Being with women with risk: the referral and consultation practices and attitudes of New Zealand midwives.
The management of risk continues to be a critical part of contemporary midwives' work and there are certainly challenges as midwives attempt to work a 'birth is normal' paradigm within a 'birth is risky' social and political context (Skinner, 2003). Risk, as it is currently expressed, has been seen by some as a social construct to increase surveillance (Heyman, 1998). In the case of maternity care this relates to the surveillance of midwives and by midwives. Others have seen the risk environment as a product of the anxiety related to late modernity, and to the not-always-positive effects of technology (Beck, 1999; Douglas,1992; Lupton, 1999). However it is understood, midwives and consumers of midwifery care are both influenced by global and local anxieties associated with the management of risk. Midwives have the double-edged task of identifying and managing risk, while at the same time supporting the normal and promoting anxiety-free birth (Scamell, 2011).
The place where risk in practice is most apparent is in the referral for obstetric consultation. It is here where risk is most clearly identified and where the midwives' actions and attitudes to risk can be made explicit. This paper presents part of a piece of research that looked at how midwives managed or made sense of risk by exploring their referral for obstetric consultation practices and attitudes. Other findings are reported elsewhere (Skinner, 2010; Skinner & Foureur, 2010). This research is particularly pertinent in New Zealand where 85% of New Zealand women have midwifery-led care. It also has current relevance as the New Zealand Government is in the process of a Maternity Quality Initiative (Ministry of Health, 2011a). Part of this initiative has been a review of the referral for obstetric consultation guidelines. Interestingly, the new reviewed guidelines, now called Guidelines for Consultation with Obstetric and Related Medical Services (Ministry of Health, 2011b) have not been changed significantly. They reiterate the centrality of women in the decisions regarding referral and the importance of three-way communication between woman, midwife and obstetrician. They also contain updated information related to conditions requiring referral and introduce a change in referral categories to clarify process. The guidelines remain fundamentally the same, reflecting an opinion that they have provided a useful tool that has served the maternity sector well, since their introduction in 1996.
This research sought to examine how midwives referred when using the referral guidelines. It asked firstly what the referral practices were, and then asked midwives about how they experienced the referral guidelines. Did they, in fact, provide useful guidance and what impact did they have on the 'with women'-ness of midwifery?
The research took a mixed method approach. Firstly, a total population survey of Lead Maternity Carer (LMC) midwives was undertaken. The midwives were identified from data obtained from the New Zealand College of Midwives database, District Health Boards, telephone books, websites and local contacts. The postal questionnaire was extensive and asked for: demographic data of the midwives, and the numbers of, and reasons for, obstetric consultations over a 4 month period. The questionnaire asked the midwives to state whether they had continued to provide care when transfer of clinical responsibility had occurred. It also contained ten Likert-scaled, attitudinal measures which included questions about the midwives' attitudes to the referral guidelines, to the nature of the collaborative relationships, and to the risk environment. The survey population included both LMC midwives who were self employed and those midwives working in LMC models but employed by District Health Boards or in primary health care services. After it was pretested, the questionnaire was sent to 649 midwives. There was a 56.5% response rate. Those midwives who responded were identified as being representative of New Zealand LMC midwives by demographic characteristics and by regional distribution when compared with data from the New Zealand workforce statistics (Health Information Service, 2001). The data were entered into SPSS and analysed using descriptive and co relational statistics.
Once preliminary analysis of the survey data had occurred, six focus groups were conducted in a variety of New Zealand settings. Two were held in rural and four in urban settings. Four groups were in the North Island and two in the South. The locations were also chosen to reflect difference in the quality of the collaborative relationships, according to the preliminary analysis of the survey data. Midwives volunteered to participate in the focus groups either by indicating their interest on the returned questionnaire, or by invitation from local contacts. In total 32 midwives participated in the discussions. The point of the group discussions was to gain a more in-depth understanding of the midwives' experiences of the interface between primary and secondary maternity care, and thus to reveal how midwives managed risk in their practice, both the women's risk and their own risk. The focus group data were analysed thematically, taking a content analysis approach. The research was completed in 2005. Ethical approval was granted by the New Zealand National Health Ethics Committee and the Human Ethics Committee of Victoria University of Wellington.
