Chapter 17 Working in partnership
Working in partnership takes maturity, self-knowledge, honesty, commitment and professionalism. It is demanding and challenging but ultimately rewarding and satisfying. It can benefit both partners. To work in partnership requires a midwife to move beyond her professional role and expose and share herself as a person with the women for whom she provides care. This chapter identifies some important aspects of partnership practice and explores how midwives can integrate these aspects into their own midwifery practice.
The central tenet of midwifery is that it is a relationship between a midwife and a woman and that this relationship is one of partnership (Guilliland & Pairman 2010; Kirkham 2010; Pairman 2006a). The development of this partnership relationship relies on midwives being able to work in continuity-of-care models so that mutual trust and understanding between midwives and women can evolve over time. Partnership relationships provide a context from which there is potential for both women and midwives to be empowered and enriched through the relationship (Guilliland & Pairman 1995; McCourt & Stevens 2005; Siddiqui 1991).
Promoting normal (physiological) birth is only one aim of midwifery care. Equally important is the aim of supporting women to be confident in their roles as mothers, with the consequent positive impact on families and communities. A one-to-one relationship between a midwife and a woman over nine to ten months of the childbirth process provides a unique opportunity for the midwife to reinforce and support each woman’s ability as a decision-maker and her sense of self-determination. Confidence in her body and in herself will stand a woman in good stead as she takes on the complex role of mother that is central to the healthy functioning of a family.
While personally demanding (see Ch 15), working in partnership with women is also extremely rewarding and empowering for midwives (Page et al 2006). One-to-one continuity of care provides a context in which midwives can truly embrace their full role and scope of practice and explore what it means to ‘be with’ women during childbirth. This meaning will differ for each midwife, who will identify and develop her1 own practice strategies to enhance her partnership relationships with women (see Ch 16).
This chapter looks at some of the practicalities and issues relating to practising in partnership with women with the aim of promoting women’s confidence and sense of self-determination. The chapter also examines the partnerships that midwives form with midwifery colleagues. The philosophy and particular nature of midwifery partnership is explored, with practical references to an approach that:
There is a growing awareness of the benefits to women of being able to access one-to-one continuity of midwifery care (or midwifery caseload practice), which is the foundation of partnership (Benjamin et al 2001; Fereday et al 2009; Homer et al 2001, 2002a; Page et al 2001; Sandall et al 2001; Turnbull et al 2009). These benefits include increased satisfaction with their care and a reduced likelihood of interventions, including: being admitted to hospital antenatally; having drugs for pain relief in labour; having an episiotomy; and their baby requiring resuscitation (Sandall 2004; Sandall et al 2008). There is evidence that these benefits extend to women who experience complications and need also to have care provided by obstetricians, paediatricians and other medical specialists (Farrell et al 2002; Homer et al 2002b; Turnbull et al 2009). In weighing up all of the benefits of continuity of care from a small group of midwives who the woman knows (see Ch 19), a Cochrane Systematic Review concluded that all women should have access to ‘midwife-led care’ (Hatem et al 2008).
A central component of midwifery caseload practice is continuous support in labour, which has a positive impact on both women’s experiences and birth outcomes (Hodnett et al 2007). Women who have continuous support are more likely to have a spontaneous vaginal birth, less likely to use analgesia in labour, less likely to have an operative birth or caesarean section and are more likely to be satisfied with the birth experience (Hodnett et al 2007).
In New Zealand, where over 78% of women receive continuity of care through caseload midwifery models, the impact of this care in improving outcomes for women and babies is now being recognised (NZCOM 2008a; NZHIS 2007). While the rate of caesarean section has not declined dramatically, the rate of increase is much slower than in other Western countries, such as Australia, where it has continued to climb. Indeed the data over the three years from 2003 to the most recent available in 2005 indicates that New Zealand’s caesarean section rate has remained relatively stable, moving from 23.1% in 2003 to 23.8% in 2005 (see Ch 1) (NZHIS 2006, 2008). By contrast, Australia’s rate in 2003 was 28.3% and this increased to 30.3% by 2005 (Laws et al 2007; Laws & Sullivan 2005). Since midwifery autonomy was reinstated in New Zealand in 1990 and then the LMC (lead maternity carer) model was introduced in 19962 (see Ch 1), rates of instrumental delivery and induction of labour have been contained or have declined. Instrumental vaginal births have decreased from 12.4% in 1989 to 9.7% in 2005; inductions have decreased from 21.5% in 1998 to 19.8% in 2005; and epidurals have only marginally increased, by international standards, from 23.3% in 1997 to 28.8% in 2005 (Ministry of Health 1999a, 1999b; NZHIS 2008).
