Overgaard, Charlotte

English

    Aalborg UniversitetMidwives in ante and postnatal careEuropean experiencesOvergaard, CharlottePublication date:2018Document VersionAccepted author manuscript, peer reviewed versionLink to publication from Aalborg UniversityCitation for published version (APA):Overgaard, C. (2018). Midwives in ante and postnatal care: European experiences. Paper presented atPercorso nascita : 2° incontro: l’ostetrica dedicata alla gravidanza e al puerperio, Trento , Italy.General rightsCopyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright ownersand it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights.            ? Users may download and print one copy of any publication from the public portal for the purpose of private study or research.            ? You may not further distribute the material or use it for any profit-making activity or commercial gain            ? You may freely distribute the URL identifying the publication in the public portal ?Take down policyIf you believe that this document breaches copyright please contact us at vbn@aub.aau.dk providing details, and we will remove access tothe work immediately and investigate your claim.Downloaded from vbn.aau.dk on: August 24, 2021Midwives in ante and postnatal care- European experiencesTRENTO 20 Jan 2018 Charlotte OvergaardMidwife, MSc in Health Science,  PhDAssociate professor, maternal, child & family health.Public Health & EpidemiologyAalborg University, DenmarkContents of this talk Midwives in modern maternity care services:  Broading of the ante and post natal role of midwives Midwifery led care: what it is and how it compares to other models of care internationally Midwifery the Nordic and Danish way• Reorganising birth services: • Key issues in efficient, high quality care for women and families – continuity, competence, collaboration23Broadning of ante natal rolesAlthough there are HUGE variations, the field of midwifery is broadening and we now se midwives providing: Autonomous  antenatal care for low risk women including childbirth and parental education (some in private practice) Shared antenal care for high risk women Specialised shared care for  pregnant women with complex medical needs (twins, heart disease, diabetes ect. ) Counselling for eg. women with fear of childbirth Counselling couple with marial or sexual health problem Specialised shared care for pregnant women with complex psycho-social needs(vulnerable women)4Postnatally and other:Care in relation to women’s general health care needs related to their reproductive and sexual life circle • (contraception, screening – community based or employed by a general practitioner)• Shared care in antenatal hospital wards for women with complications• Ultrasound scans (after having sonographic training):• Rutine scans i relation to screening malformations (hospital)• Scans on indication (e.g. assessment of fetal growth)• Non-medically indicated scans for fetal wellbeing in private practice• Autonomous postnatal care for low risk women:• Familiy units in ”patient-hotels” • Who are early discharged from hospital• Private, midwifery led/owned post natal clinic• Freelance post partum councelling related tobreastfeeding, sexual health, family health (private practice)Why is this happening?5On the positive side:  more midwives have access to specialised / high level training and usetheir skills to improve health and wellbeing Greater awareness of midwive’s competencesOn the negative side:  In Denmark: care for low risk is reduced, care for vulnerable and high risk is increased and specialsed cut backs in the public budget: leaving women and new parents with care needs that areunattended by the public service.  Reducing public services to a level that is unacceptable to midwives(burnout and loss of public midwives)Facts in Danmark and many other European  Funding of public health care services are being cut – often 5 % reduction of budgets year after year.  Health care needs are not reduced: we must do more for less Services are being centralised and units are getting larger Lack of continuity (staff is moved around to fill gaps) Women often see different midwives (and doctors) during pregnancy  Discontinuity of care is associated with loss of information, less attention to patient needs, delay of appropriate action: concern for patient safety! The distribution of services is inequal and inappropriate: those most in need may get too little  others (especially in private obstetric-led care) may get more than is good for them (overuse where benefits does not outweigh harms) 6WHO recommandationsStrengten the use of midwivesand midwifery-led care 2020 strategi: ”Vital ressources for health”Important fundation for this is:  The Lancet 2014 series on Midwifery:1. Midwifery and quality care: findings from a new evidence-informedframework for maternal and newborn care. 2. The projected effect of scaling up midwifery. 