You can download a pdf copy of the report here. The full report is published below.
Proposal Title: “Unpacking Complications: Midwifery Care for Pregnant Women with Presumed Risk”
Host Institution: Preston Birth Centre, Lancashire Teaching Hospitals, England
by Iloana Neshkova
Visiting the Preston Birth Centre on the STSM grant provided me with first-hand observations on the two key ingredients for good outcomes in maternity services – thoughtful organisation of midwifery care and strong midwifery leadership.
The proposal to the STSM committee entailed a comparative study between the stringent and subjective understanding of complications in pregnancy that we have in Bulgaria and the regulated selection of risk as defined by the NICE guidelines and practiced at the Royal Preston Hospital. The concept of “presumed” risk appeared when Dr. Tracey Cooper visited the only autonomous midwifery practice in Bulgaria at the beginning of 2016. She was able to see many women with straightforward pregnancies who were pushed into “high-risk” categories due to the lack of evidence-based markers and unified guidelines for risk selection. The current report reflects on specific cases of straightforward pregnancies that would be treated as high-risk in Bulgaria and high-risk pregnancies which still benefit from the advantages of antenatal care led by midwives. While I do realize that the report may seem like it is stating the obvious for readers from countries where midwifery care is encouraged as a default option for all women, the nature of this investigation confronts two different systems and two modes of thinking about birth which are opposing but are offered to women at the same point in time.
Coming from a country where clinical guidelines for maternity services do not exist, witnessing the impact of the NICE guidelines on the provision of antenatal care was monumental. The NICE guidelines were mentioned countless times on a daily basis whenever midwives needed to reassure the expecting family that the pregnancy was going well or to refer the woman to another specialist if the problem exceeded the midwife’s scope of expertise. What Bulgarian care-providers are doing without unified algorithms resembles fumbling in the dark. It is unthinkable to provide quality midwifery care when medical professionals can’t even agree on what counts as anemia in pregnancy, or how to tell regular Braxton-Hicks contractions from those requiring the woman’s hospitalisation. Still, Bulgarian maternity services pride themselves on allowing every pregnant woman to have access to high-skilled care providers (obstetricians), even though our outcomes, whenever information about them leaks into media reports, show that we are doing poorly in comparison with countries where midwifery-led care is the norm. The NICE guidelines define clearly the safe pathway for every straightforward pregnancy and allow midwives to work confidently within the scope of expertise.
During my visit at the Preston Birth Centre, I was able to accompany several of the midwives during antenatal visits in the community clinics. Having midwifery care as the default for every woman’s pregnancy, straightforward or complicated, revealed a new working model with measurable benefits. Unfortunately, this model would not applicable unless Bulgarian women and medical professionals alike undergo a complete paradigm shift in their understanding of birth as a fact of life and not an emergency.
Several examples were particularly telling in the way that midwifery care is programmed as the default option in antenatal care. A woman in integrated care came in for her regular check-up after sixteen IVF procedures and six miscarriages. Another woman with GBS at 37 weeks of gestation was given advice to show up early in labour for antibiotic treatment in order to proceed safely with her natural birth. А woman ranking above the highest percentile in the expected birth weight of her child was reassured that her labour can start naturally in the birth centre, as her wish was to give birth there. Each of these women would be automatically scheduled for planned Cesareans in Bulgaria. By switching paradigms, however, one could see how each example proved that the default option for care during pregnancy with the most benefits for women was midwifery care and the default option for birth was normal birth.