Over the 4 month period in which the data were collected, the 311 midwives who completed the questionnaire cared for 4,251 women. Thirty five percent (1,477) of these women had a consultation with an obstetrician at some stage during their childbearing process. The ages of the referred women ranged from 14 to 46 years. Most were European but 16.7% were Maori. Approximately one-third of the women were having their first baby and one-third, their second (Table 1). In general, the women who required a consultation were representative of the total childbearing population.
Data on episode of referral were obtained from 1408 women. The episodes for which referral was identified were divided up into antenatal, labour/birth (intrapartum) and postnatal. Two thirds were one off referrals, referred in only one episode and a third had referrals in more than one episode. Two and a half percent were referred for obstetric consultation in all three episodes. The most common stage of pregnancy in which a referral for obstetric consultation took place was in the antenatal period. When all referrals were considered 70% (986) of referred women had an antenatal consultation (Table 2). Women who had obstetric consultations in more than one period, had them mostly in the antenatal and intrapartum periods (29.4%).
Where there was an antenatal consultation, the midwife accompanied the woman to the first consultation in 40% of cases. This was most likely to happen where the referral was made to an obstetric team, rather than to a known obstetrician, and least likely where the visit was to a private obstetrician.
The reasons for antenatal referrals were numerous (Figure 1). The question of 'reason for referral' was a multiple response question so the midwives were asked to provide as many reasons as they felt were appropriate. In the antenatal period no reason for referral was provided in 20 cases and thus was classified as missing data. Ten of the referrals had two reasons, and in six cases of referral there were three reasons provided.
The most common reasons for antenatal referral were pre-existing medical conditions and 'other'. There were also many referrals for prolonged pregnancy. The large number of referrals for 'other' was expected, as most existing referral and admission databases have a very high rate in this category, reflecting the variety of possible complications of pregnancy that can occur (New Zealand Health Information Service, 2003; Wallace et al., 1995).
Eight hundred and eleven (57%) of the referrals occurred in the intrapartum period. As with the antenatal period, the reasons for referral were numerous and there was also a large number of referrals for 'other' (Figure 2). There was a significant number of referrals for fetal distress. However, most intrapartum referrals were made for lack of progress.
Of the 1477 women who had a consultation in any period, 43% (608) had the clinical responsibility for their care transferred to the obstetrician. Once transfer of clinical responsibility had occurred, 74% (415) of these 'transferred' women continued to have some midwifery care provided by their LMC midwife (Figure 3). In 26% (108) of cases the midwives who continued care received no payment. One hundred and forty nine women had no ongoing care with their midwife. This represents 10.4% (147) of all the women who had referrals for obstetric consultation and 3.5% of the total caseload of the midwives. Ninety six percent of women cared for by this group of midwives therefore, maintained contact with, and received some midwifery care from, their original LMC midwife through the childbearing process, regardless of their level of risk (Skinner, 2010). When asked about the usefulness of the referral guidelines most midwives responded that they were a useful tool (Figure 4).
This practice of staying 'with women' despite the level of risk was reflected in the answer to the attitudinal question which asked whether LMC midwives should care only for low risk women. Seventy percent of the midwives disagreed with this statement (Figure 5). Thirteen percent neither agreed nor disagreed.
The survey revealed that midwives, despite there being identified risk factors in women and transfer of clinical responsibility, continued to have a strong commitment to being with women. They were frequently present at the first antenatal consultation, and continued the midwifery component of care once obstetric care was required. They overwhelmingly disagreed with the statement that LMC midwives should care only for low risk women.
The focus groups
The focus group data confirmed this finding. Throughout the conversations the woman was seen as central in the provision of care. Of the four core themes that emerged, the central theme--from which the others emanated--was named 'being with women'. The other three themes provided support for the midwives as they focused on meeting women's needs. They are named 'working as a professional', 'working the system' and 'working with complexity'. An in-depth discussion of these three themes is reported elsewhere (Skinner, 2010). Being 'with women' then remained the focus of the midwives' work and they went to some effort in order to support and be alongside her on the journey into motherhood, whether or not she required obstetric assistance. The discussions were heavily laden with stories from practice, connecting the midwives with the women for whom they cared. The real, complex, and challenging work of meeting the needs of the women was seen as paramount. Many women were seen as having some degree of complexity where attention to risk was needed, whether or not a referral was required.
