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AUTONOMY AT WHAT PRICE? ISSUES AND EVIDENCE Georgie Stamp, RM, RN Student Master of Science (Primary Health Care) Flinders University ACMI, Midwife Researcher Queen Victoria Hospital, Adelaide Visiting Midwife Queen Victoria Hospital and Queen Elizabeth Hospital, South Australia Homebirtb Midwife Maggie Haertscb , RM, RN, Grad .Dip.Hsc. (Newcastle) ACMI, Lecturer Midwifery & Women 's Health Homebirth Midwife, Hunter Valley Visiting Miduiife, john Hunter Hospital, Newcastle
Abstract A discussion ofthe meaning ofautonomy in relation to midwifery practice isfollowed by an outline ofsome of the issues that may arise for midwives undertaking a more autonomous role. It is proposed that in addition to basic competency, effective practice demands a clear understanding of the implications of the findings of research and that an ability to aI/ow evidence to guide practice is essential for the midtoifery profession to advance. Effective research methodology is described. Midwives are encouraged to undertake research and add their work to an increasing body of midunfery research of which some examples are presented.
Introduction It is generally believed that autonomy is a key concept that will lead to the self determination of Australian midwifery practice. Autonomy literally translates as self government. In relation to midwifery practice, it could be argued that the meaning of autonomy lies in the community of midwives as a collective governing the profession. There are two levels of self government: that as an individual, and that as a member of a defined group. We have identified some characteristics of self government: the ability to take responsibility; the ability to be accountable; and the right to make decisions. This paper will address each of these characteristics and draw on some issues and evidence for midwives as individuals to challenge their practice and understand the consequences for autonomous practice and its relationship with midwifery as a profession. Why isautonomy an issue for midwives? Both midwives and women have wanted to have a greater role in the birthing experience, but there are a number of other issues that have been pushing midwifery PAGE 28
practice into the larger picture. These include a decreasing number of obstetricians willing to practise, fewer general practitioner obstetricians, professional indemnity insurance costs, litigation stress, international role models of midwifery practice, experimental forms of care being trialled such as team midwifery, publicly funded homebirth services, as well as in a global recession, the relatively lower costs of midwifery care. There have been a number of statements on an expanded role of midwives. This has been evident in State maternity services reviews (Health Department NSW 1989, Health Department WA 1990 and Health Department Victoria 1990), the National Health & Medical Research Council guidelines on homebirth (NHMRC 1992),the Ioint Birth Consultative Committee (Birth 2000,1991), AustralianCollege of Midwives Accreditation (ACMI 1990) and the move of midwifery education from hospitals to universities. Midwives, whether they like it or not, are having to take on increasing responsibility. There is already a variety of examples of midwifery practice that involve increasing levels of autonomy. Such practices may or may not be effective in providing the best possible care for women and babies. It is one thing to have the power to make and act on decisions, but how are those decisions made, and on what basis?
Issues Midwives are now in the fortunate position of being able to access an increasing body of research evidence. This evidence is, and should continue to have, a considerable effect on practice. University education and training for midwifery education is enabling a growing number of midwives to conduct their own research. Research
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of that collaboration was the publication of what is affectionately known as ECPC, or Effective Care in Pregnancy & Childbirth (Chalmers et al, 1989). Many midwives have their copy of the Guide to Effective Care in Pregnancy and Childbirth (Chalmers et at, 1989) which is a summary of the findings of the larger reference work (ECPC). Produced at the same time was the twice yearly updated electronic database, the Oxford Database of Perinatal Trials (DDPT). This has now been superseded by the Cochrane Collaboration Pregnancy & Childbirth Module (CCPC, 1993). The neonatal equivalent, Effective Care in the Newborn, was published last year (Sinclair and Bracken , 1992).
can be exciting and fulfilling, but there are a number of pitfalls. Qualitative research, much favoured by nurses and many midwives can lead to research questions warranting further investigation. It does not however, produce generalisable results nor give clear answers about the advantages and disadvantages of different forms ofcare to guide practice. The randomised controlled trial (RCT) is the most powerful means of ascertaining small but significant differences between forms of care, helping reach decisions about the balance between risks and benefits involved. Qualitative methods have an important place in ascertaining how birthing women feel about the forms of care they receive, indeed, Oakley (1993) states this should be an essential component of any trial.
The USPreventive TaskForce (Fischer, 1989) placed methods of assessment less subject to bias and misinterpretation in rank order as follows: • • • • • • •
randomised controlled trials non randomised controlled trials cohort studies comparisons between time and place uncontrolled experiments descriptive studies expert opinion.