Guidelines for clinical care alone would not suffice for this model to be successful. What was very noticeable during the antenatal visits was that midwives expect a tremendous amount of input from women. Women receive information regarding each step of the pregnancy when decisions ought to be made and the assumption is that at the next antenatal visit they have made up their mind to state their choice. Whether it concerns chromosomal abnormalities screening, iron supplements or place of birth, women are expected to choose after the benefits and risks are explained to them. What the vast majority of Bulgarian women expect from antenatal care is just the opposite – women here prefer clear directions on what decision is best for them to make. The general assumption is that pregnancy and the clinical thinking behind it is impermeable for people without a medical degree. Coupled with no unified national guidelines, the choices that women are making are entirely based on whatever their care-provider, the obstetrician, has prescribed for them. A good example of how much trust on women’s judgment is placed is the importance of women’s perception of fetal movements. CTG is only administered to women who report abnormal fetal movements; those who experience the normal frequency of fetal movements are automatically granted agency to decide for themselves that they need to be treated as low-risk – a concept which is very difficult to grasp in the Bulgarian context.
Another major link that builds trust between care providers and women is the concern that medical professionals express for the mental wellbeing of women during pregnancy. I attended the regular day-long classes geared toward upgrading midwives’ skills and one of the topics that received great attention was recognizing mental health issues. In addition to having a great support network to refer women experiencing depressive states, midwives are encouraged to acknowledge the seriousness of mental illnesses and to incorporate appropriate screening into their antenatal care. Another nuance was observing the midwives discuss the ability of women to assert themselves as competent mothers postpartum, to care for their babies autonomously and make decisions by themselves. The opposite would alert the midwife to refer the woman to get help.
Another critical piece of the picture was the role of midwifery leadership in the excellent outcomes of the Preston Birth Centre. The smooth operation of the unit would be difficult to achieve with evidence-based guidelines and excellent midwives alone. Four years ago, the birth centre had a much lower turnout of women and did not provide the services that are available today. The hospital Head of Midwifery and Consultant Midwife are two key figures who have spent much time and effort into creating a structure for the birth centre and the hospital that reflects the spirit of woman-focused care and the excellent practices as defined by evidence. The promoters of this spirit of midwifery care were able to produce a complex midwifery-led unit which offers continuity for women in all stages of maternity and reaches out to the community to promote the resources that are available to them.
To compare this enormous achievement at the hospital in Preston with what their situation would have been like if there had been no strong management, I visited two birth centres in Birmigham – an alongside and a freestanding unit. It was striking to see that the freestanding unit had all the amazing features that make a birth centre a comfortable, even luxurious place of birth, but was under threat of being closed down, as it was severely underused. The stylish, designer-made birth centre with a tranquil outside patio, huge birth pools and plenty of space for the whole family to room in after birth had no one to manage it well enough so that more women would take advantage of the excellent birth setting. As in any other venture, leadership is crucial to develop any project to flourish and reach its intended audience.
The management of the Preston Birth Centre pledged their commitment to our ongoing exchange in the future – we already made firm plans about hosting some of their midwives to help us out in Bulgaria and sending Bulgarian specialists to visit the Royal Preston Hospital. The Birth Centre shared several particularly helpful guidelines regarding antenatal care and birth with me. This will be particular helpful for the midwifery practice that I am running because in the next few months we are expanding our services. We have already started building a team of midwives and obstetricians who are going to offer antenatal and intrapartum care according to evidence-based guidelines. Our first attempt at running a midwifery-led unit requires a discussion of protocols and the STSM experience has given me an opportunity to share practical tips with the hospital management and to be confident in my vision. The Preston Birth Centre protocols will be adapted to our context but the general direction of this new project is in line with the spirit of continuity of midwifery that I witnessed.
The evolution of this exchange experience will be reflected in the upcoming Zebra Midwives project. Before Dr. Cooper’s visit and my subsequent travel to the centre where she is a consultant midwife, I was unable to materialize my visions of an integrated service which covers antenatal, intrapartum and postpartum care. It is precisely in the exchange of observations that possibilities for action emerge and the actions that we have taken up because of this fruitful exchange have been very real. The support of our hosts is invaluable and has allowed us to fast forward years of efforts which we thought would be spent in difficult struggles. The future birth centre which we are hoping to establish has a strong backbone before its launching because our STSM hosts believe in the power of international cooperation and will continue to provide their expertise in the face of adversity.