Perhaps more importantly, it appears possible that continuity of midwifery care may make a positive impact on outcomes and health over a longer timeframe (Guilliland 2005; Guilliland 2009). For example, since the commencement of New Zealand’s one-to-one partnership model of midwifery care in 1996 (see Ch 1),perinatal mortality rates have continued to decline, antenatal admission rates for women with serious complications have declined, 95% of babies receive their six-week immunisation (a rate higher than at any other time in the immunisation schedule), 97% of women initiate breastfeeding, rates of exclusive breastfeeding at six weeks and three months are increasing, and 96% of women are satisfied with their maternity service (Guilliland 2005, 2009; Health Services Consumer Research 2008; Ministry of Health 1999a, 2001, 2003; NZHIS 2003, 2004, 2006, 2007, 2008; Perinatal and Maternal Mortality Research Committee 2009).
The picture for Māori and Pacific Island women as well as women from lower socioeconomic groups is also positive. Māori and young women from lower socioeconomic groups are more likely to choose midwives as their lead care providers, and Māori women are more likely to birth in primary maternity facilities than any other ethnic group (NZHIS 2007). A study of over a million births from 1980 to 2001 shows that while preterm birth rates for Māori women are still higher than for non-Māori women, there has been a slight decline in the rates for Māori and Pacific Island women, in contrast to a marked increase for European women (Craig et al 2004). While rates for small-for-gestational-age (SGA) babies have decreased for Māori, Pacific Island and European women over this period, the rate of decline for Pacific Island and Māori women has been greater (Craig et al 2004). Despite the higher rates of preterm birth and SGA babies among Māori women, perinatal mortality rates for Māori babies are lower than those for Pacific Island and Indian ethnicities although higher than New Zealand European (Perinatal and Maternal Mortality Research Committee 2009). The outcome gap between rich and poor is less than in other Western countries with similar economic and social contexts (Guilliland 2009). One-to-one midwifery care also has a positive impact on smoking cessation during pregnancy and before discharge from midwifery care, particularly for women under 25 years of age and women who identify as Māori (Dixon et al 2009).
Midwifery care is linked to better outcomes than care with general practitioners and obstetricians, with higher normal birth rates and lower rates of caesarean section, instrumental births, episiotomies and epidural use (NZCOM 2008a; NZHIS 2007).
The context for childbirth in Western societies remains characterised by the increasing use of intervention and technology, and the reasons for this are complex. Reducing unnecessary intervention in childbirth and reframing birth as a physiological life process is no simple matter, but providing midwifery care through one-to-one continuity of care in partnerships with women is one place to start (Homer et al 2008; Page 1995). The relationship between a woman and a known midwife can ameliorate the impact of institutionalisation (Berg et al 1996; Halldorsdottir & Karlsdottir 1996; Kirkham 2000, 2010), and repeated studies demonstrate that women’s feelings about this relationship and the related interactions override all other factors when women reflect on their experiences of labour (Hodnett 2002; Hodnett et al 2007).
Like any human relationship, the development of partnership between a midwife and a childbearing woman is a complex process requiring self knowledge, well developed communication skills, willingness, honesty, trust, generosity and time. (Pairman 2006, p 74)
The International Confederation of Midwives’ definition and scope of practice of a midwife (accepted in Australia and adapted in New Zealand) identifies that midwives work with women during pregnancy, labour and birth, and the postnatal period—identified by the World Health Organization (1999) as six weeks following birth—in the provision of ‘woman-centred’ midwifery care (ACM 2009; Midwifery Council of New Zealand 2004; NZCOM 2008b). The childbirth experience is a discrete period of profound significance to women and their families/whānau. Unlike any other episode where people seek healthcare, pregnancy, birth and breastfeeding are physiological processes. ‘Woman-centred care’ is articulated as different from the care given by other practitioners in that, throughout centuries and across cultures, women have asked midwives to be alongside them in their journey to motherhood in a relationship of mutual trust and respect embodying feminist principles and focusing on the individual needs of each childbearing woman (Guilliland & Pairman 1995; Leap 2009; Thompson 2004).
In maternity services in New Zealand, and to a lesser extent in Australia, women can access models of care where midwives are alongside them throughout this period as primary carers. What women seek from midwives is support and skills in addressing the physical, emotional, social and spiritual aspects of a rite of passage that has far-reaching consequences for all involved and for the wellbeing of societies (Kirkham 2000; Kitzinger 1988; Thompson 2004).
