non-randomised comparative studies, 21 retrospective studies and 4 descriptive studies in the UK, Scotland, Canada, North and South America, Sweden, Hong Kong and New Zealand (Biro 2003). More than 20,000 women have participated in the randomised controlled trials alone, which indicates the level of interest women have in how their care is delivered. Almost all of the trials have found decreased rates of all interventions in childbirth. In Chapter 6. Caroline Homer provides details of one of the studies conducted in Australia which found significant differences in the rate of caesarean section for women receiving continuity of care provided by a small team of midwives located in the community (Homer et al 2001). Not only are well women kept well; their babies are well, women are more satisfied with the process and feel valued and listened to, but costs to the health system and therefore to society are lower. This is surely one of the most significant contributions we can make to public health. Or is it? What is becoming more apparent, as we examine and reflect on models of continuity of care, is that while it is a model that women prefer, it may not provide the health gains we anticipate.

Over 10 years ago I conducted a randomised controlled trial of continuity of care provided by a team of midwives in an Australian maternity unit (Rowley et al 1995

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