Defining and delivering core midwifery care: International Midwives Day is celebrated on May 5. In this article, a core midwife outlines her philosophy of care and argues the work she does is integral to the model of midwifery as a partnership.

CORE MIDWIVES are employed to provide care to women, who have either chosen to stay in a primary unit, or maternity hospital for postnatal care, or who require secondary care.

Three years ago, it was estimated that 93 percent of women having babies would come into contact with a core midwife durbig childbirth. (1) The term core midwife has evolved out of the changes brought about by the Nurses Amendment Act, 1990. With the passage of that Act, many colleagues left their positions as employed midwives to establish practice as independent midwives, later called lead maternity carers (LMCs). Core midwives make up 50.6 percent of the New Zealand midwifery workforce. (2) We are the constant midwifery presence for women in a maternity hospital or birthing unit.

Legally, midwives, whether employed or self employed, are covered by the same legislation. Core midwives are not directly funded under Section 88 of The New Zealand Public Health & Disability Act 2000, but it does impact on their practice. (3) The 1990 Amendment to the 1977 Nurses Act and associated Acts outline the requirements for registration as a midwife. (4)

Over the last decade, partnership has increasingly become the relationship midwives seek with the women they are caring for. This relationship has grown from an understanding by midwives of what women want from their maternity experience. The principle of partnership has consequently been accepted by midwifery's regulatory body, the Nursing Council [the Midwifery Council from later this year] and is identified as the essential principle in the competencies for entry to the register of midwives. (5)

The College of Midwives' philosophy and its Code of Ethics are the foundations for midwifery practice. (6) Standards of practice are grounded within the concept of partnership, which is described as: "the purposeful relationship between the midwife and the woman. It may be long or short term depending on the context in which the midwife works." (6)

The type of relationship we need to have with women is also clearly defined in the Health and Disability Commissioner Code of Consumers' Rights. (7) The Code gives New Zealanders the right to expect a partnership approach in their health care. It outlines the responsibilities of the health provider to ensure the consumer is treated with respect, dignity, support, without discrimination, coercion, harassment or exploitation and that care is informed and given with the consumer's consent.

Core midwives have been almost invisible in midwifery publications. Perhaps this is because of the difficulties we have encountered and the changes we have faced as a new maternity care service has evolved in New Zealand. One commentator has challenged us to recognise our important place in New Zealand's maternity system and to debate and define our role. She also said we were undervalued by ourselves and the profession. (1)

In response to this challenge, a group of Middlemore Hospital core midwives wrote about their feelings and questions, as Section 88 was about to change their role. (8) Up until that point, their practice had changed little, as many of the women who birthed at Middlemore Hospital had not had midwife LMCs. These midwives were about to face the changes in their practice, which other core midwives had been confronted with over the previous ten years. They were wondering about their future and what would happen to their expertise in keeping birth normal, as LMC midwives took over their role. Their questions and statements struck a familiar chord. The Middlemore midwives, along with commentator Norma Campbell, concluded that core midwives needed to define and debate their roles in maternity care.

I have spent time reflecting on how my midwifery practice has changed in 14 years since I trained. What forces and influences moulded me into the midwife I am today? One of the most profound influences were the changes brought about by the 1990 Amendment to the 1977 Nurses Act.

Those of us who decided to stay as employed midwives in maternity hospitals or units had to learn to work with independent midwives. These were our colleagues who had taken up the challenge to be self-employed. When women they were caring for were in hospital, we were expected to follow their care plan. This was new and different. Previously, all women had had a GP or an obstetrician as their main cater. The midwifery care had been our domain.

I can remember feeling distressed when a LMC midwife wrote a plan for breast feeding, which was not current practice and not evidence-based. There were many grey areas, which lead to confusion and sometimes ill feeling. Nobody really seemed to know what was happening and what the future would be for midwives who chose to remain employed in hospitals. Would all women choose to have their babies at home? How much were hospital midwives expected to do for women who chose to stay in after childbirth?

Secondary care

One area of our practice that did not change was our responsibility to women who required secondary care ante-natally or post-natally. I had always found this area of practice satisfying and was relieved it did not change. This is because the woman, as an inpatient, requires obstetrician care, her LMC provides social support and her midwifery care is provided by the core midwives. However, at Christchurch Women's Hospital we do call in the LMC midwife once labour is established, if this is requested.

As well as these profound changes in our practice environment, there were huge changes taking place in the wider health service. The first half of the 1990s were dominated by the so-called health "reforms". These changed our whole support structure, which in some cases disappeared. The funder/provider split added another complicated dimension to our working and professional environment. The health "reforms" sapped much of my energy. Health spending cuts meant we constantly had to work smarter and harder. A ward was closed and the fear of redundancy emerged. We had to fight very hard to maintain working conditions and, even so, saw some slide away. We were forced into planning, and sometimes taking, industrial action. Sometimes it felt as if our working world had been turned upside down.