3. Country experience with strengthening of health systems and deployment of midwives in countries with high maternal mortality. 4. Improvement of maternal and newborn health through midwifery.  A opdated Cochrane Review of randomised controlled trials of midwifery led care (Sandall et al. 2013)78Facilitationevidence-basedpracticein midwiferyin the whoeuropeanregion, 2015 Jylhaet alSo: there is a policy push for midwifery-led care- but what it that exactly?9A care model where:  a midwife is the lead professional in the planning, organization, and delivery of care throughout pregnancy, birth, and the postpartum periodMidwifery led care is NOT about pushing out obstetricians or providing ”loving” but unsafe care. A helpful focus may be:  ” Every woman needs a midwife, and some women need a doctor too”  ( Sandall 2013)How do midwifery-led continuity models of carecompare to medically-led or shared care?10Cochrane Review of  randomised, controlled trials show that:Women in midwifery-led continuity models compared to hospital-led care are: Less likely to experience: overall fetal/neonatal death preterm birth regional analgesia, episiotomy, and instrumental birth More likely to  experience spontaneous vaginal birth  feel in control during childbirth  initiate breastfeedingSignificant benefits for mothers and babies without showing any adverse effectsFurthermore, a cost-saving effect has been seen (may depend on heath care system).See: Sandall et all 2013 (Cochrane Review), Devane et al 2012. Midwifery the Nordic way11 Midwifery is a cultural and historical institution in the Nordic countries More than 300 years for  regulations for midwives Sweden 1711 Denmark & Norway 1714 Until recently (10-20 years ago): trained and examined by doctors/obstetricians (now an autonomous profession working independently within a set of regulations) In all Nordic countries: low level of interventions, low maternal and perinatal (<6/1000)  mortality Authorized by the state to provide autonomous care for women at low obstetric risk during pregnancy, birth and the post partum – in hospital and out of hospital Midwives may set up their own practice/clinic but most are employed at an obstetricunit Close interprofessional collaborationChildbirth in Denmark – a few facts A population of approx 5.000.000 people (the North Denmark Region approx. 500.000) Approx 60.000 births 3% home; 1% freestanding midwifery unit; 96% obstetric unit Perinatal mortality 6/1000; caesarean section 20% All childbirth and health care services are free (tax paid) >99% of women attend the Danish pregnancy program: ALL women have shared care in pregnancy between midwife (key professional, 4-7 visits) and general practitioner (3 visits)  All women offered pregnancy screening for fetal malformations:  2 scans – week 12 + week 20 and blood test.  NO RUTINE scans for fetal growth ONLY high risk women see an obstetrician (or specialised midwife) 12Midwifery in Denmark Trained in a 3.5 year direct-entrance Bsc. program (Danish midwives are not nurses) No routine use of cardiotocografi (CTG) during birth No obstetrician or paediatrician routinely present at/after birth  Midwives are authorised to independently: give medication to stop post partum bleeding give pain relief for and perform suturing of 1 + 2 degree perineal tears initiate resuscitation / emergency treatment of mother and child(no other prescriptions unless authorised by e.g. the obstetric head of department) Many midwives do antenatal care 1 day a week and labour ward 4 days Last 10 years: continuity models of care has come into focus13Why is continuity so important- Let’s get ”confortable” with the concept:14four forms of continuity exists – all vital to high quality care1) A stated staff commitment to a shared philosophy of care2) Continuous carer responsibility Same midwife all though birth – BUT she may care for two or more women at the same time3) Continuous midwifery support during labour A midwife is present with the woman all through birth –one to one care (but maybe not the same midwife)4) Continuity/“knownness” of carer (caseload midwifery) Care throughout pregnancy, labour, birth and the postnatal period is provided by