A spiral of change in Czech midwifery: turning full circle but one step higher: Zuzana Stromerova describes new legislation for midwives in the Czech Republic, the current challenges and an innovative educational course to help them fulfil their roles.

For midwives in the Czech Republic, 2004 has been a memorable year and maybe a turning point. In April a new law was adopted, which concerns the achievement of professional status for nonmedical healthcare providers. This law sets the conditions under which a midwife is allowed to work without medical supervision.

In May 2004, the Czech Republic became a member of the European Union (EU). This move will influence the life of many people in many directions. The practice of midwifery, will be influenced fundamentally. The EU respects midwives as autonomous care providers, experts in healthy childbirth. In contrast, in the Czech Republic, midwives have had quite a different role: for long years they have been perceived as doctors' assistants, or as nurses in deliver- theatres, who work under the guidance of the doctors. And in those long years midwives have accepted this role, although many of them felt it should be different. Because of this, we greatly appreciate the efforts of all those who participated in setting up the new regulation. Not only ministerial staff worked hard, but also consumers' and midwifery associations. This regulation specifies the activities and competencies of midwives and is very clear about the autonomous work of a midwife. With this regulation we have reached, in written form, the level of democratic EU countries.

But it is not always possible to harmonise theory and practice together immediately. Among those who were caught unawares were some of the midwives themselves: it seemed as if they did not know what to do with all the freedom! Now, according to the law, a midwife may provide care to healthy pregnant women; she is allowed to conduct a normal birth, in a setting the woman chooses. She can work as an independent care provider or be employed in a hospital or gynaecologist's office. Her activities and possibilities are broad.

This is all the good news. But what about the midwives themselves? Do they meet the women's needs and demands? The answer is: not yet. We still have a shortage of midwives who will work as community midwives, and will take complete responsibility for what they do or do not do. In the past few years, the situation for midwives has been dismal, with poor recognition in society, and poor co-operation between hospitals and community midwives. Can anything be done to bring midwives together again, to make them more self-confident and raise their self-esteem?

'A Midwife in the EU'--an innovative course for midwives in practice

The answer is: yes. To reinvigorate the midwifery" profession in the Czech Republic and to revive the traditional art of midwifery, the civic society Active Birth Centre, together with the public corporation Birth House At Stork's and Pegasus Zentrum (Germany), have organised seminars for midwives and interested obstetricians about out-of hospital care. We started in December 2002 and since that time, we have covered topics such as 'how to run a birth house successfully', 'safe out-of-hospital birth', 'risk at birth', and 'transferring theoretical knowledge into practice'. Eight seminars of this kind have all focused on practical skills, and all have been much appreciated by the participants.

A new idea arose after the Czech Republic joined the EU: let's make these seminars into a course! And so we have done. The new midwifery course is held in the a obstetric clinic in Prague in order to attract the interest of care providers from the Hospital in the out-of-hospital setting, as there needs to be good cooperation Between the two.

The aim of it is to deliver the almost forgotten wisdom, knowledge, skills and experience of the 'old', traditional midwives, whose main tools for providing quality care were their head, hands and (last but not least)--heart. This course should show midwives how to bind together theory" learned at school with real life. It is a first step to creating self-confident, knowledgeable and wise midwives.

Moves within the midwifery profession

The following analysis of the changes within midwifery is a description of what has happened in Czechoslovakia/the Czech Republic, but it may have similarities to the situation in other countries too, not only those from Eastern Europe. It can be called a 'spiral of change': the development starts at a certain point--and ends up at the same point, but one level higher. This model shows that the demand for natural birth without intervention is a step forwards, not backwards. Three significant stages over the last century were:

* Independent midwifery as the norm (up to the end of World War II): practitioners have very good midwifery skills and the art of midwifery is well accepted

* Centralisation of births into hospitals (from World War II to now): the art and independence of midwifery slowly dying out

* A return to independent midwifery (from now on ... )--the regaining of old skills on a higher level with better knowledge and an advanced technical background.

Threats to the midwifery profession

* Loss of traditional midwifery skills, owing to overuse of technology in obstetric and midwifery care and also sometimes to education curricula, which focus mainly on care provided by midwives in hospitals, with extansive use of technology.

* Dissension among midwives

* Public misunderstanding of the midwifery profession (midwife = nurse in gynaecologic or obstetric wards)

* Individuals' fears of all kinds, e.g. of knowledge and skills not being adequate, of responsibility for decisions, of losing one's job because of not following hospital policy

What can help?

* Good legislation, in accordance with EU regulations and demands (EEC 80/155)

* Good education (regular courses, postgraduate courses, additional courses, seminars)

* International co-operation

* Spreading information to the public

* Listening to the women, engaging with parents

* Honesty (to oneself, and to the clients)

A few months after accession to the EU, the Czech Republic has:

* a new legislative frame in force

* a change in the education of midwives to a three-year course at bachelor level

* the opportunity for midwives to work independently (without direction or supervision of obstetricians)

But there are still:

* health insurers refusing to make contracts with midwives: only payment for services demanded by the obstetrician or gynaecologist can be recovered from public health insurance

* difficulties for women who wish to find a midwife who will be able to offer a continuum of care during pregnancy, normal birth and posnatally

* There are no suitable places for practical training of independent community midwives.

The challenge is to revive and strengthen the traditional wisdom of midwives. The following steps are a suggestion for action:

Step 1: Search for successful models of midwifery practices in European countries, which would be worth spreading to other countries and which clearly work in favour of strengthening midwifery and support of natural birth. Search for teachers who would be able to teach about those models effectively

Step 2: Organise a meeting of directors or policymakers of those chosen practices and develop a strategy for dissemination of those models throughout the Europe

Step 3: Prepare a special international master's course in midwifery, for midwives carrying the midwifery torch on in their countries. Key subjects will be: causes and effects in obstetrics and midwifery; person-centred counselling; how to run a midwifery practice; communication midwife client, midwife-midwife, midwife other professions, midwife-authorities, e.g. government ministries and health insurance offices. (These should be basic subjects within regular midwifery education, but in the master's course, they will be covered in depth and with application to practice).

Step 4: Try to get financial support from EU funds in a framework of 'human resources' or 'sustainable development'.

'A midwife in the EU'--an innovative course.

The languages of the course are Czech and English--interpretation is provided.

The structure of the course comprises four four-day meetings during one year:

1. Complex prenatal midwifery care: diagnosis of pregnancy; documentation of own work; a midwife = social support + healthcare provider; practical--external examination : gestation of pregnancy, positioning of the baby, etc

2. The end of pregnancy, start of the labour: prolonged pregnancy; how to support a natural outset of the labour; how to read the contractions; practical--external examination: specification of the due date

3. Complications during natural birth: malpositioning; problems with the mother; problems with the baby; case study

4. Postnatal period up to one year; early postnatal time up to 10 days after the birth; puerperium; breastfeeding support from the EU perspective; a midwife = social support + healthcare provider

The main goals of the course are to:

1. Revive traditional midwifery knowledge and skills, and bring them into the practice of midwives in developed countries in the third millennium

2. Raise the awareness of the midwives: who they are as women, as citizens, as professionals

3. Find the connections between causes and effects in midwifery care

4. Help the midwives to find their own independent position as professionals who deliver high standard quality care to pregnant and birthing women, women in the postnatal period and to their families

Applications for this course can be sent to Zuzana Stromerova [e-mail]