Partnership model

But in 1995, I was excited about the publication of The Midwifery Partnership: A Model for Practice. (9) It described the partnership between LMC midwives and women. However, the authors, when describing this partnership, had not acknowledged the role of the core midwife in supporting the partnership. It appeared they thought there was only a need for independent midwives to provide midwifery care. In fact, the authors did not seem to think core midwives even practised midwifery, as we worked in a "supportive role to another health discipline". They qualified this further by excluding us from the midwifery partnership by stating: "They do not have the supporting structure of autonomy and continuity of care necessary to function within the midwifery partnership." (9)

These words did not help core midwives establish our place in New Zealand's new and evolving maternity system. However, although our role was changing, we were still needed. There were also mutterings that we were practising as obstetric nurses, not midwives, I now understand that when that model was written, independent midwifery was in its infancy. Perhaps it was envisaged women would not choose to stay in hospital post-natally, and that those requiring secondary care would be cared for by nurses, not midwives.

After nearly 14 years in practice, experiencing all the changes associated with an evolving maternity service, and witnessing some of the tensions this created, I can now confidently articulate the partnership I have with the women I care for. I aim to be "with" women, rather than in "control of' and I endeavour to care for them with respect and without discrimination, coercion, harassment or exploitation. I also do my best to ensure care is evidence-based and with informed consent.

I have worked as an employed LMC in the community, and know that in many ways the relationship with the women I care for as a core midwife is provided with the same intent as that of a LMC, no matter the duration of the encounter. I am responsible for setting the scene to enable an effective partnership, which will vary as I adapt to each individual woman's needs. I am also mindful of the differences as well. A woman does not choose me as her core midwife, I am assigned to her. I am very mindful I am entering an existing relation ship between the woman and her LMC and I respect that. I am supporting the partnership between the LMC midwife and the woman, and take care not to place myself in the middle, but in a supporting role, on the side.

Frequently I take over the care from a LMC midwife when a woman requires secondary care. If this is on the brink of an emergency caesarean, I am really asking the woman, her partner and the LMC midwife to trust me. I try very hard to be an advocate to ensure the woman and her partner are informed. But this can be difficult in emergency situations. During the two hours of post-caesarean recovery, i am encouraging early bonding between mother and baby and also ensuring post-operative safety. I also try to be as inconspicuous as possible during this special time. It is unrealistic to expect a woman to contemplate forming a partnership relationship with me under those circumstances. Some of the women I care for are so ill that they have no memory of my role in their care. I have visited a baby in the neonatal unit and had to introduce myself to the mother, despite having spent a very intense eight hours with her only a few days previously.

When practising midwifery, I aim to develop a purposeful and helping relationship with women, whether I provide care during the antenatal, labour and birth or postnatal periods.

When a woman requires secondary care because she and/or her baby is at risk, I am part of a multidisciplinary team. But this situation does not minimise that woman's right to have a midwife caring for her throughout this time. This care will be far more effective if the LMC and I can work together in supporting the woman, by sharing information and observations. If this does not happen, it is the woman who suffers, as conflicting information and lack of continuity of care can result.

I have worked at defining what it is I am trying to do as a core midwife. I have found on many occasions when I am saying goodbye, women will thank me for my help. I used to find that something of an understatement, but now, on reflection, I feel very positive about these words. If the woman thinks I have been helpful, I am happy. The kind of "help" I aim to provide is not that which needs to be reciprocated by the receiver, but the kind nursing writer Patricia Benner writes about. She observed the interactions between nurses and patients and recognised that patients expected and wanted a different type of help from nurses (midwives). (10) interpret Benner's helping as care, which provides information and assistance, and is given in a manner that does not take the power away from the woman, or leave her feeling obligated. I can apply Benner's model of nursing care to my midwifery practice. Many of the women I care for require a combination of my nursing and midwifery skills. I am finding that as birth technology increases, I am caring for women with some very complex medical conditions. Benner's emphasis is on the creation of a climate where psychological and physical healing can take place, while ensuring the presence with the client is "with" rather than "in control of". She also identifies help as "teaching and coaching". (10) I constantly assess a woman's learning needs and plan to provide her with the appropriate teaching and coaching.

To help define my practice as a core midwife I have reflected on my experiences, as New Zealand midwifery appeared to split into two camps, core and independent. I can relate the process I have been through to "emancipatory reflection". (11) This process has been described as a tool to "construct, deconstruct, confront and reconstruct" our practice. This process of reflection has enabled me to reconstruct what has happened during the last 14 years and understand how I have been affected. This process of emancipatory reflection 'also helps us interpret our "roles and social obligations" and leads to "transformative action". This action trees us from our oppression and enables us to move on, without the assumptions we were holding about ourselves, which is how practice become praxis.

Through this tool, I have come to a deeper understanding of my role and social obligations as a core midwife. I have also been freed from any oppression I experienced as a core midwife and am now able to articulate my partnership role in caring for women in childbirth.