same or a small group of 2-3 midwives15Caseload midwifery16Widely used in Denmark introduced small scale in almost all Danish obstetric units Introduced large scale in a few units (approx ensured for 1/3 af the women) One small obstetric unit is run exclusively by caseload groupIncluded in NICE guidelines from England and included in national policiesNot yet prioritised in Sweden – but there is a push for itNot the rule in Norway, but in rural / sparsely populated regions, the local midwife may: arrange transfer to hospital, do intrapartum care, transfer the low risk women back to provide post partum care in her home/a local clinic. What form is most important?No consensus in the literature on which aspect is most important - however strong evidence to support point 3 (continuous support) and 4 (known midwife). All four forms can – and should - be provided simultaneously:1. Shared care philosophy among staff2. Same midwife all through birth3. Continuous support/one-to-one care all though labour4. Known midwife: continuity of carer though pregnancy-birth-post partumA peek at preelimnary results from work in progress on the impactof continuity af intrapartum carer (please do not cite)18(removed from this public version of the presentation)Points for consideration in the reorganisation  of your maternity care servicesThe province of Trento is doing amazingly well in this process of change. Let med remind you - in times of change – and especially when changes include professional competences and roles: The chance of success is lower if several changes in organisational structures occur simultaneously.  Learnings from a Danish context and the literature: Be patient Be respectful, listen to arguments Good training of new competences is crucial, feedback and peer support Participate in joint training activites – read and discuss the same evidence Carry out interprofessional audit sessions  Continuity of care throughout pregnancy, birth and the post partum holds great potential for improvement of health and well-being among low risk women (and high risk women too..19Thank you for listening!Contact:Charlotte OvergaardEmail: co@hst.aau.dkPhone: 0045 2482 9815Public Health & EpidemiologyDepartment of Health Science & TechnologyAalborg University, DenmarkSelected references - midwifery led care:21 Sandall J. Every woman needs a midwife, and some women need a doctor too. Birth. 2012 Dec;39(4):323-6. doi: 10.1111/birt.12010. Epub 2012 Nov 5 Sandall J, Soltani H, Gates S, Shennan A, Devane D. Cochrane Database Syst Rev. Midwife-led continuity models versus other models of care for childbearing women.2013 Aug21;8:CD004667. doi: 10.1002/14651858.CD004667.pub3. Facilitating evidence-based practice in nursing and midwifery in the WHO European Region. Virpi Jylhä, Ashlee Oikarainen, Marja-Leena Perälä & Arja Holopainen. WHO 2015 Devane D, Brennan M, Begley C, et al. A Systematic Review, Meta-Analysis, Meta-Synthesis and Economic Analysis of Midwife-Led Models of Care. London: Royal College of Midwives, 2010.Introducing caseload midwifery: Burau V, Overgaard C. Caseload midwifery as organisational change: the interplay between professional and organisational projects in Denmark. BMC Pregnancy Childbirth. 2015 May 27;15:121. doi: 10.1186/s12884-015-0546-8. http://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-015-0546-8The Lancet series on Midwifery 201422An Executive summary:http://www.thelancet.com/pb/assets/raw/Lancet/stories/series/midwifery/midwifery_exec_summ.pdf Renfrew MJ, McFadden A, Bastos MH, et al. Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care. Lancet 2014; published online June 23. http://dx.doi.org/10.1016/S0140-6736(14)60789-3. Homer CSE, Friberg IK, Bastos Dias MA, et al. The projected effect of scaling up midwifery. Lancet 2014; published online June 23. http://dx.doi.org/10.1016/S0140-6736(14)60790-X Van Lerberghe W, Matthews Z, Achadi E, et al. Country experience with strengthening of healthsystems and deployment of midwives in countries with high maternal mortality. Lancet 2014; published online June 23. http://dx.doi.org/10.1016/S0140-6736(14)60919-3. ten Hoope-Bender P, de Bernis L, Campbell J, et al. Improvement of maternal and newborn health through midwifery. Lancet 2014; published online June 23. http://dx.doi.org/10.1016/S0140-6736(14)60930-2

Midwives in ante and postnatal care:European experiences

https://vbn.aau.dk/files/267906932/Trento_20Jan2018.pdf

Midwives in ante and postnatal care:European experiences

Abstract

Similar works

Full text

Available Versions

VBN