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This central theme was broken down into three subthemes: 'holistic care--being their anchor', 'having a relationship--continuity and trust' and 'informing choice and communicating risk--things can change'.
Holistic care--being their anchor'
The midwives had an holistic view of the woman rather that compartmentalising her into a low risk or high risk 'case'. As these discussions proceeded, the issues that the midwives raised were often pertinent to all women no matter how their risk status might have been identified. However, when women developed risk characteristics, rather than seeing this as an impediment to their continued participation, most of the midwives saw that their input was even more important.
My suspicion is that for the woman to have the midwives with them, there's still aspects of their care that are normal for them and so those things in a crisis situation can get lost. That there's someone there who, even though decisions have to be made really quickly, that person is still capable of what they can decide. And I think if the midwife's there, then for the woman there's more of a 'well how can we do this that it's best for the woman?' (Mary)
Having a relationship--'continuity and trust'
For many of the midwives trust was a central part of the relationship that they established with the women over the time they got to know them. This relationship was seen as even more important when risks were identified
I would also say that in high-risk women, often the risk is minimised by that continuity and trust and they are so much more relaxed. So you actually can often alleviate some of the symptoms and side effects. (Fran)
Yeah, and it can be that emergency response or it can be that anticipation of guiding them in a different direction and helping them to make those decisions. And they trust you to do that because we've worked with them through their pregnancy. (Patti,)
The midwives valued the relationships that they developed with the women. They did see, however, that the risk environment threatened the development of the trusting relationship and distanced them from the woman.
And I was saying at a meeting the other day, my midwifery's changed from the early nineties to now. I see myself as in a much more risk situation in the relationship with the client than I did when I first started going to home births, where that relationship was really close and trusting and very friendly and warm. And now I feel like I'm removed because I'm protecting myself really with more documentation, more knowledge of what can go wrong and what has gone wrong for other midwives. (Fran)
Within practice, apart from being affected by the risk environment, midwives also had to establish relationships knowing that partnership, where it existed, was tentative and where trust did not exist, risk was increased.
Informing choice and communicating risk--'things can change'
The way the midwives in the study provided information and support for the choices that women made in relation to risk, acknowledged and incorporated a value-laden approach to risk. It seemed that the connection that the midwives had made with the women and their families, facilitated decision-making that was more related to how the women perceived the problem and could understand risk, rather than being focused primarily on the scientific evidence. The following excerpt, related to the decision about whether to give Vitamin K to the baby at a birth, is typical of the way many of the midwives spoke:
I often ask them about their decision-making processes and how they make decisions in their ordinary life and how they might make decisions as parents and that this actually may be one of the first ones that they will be making. And whether they like to make decisions that are based on research or decisions that are based on their life philosophy or decisions that are based on doing something to protect their baby, or doing something that is perceived to be seen as protecting your baby, or not doing something that is seen to be protecting their baby. (Pat)
And of course there are some that will say 'oh I don't care, you know, do what you think'. Most people do. With most people it's quite common (Marg)
'What would you do or what have you done?' That's what I get often. (Jo)
None of the midwives in the groups mentioned that they provided a statistical indication of risk as a matter of course. They seemed more concerned about reducing anxiety and fear in the mothers and tended to avoid using the word 'risk' at all. They often seemed protective of the women, yet at the same time viewed the woman's choice rather than the midwives' choice as both pivotal and final. There was some tension therefore between protecting the mother and informed choice, and there was clearly an understanding that risk decision-making on the part of the women was not necessarily rational.
It's difficult though because if you dwell too much on that and they're an anxious person it's going to be very counterproductive. That's the problem. Sometimes too, like, in say a primip wanting a home birth. They'll say things like 'so what would make you have to go to hospital?' And that's sort of like an opportunity to talk about the kind of things they want to experience. (Patsy) But I don't always think that we actually use the word risk. I always find myself using words that take it away from increasing fear into saying 'this could change from what you wanted it to be'. (Yvonne)
In their dealings with women, the midwives seemed to take on the role of mediating risk. They were, in a sense, attempting to protect the women from anxieties associated with risk, avoiding the use of the word. It was paramount that women should approach childbirth with confidence rather than with fear. It was important to develop trusting relationships, and for the woman to have confidence in the midwife's decisions. In protecting the woman from anxiety they therefore tended to take on risk themselves.