Many of the currently compartmentalised components of woman-centred care are linked through relationship. The midwife becomes a ‘professional friend’ (Pairman 1998, 2000a; Wilkins 2000), supporting a woman to give birth in a way that she believes to be right for her and her baby. This relationship includes an emotional engagement, each party placing the other within a personal and biographical context (Wilkins 2000). Women have articulated the concept of the midwife as ‘professional friend’ where the following factors apply:
The midwife and the woman work together in a particular way that integrates the notions of ‘being equal’, ‘sharing common interests’, ‘involving the family’, ‘building trust’, ‘reciprocity’, ‘taking time’ and ‘sharing power and control’. (Pairman 2000a, p 210)
The concept of ‘professional friend’ embodies characteristics of friendship within a professional relationship formed for the purpose of providing professional midwifery care and ending at completion of the childbirth process (Pairman 1998, 2006). Working with women in partnership as a ‘professional friend’ involves the integration of knowledge, skills and attitudes as reflected in the philosophies, competencies and other standards of the midwifery professions in both New Zealand and Australia. The midwifery role of ‘being with woman’ (the meaning of the Anglo-Saxon word mid-wyf) underpins these professional frameworks and is recognised by midwives internationally.
As identified in Chapter 16, the midwife–woman relationship was first articulated as a feminist concept of partnership by New Zealanders Sally Pairman and Karen Guilliland in their 1995 monograph, The Midwifery Partnership: A Model for Practice (Guilliland & Pairman 1995). The notion of ‘being with’ as opposed to ‘doing to’ is associated with rites of passage such as birth and death (Powell Kennedy et al 2003). Fundamental to this understanding is recognition of the autonomy of the individuals involved in these significant events. The midwife’s role is to ‘be with’ each woman and support her independence and growth through pregnancy and birth so that she feels strong and confident in her abilities as a woman and as a new mother (Katz Rothman 1991).
At every stage of our interactions with childbearing women, as midwives, we should be adopting behaviours that will ensure that women can take up the power that will enable them to lead fulfilling lives as individuals and as mothers. This process of empowerment may have far reaching consequences in terms of women’s feelings of self worth and confidence. (Leap 2010)
In order to promote confidence in women, the midwife needs to be secure and confident in herself, both as a woman and as a midwife (Kirkham 2000). This often entails a mature approach to resisting the temptation to ‘make things better’, ‘sort everything out’ and take control as the ‘expert’. It also means understanding how to avoid creating dependencies. There is a danger that ‘needy’ midwives can create ‘needy women’, and inadvertently create dependencies that interfere with a woman’s sense of her own expertise and ability to be self-determining.
Instead of seeing themselves as the ‘experts’ who need to ‘instruct’ and ‘educate’ women, midwives need to conceptualise the relationship as one based on mutual learning and reciprocity (Guilliland & Pairman 1995; Pairman 1998). This begins with the midwife asking open-ended questions and having good listening skills.
If a relationship is such that the practitioner does not listen, does not come to know the hopes and fears of the woman, does not respond to her anxieties, then the mode of care can only … be based on the semblance of what the practitioner thinks should be happening. It lacks attention to the things that are ‘mattering’. It traps the woman into a passive role of accepting inappropriate, unsafe care, rather than freeing her to involve herself in the accomplishment of personalised care that promotes all that is safe. (Smythe 1998, p 202)
If midwifery is about promoting self-determination for women, then the notion of ‘advocacy’—often seen as an important part of the nursing role—needs to be questioned (Guilliland & Pairman 1995). Arguably women should be advocating for themselves if they are to feel powerful. In most situations this is possible, particularly where the relationship with a midwife has enabled the woman to access information and articulate her needs. Where pain in labour or severe illness interferes with this process, the midwife may have a role in presenting the woman’s wishes, but this is done from a position of knowledge and trust that has been established and negotiated. This is all part of being clear about expectations at the initial visit and subsequently as the relationship develops.
Critical thinking exercise
1. Continuity of midwifery care is common in New Zealand, but not in Australia. Think about the implications for women who cannot access continuity of midwifery care. How might this affect their relationships with midwives? What impact could this have on their experiences of maternity care?
2. If you work in a setting where continuity of care is not available to women or midwives, how can you incorporate some of the principles of partnership into your midwifery practice? Think of six changes you can make to your practice that will help you to develop a more equal relationship with the women you work with and to give them a stronger sense of power and control.
Valuing a woman’s expertise in monitoring her baby’s wellbeing throughout pregnancy and in the early weeks of motherhood is often about stepping back and sending a message of trust. The balance between ‘trusting the process’ and being alert to signs that there is a need to intervene—either by making suggestions or by taking action—is a core midwifery skill that is often invisible and is hard to articulate in its complexity. The individuality and unpredictability of each woman’s experience means that often both women and midwives find themselves in situations where they feel they are outside their comfort zones and where they need to draw on courage as well as knowledge and experience.