This reflective process has helped me realise how important core midwives are. I am proud to be a core midwife. I hope that sharing some of my personal reflections will stimulate other core midwives to define and debate our role. I hope that identifying what has happened is not interpreted as dwelling on the past and the opening up old wounds. The evolution of core midwifery has not been easy--there has been change and pain and growth, personally and professionally. But I am now confident in my role and practice as a core midwife and know that I work in partnership with the women I care for.

I would like to see the Midwifery Partnership Model revised to include the core midwife in the relationship between the LMC midwife and woman. There is also a challenge for core midwives to develop a model that reflects our practice and relationship with the women we care for, and the midwives and other health professionals we work with, for the benefit of all the women we care for.

Moving to midwifery

FROM THE time she trained as a nurse at Christchurch Hospital in the mid-'60s, Beth Wynn-Williams knew she wanted to do midwifery. This desire was enhanced with the birth of her three children and involvement in child birth education when she and her family rived in Ontario, Canada in the late '70s,

But it was not until 1990 that family responsibilities were such that she could begin the year-long advanced diploma of nursing which, strangely enough, led to a midwifery qualification.

Wynn-Williams describes that year as akin to "jumping through a fiery hoop". It was the year of the momentous amendment to the Nurses Act which allowed autonomous midwifery practice. And it was a return to fulltime study.

Her first position as a midwife was in a post-natal ward at Christchurch Women's Hospital where women who used methadone during their pregnancy, and their babies, were cared for. "I worked there for a year and was absolutely bown away by the expertise of the midwives, Karitane and enrolled nurses in that ward. They were all so respectful and I saw how the women responded to that care and respect for them."

Since that position, she has worked in a variety of midwifery practice areas: delivery suite; other post-natal wards; as a community midwife; in the primary birthing unit at Lincoln Hospital, and as a research midwife for the paediatrics department of the School of Medicine. This role, which has just ended after three years, involved following up those children admitted to the neonatal unit at Christchurch Women's Hospital in 2001 at two years of age. The "Footprint Study" involves comparing these children's growth and development with a control group of children and involved 685 children. Wynn-Williams was involved in recruiting the children and in organisation of the study. "It is a fascinating study. As I was following up the children at age two, I listened to parentss' experiences about having a preterm or sick baby. It has made me realise how much they remember and appreciate the care. It made me feel proud of the care of children in the neonatal unit."

Not satisfed with taking on a new career in her '40s, Wynn-Williams is half way through a masters degree in her '50s. "I always want to learn more."

Throughout her careers, she has worked to support colleagues and has maintained her allegiance to NZNO. Now working two shifts a week at Christchurch Women's Hospital, she is back on the delegates' committee promoting issues such as midwifery leadership.

As a core midwife involved in caring for some very sick women, she continues to use many nursing skills in her practice. She does not regret her career move to midwifery. "I get a lot of satisfaction from my work. A baby's first breath is still amazing."

REFERENCES

(1) Campbell, N. (2000) Core Midwives - The Challenge! Paper presented at New Zealand College of Midwives' Conference, Hamilton, 2000.

(3) Ministry, of Health. (2002) Notice Pursuant to Section 88 of the New Zealand Public Health and Disability Act 2000. Wellington: Government Printer.

(2) New Zealand Health Information Service (2001) Electronic References. Retrieved June 20, 2002, from htp:// www.nzhis.govt.nz/stats/nursestats.html.

(4) New Zealand Statute (1990) Amendment of the Nurses Act. 1977. Wellington: Government Printer.

(5) Nursing Council of New Zealand (1996), Competencies for Entry to the Register of Midwives. Wellington: Nursing Council of New Zealand.

(6) New Zealand College of Midwives. (2002) Midwives Handbook for Practice. Dunedin: New Zealand College of Midwives,

(7) The Code of Health and Disability Services Consumers' Rights, (1996) Electronic References. Http://www.hdc.org.nz/ about/rghtindx.html.

(8) Earl, D., Gibson, Isa, T., McAra-Couper J., McGregor, B. & Thwaites, H. (2002) New Zealand College of Midwives Journal; October 2002.

(9) Guilliland, K. & Pairman, S.(1995) The Midwifery Partner ship: A model for practice. Monograph series. 95/1, Department of Nursing and Midwifery, Victoria University of Wellington, New Zealand.

(10) Benner, P. (1984) From Novice to Expert. Excellence and Power in Clinical Nursing Practice. California: Addison-Wesley Publishing Company.

(11) Taylor, B. (2000) Reflective Practice A Guide for Nurses and Midwives. Australia: Allen and Unwin.

--Beth Wynn-Williams, RGON, RM, BHSc, is a core midwife at Christchurch Women's Hospital. This article was developed from an assignment she wrote as part of her studies for an MA (Applied) Midwifery.