Expert opinion comes last, and faith in it is by no means confined to the medical profession. Midwives can be very convinced that we 'know', often stating that research is not needed to support what may be a particularly strongly held belief. Afrequent criticism, when establishing a trial, relates to the ethics of random allocation ofdifferent forms of care. However, unless clear evidence exists to support a particular form of care, it may be unethical to promote it. In midwifery, many practices that were uncritically accepted have now been abandoned. Routine shaving (Romney 1981) and enemas (Drayton & Rees, 1989) are examples. In the UK in the 1970s, three obstetricians became concerned that obstetrics was full of practices that had never been subjected to systematic review. Contacting 40,000 obstetricians and paediatricians in eighteen different countries seeking published and unpublished studies going back to the 1950s, they established the National Perinatal Epidemiology Unit (Chalmers , Enkin & Keirse, 1989). The result MARCH 199 4
Research findings challenge practice. There are a number of studies where the findings may be contrary to popular belief or may be plausible but conflict with a practitioner's ideology and therefore not be considered. Such examples are active as opposed to conservative management of the third stage of labour to reduce the incidence of postpartum haemorrhage and external cephalic version at term to reduce the incidence of breech births. With some forms of care there are clearly improved outcomes, such as support from care-givers during childbirth. Other forms of care should be ceased as the research concludes that they provide no benefit to women or their babies. Examples are the routine weighing of all women antenatallyand doctors being involved in the care of all pregnant women during pregnancy. As we know, these forms of care are still very much part of current practice (CCPC 1993). There are also forms of care where the implications for improved outcomes are not clear and further research is needed, such as symphysis-fundal height measurements to detect abnormal fetal growth, active as opposed to conservative management of pre-labour rupture of membranes at term, elective caesarean section for breech presentation at term and intensive postnatal pelvic floor exercises. This information is vital when providing women with information to enable them to make informed decisions (CCPC 1993). The challenge for all health care practitioners, but for midwives specifically, is the danger of being selective about research findings to support individual practice. One example could be the homebirth
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midwife accepting the finding that doctors should not be involved in routine care during pregnancy, whilst not acknowledging the evidence ofthe benefits of prophylactic oxytocics for third stage of labour.
Summary Autonomous practice needs research as its essential component. Unlesscare is based on sound research, then the foundations on which decisions are made will be weak, possibly ineffective and may even cause harm . In areas where there is littleor no research, midwives can initiate such projects, gaining skills in using the most powerful of research methodologies. Midwifery is not about territorial struggles, it is about actively participating in the improvement of health outcomes for women, babies and their families. Women hear many conflicting views about what is safe in childbirth, which leaves them not knowing who to believe, and often not happy with the care they are being offered and which they feel forced to accept. Maternity services should be centred about women and their babies, not around the caregivers. (Homebirth Australia 1992)
References Australian College of Midwives Inc. (1990) Accreditation of Independently Practising Midwives. ACMI. Chalmers I, Enkin Mand Keirse MJNC (1989)Effective Care in Pregnancy & Childbirth. Oxford University Press, Oxford, UK. Chalmers I, Enkin M and Keirse MJNC (1989) Guide to Effective Care in Pregnancy & Childbirth. Oxford University Press, Oxford, UK.
Cochrane Collection: Pregnancy & Childbirth (1993)Update Software Ltd, Manor Cottage , Little Milton, Oxford, UK. Drayton Sand Rees C (1989)Is anyone out there still giving enemas? In Midwives, Research & Childbirth l. 139-53. (Eds, Robinson S and Thompson AM). Fischer M(Ed)(1989) Guide to Clinical Preventive Services: An Assessment of Effectivenes s of 169 Intervention. Report of the US Task Force. Williams & Wilkin s, Baltimore, p25. Health Department of NSW (1989) Review of Obstetric Services. Health Department of Victoria (1990) Having a baby in Victoria - Final report of the Ministerial Review of Birthing Service in Victoria (Chair J Lumley). Health Department of Western Australia(1990)Report ofthe Ministerial Task Force to Review Obstetric Neonatal & Gynaecological Services in Western Australia (Cha ir CA Michael). National Health & Medical Research Council (1992) Homebirth guidelines for parents. NHMRC, Canberra ACT. Homebirth Australia(1992)Better Cooperation Saves Lives. Press release 7th October. Homebirth Australia Inc. PO Box 198, Maitland 2323 . Joint Birth Consultative Committee of the Royal College of Obstetricians and Gynaecologists, the Royal Australian College of General Practitioners and the Australian College of Midwives Inc. OBCe 1991)Birth 2000, Who will deliverthe women oftomorrow? Dallas Brooks Hall, Melbourne 23 August. Oakley A(1992)Perspectives ofthe users of the services.lnt J Techno/ Assess in Health Care. 8, Suppll. 112-22. Oxford Database of Perinatal Trials (1992) (Eds Chalmers 1, Enkin M and Keirse MJNC). Oxford University Press, Oxford, UK. Romney ML (1980) Pre-delivery shaving: An unjustified assault ?] Obstet Gyneco/. 1,33-5. Sinclair JC and Bracken MB (1992) Effective Care of tbe Newborn. Oxford University Press.
MOVING TO NEW PREMISES The Australian College of Midwives' National Office will be moving to:
Suite 23, 431 St Kilda Road, Melbourne Victoria 3004 March 28th, 1994.