Thus ‘being with’ encompasses the ability of midwives to trust the process of birth while using practice wisdom to guide and intervene as necessary. Because midwives cannot always be certain about their decisions or women’s decisions, the balance between trusting and facilitating a process, and intervening through action, is finely balanced and individual to each woman’s experience. It takes a degree of maturity on the part of the midwife, and characteristics and skills such as honesty, integrity, decisiveness, practicality, reflectiveness, generosity, positivity and autonomy (see Ch 15).
The fundamental starting point for partnership is the recognition that women and midwives both have expertise that will contribute to an optimal experience for each woman and her family. The way in which both a midwife and a woman will contribute to the relationship needs to be individually negotiated. Each will bring different expectations and skills.
The woman, with her knowledge of self and family … brings a willingness to participate actively in her care, sharing responsibility for her decisions and assuming control over her experience. The midwife, from her foundation of professional standards and ethics, brings her ability to be ‘with woman’. In this, she utilises her knowledge, skills and self in practice and is accessible and supportive to the woman. (Pairman 2000a, p 210)
Women seek midwifery care because of the knowledge and skills that midwives bring to the relationship. Indeed, the only reason for midwives to be involved with women is to bring this expertise. Safety is a priority for women and they expect midwives to act on their professional judgements. For example, a woman who is bleeding heavily immediately following birth does not want to engage in a long conversation about her ‘choices’ regarding the administration of an oxytocic. She trusts the midwife’s expertise in acting swiftly and appropriately in the interest of safety. However, making professional judgements does not give midwives licence to deny women choices or to make decisions on their behalf under the guise of ‘professional judgement’. Partnership requires each midwife and each woman to clarify their expectations of each other, to understand the philosophical base from which each works and to work out together the limits and extent of decision-making processes.
Partnership is linked to continuity of care because it takes time for midwives and women to get to know each other, to trust each other, to clarify and negotiate expectations (Pairman 2006). The best place for these discussions to occur, at least initially, is in the woman’s home, where she is comfortable and the midwife is a guest. Working in partnership means working in a relationship where the power balance between the partners is equalised and negotiated. When midwives visit women in their homes for the booking visit, there is a subtle shift of power to the woman, and midwives and women can get to know each other on a more personal level in an environment that is familiar to the woman. Generally, women feel more confident in sharing information and thus the midwife is able to get a sense of what matters to the woman as well as her social context.
Subsequent visits can be negotiated according to both the woman’s and the midwife’s situations. There may be value in most of these being at the midwife’s practice premises if this means that the woman will be able to meet other pregnant women and attend antenatal groups; however, there may be reasons why it suits both for all antenatal care to take place in the woman’s home. Either way, as identified in Chapter 19, there are many benefits when the midwife carries out a visit in late pregnancy to bring together the woman’s supporters and plan for labour and the early postnatal period (Kemp & Sandall 2010). The woman identifies the people in her family/whānau and community who will play a role in her experience of labour, birth and mothering and, where appropriate, the midwife can facilitate situations that ensure these support structures thrive. She can talk through likely events and how the woman might react to them, and enable time to discuss everyone’s roles and expectations.
The value of midwives facilitating groups as opposed to running classes is also discussed in Chapter 19. This approach is about a social model of midwifery care, one that sees bringing women together in groups as a crucial strategy to develop a forum where they can learn from each other and develop friendships and support networks (Leap 1991). As suggested by Mavis Kirkham, ‘linking women with others makes them stronger’ (Kirkham 1986, p 47). Where the focus of antenatal groups is on antenatal care as well as education and support, significant improvements in outcomes have been identified in disadvantaged communities in the United States (Ickovics et al 2003, 2007; Schindler Rising 1998).
Where midwives work in partnership with women, they tend to develop a different attitude towards how maternity records are developed and kept. This includes encouraging the woman to write in her notes, using woman-friendly, descriptive language, avoiding alienating abbreviations and enabling the woman to keep a copy of the record when the midwifery partnership ends approximately six weeks after the baby’s birth. Anecdotal evidence suggests that women cherish the record of their pregnancy, labour and the early weeks following birth, particularly where a story has been told using language that does not shy away from emotions.
During pregnancy, women can record how they felt at each stage of their pregnancy when the record stays with the woman rather than with the caregiver or institution. The concept of ‘woman-held’ maternity records is increasingly being seen as an important principle in maternity care and is a fundamental component of the midwifery partnership model. However, there is still resistance to their use in some quarters where midwives are employed, and therefore an overview of the evidence relating to this subject may prove useful.
Woman-held maternity records are popular with women and are widely used in New Zealand (Hendry 2003) and the United Kingdom (Hart et al 2003). In Australia, although their use has been encouraged by government policy (NHMRC 1996; NSW Health Department 2000), widespread introduction has been relatively slow. Freedom of information, access to and ownership of medical records are current and controversial issues in Australia, and the debate provokes emotional responses (Phipps 2001