There are two important findings of this research, both of which have implications about what should be retained and protected as fundamental midwifery values. The first is that midwifery, as practised in New Zealand, is not about caring only for low risk women, but about being with all women as they give birth. The survey revealed that 35% of women required a referral for obstetric consultation for a variety of reasons most of which were one-off consultations. However, when there was a need to transfer clinical responsibility, the majority of the midwives continued to provide some midwifery care. In their discussions about risk, the midwives did not distinguish between their attitudes to women with different risk diagnoses. This has not been explored in any other midwifery literature, and may well be unique to the way New Zealand midwives provide continuity. The second finding is that this belief in continuing care, even when risk was identified, was based in the relational nature of midwifery. The 'being with' was revealed not only in how the midwives spoke about practice but was also revealed in how they acted. Being 'with women' is clearly not mere rhetoric but is acted out in practice. The recently updated referral guidelines, continue to support continuity of maternity care and women-centeredness, but some consideration needs to be given to the continued ability and/ or commitment of LMC midwives to stay and work closely 'with women with risk'. This research was completed in 2005 and provides a snapshot of midwifery's position and practice at that time. It is suggestive of midwives being highly committed to being with women despite the identification of risk. The question must be posed as to how the next generation of midwives will feel about being so closely involved with women with risk. As we acknowledge a growing body of knowledge identifying the challenges of working this demanding model (Cox & Smythe, 2011; Wakelin &Skinner, 2007), and the continued pressure of accountability, we need to keep attentive to: if and how midwives might be shifting in this way of working and how best to provide care in ways which sustain midwives to be able to do this.
Strengths and Limitations
This research provides strong evidence of midwives' commitment to being with all women as they make the transition to new motherhood, despite the level of risk. Both the high response rate and the mixed method nature of the study, added validity. However, the study did not examine the attitudes of core midwives towards: the referral guidelines, continuity of midwifery care, or the extent to which they can support the LMC model. Additionally it did not explore the processes of consultation and referral. Further research needs to be undertaken both into how today's LMC midwives are faring in managing to stay with women with risk, and how best to support collaboration. Further work needs to examine how the current model of care works collaboratively, exploring how midwives in all settings--LMC midwives, core midwives, managers and educators--support each otherwhen the women in their care are experiencing complexity.
Midwives face considerable challenge in working the balance between the normality and the riskiness of childbirth. The risk context in which they work puts pressure on them, both to support the normal process and identify and act on risk, both at the same time. There is often a fine line which can be difficult to discern. What the midwives do manage to do is to keep women at the centre of care. They demonstrate this in the extent to which they stay involved when women's care becomes complex. In order for our community to support midwives to continue to do this in the future, attention needs to be paid to ways that facilitate this. The referral guidelines have been one such support mechanism and the revised guidelines continue to do this. They support midwives and the midwifery profession to identify risk and to refer appropriately. We need to ensure that they are used thoughtfully and collaboratively.
Accepted for publication September 2011
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* Joan Skinner, PhD, MA (Applied), RM Senior Lecturer
Graduate School of Nursing, Midwifery and Health
Victoria University of Wellington
Table 1: Demographic data of women referred to obstetric consultation. N * % Mean SD Range 95%CI Age 1387 100.0 28.8 6.0 14-46 28.5, 29.1 European 1012 71.7 69.3, 74.1 Maori 236 16.7 14.7, 18.7 Pacific 70 5.0 3.8, 6.2 Asian 56 4.0 3, 5 Other 22 1.6 0.9, 3.3 Parity 0 474 34.1 31.6, 36.6 1 466 33.5 31, 36 2 270 19.4 17.3, 21.5 3 98 7.1 5.7, 8.5 >3 82 5.9 4.6, 7.2 Table 2: Numbers of women referred according to childbearing episode. Childbearing episodes in Number % (95%CI) which women were referred Antenatal only 516 36.6% (43,39.2) Intrapartum only 383 27.3% (24.5,30.1) Postpartum only 22 1.5% (0.9, 2.1) Antenatal and intrapartum 411 29.4% (27,31.8) Antenatal and postpartum 23 1.5% (0.9, 22.1) Intrapartum and postpartum 17 1.2% (06, 1.8) All three episodes 36 2.5% (1.7, 3.3) Total 1408