Nordic conference brings together 500 midwives in Reykjavik, Iceland, May 2004.
The Nordic Midwives' Association ('NJF') was founded in 1950 on the initiative of the Swedish Midwives' Association. The purpose of the organisation was, and is still, to exchange among the member states experience of midwifery education, of the organisation of midwifery care and of the scope of practice of midwives in the Nordic countries. It was decided that NJF should hold a congress for members at least every fourth year, hosted in turn by the member states, counting Sweden, Finland, Denmark, Norway, Iceland and the Faroe Islands.
Expansion of Nordic boundaries?
At the annual steering committee meetings, reports are given on the work and progress of the ICM and the EMA (European Midwives' Association). Taking into consideration the recent expansion of the European Union, thoughts have been given to enlarging the NJF by offering membership to midwifery associations in the Baltic countries, which are now members of the EU. Language issues stand in the way of this decision, as the working language in the steering group and--till recently also in the congresses--is our common 'scandinavian': all of us can understand each other's languages by bending and meeting a little.
Issues for debate
At the steering committee meeting before the congress in Iceland, the following issues were debated:
* Ultrasound scanning of pregnant women. Are the women sufficiently informed about the procedure? How do we ensure that future parents have enough knowledge to choose whether or not to accept the offer of a scan? Should we define ultrasound scanning in week 17-18 as antenatal diagnostics?
* The increased medicalisation of birth with special focus on the rise of the numbers of Caesarean sections (CS) because of maternal request. How do midwives gain political and professional impact in this question?
* Introducing commercial products to parents via midwives. The steering committee decided to work on a Nordic version of the ICM's International Code of Ethics for Midwives for commercial products.
* The steering committee decided to support a project: "Going South" in co-operation with the Nordic Association of Gynaecologists and Obstetricians ('NFOG'). The object is to strengthen the efforts within reproductive health in developing countries through joint projects of education of midwives and other skilled attendants.
'For midwives, by midwives'
The congresses of the NJF have over the years developed more midwifery content and are today professional meetings arranged for midwives, by midwives.
Of the many, many interesting subjects presented from all the Nordic countries, we would like to emphasise a few, regretting that we cannot honour the efforts of all the midwives active in congress properly.
One of the keynote speakers raised the question of how midwifery care can survive in a hospital setting where values and structure focus on technology' and treatment and not on natural physiological processes. Jane Sandall, Professor of Midwifery and Women's Health at King's College in London, drew attention to the 'Albany project' being carried out in a London suburb. Here the focuses were:
* Democracy in access to information
* The right to evidence-based information
* Encouragement to 'client autonomy'
* Partnership between woman and midwife
The result of the project was that 77% of the women being cared for by the 'Albany' midwives had a normal delivery- (defined as a birth with no induction, regional analgesia or instrumental delivery). This compares with a UK total of 63%. Also remarkable is that 92% of the women in the Albany project knew their delivery midwife in advance of labour, as opposed to 48% in the UK population of women giving birth. There were group consultations; the women decided the place of birth; and they were kept updated with information and possibilities of choice. Last, but not least, the women received a visit from the midwife at home at the beginning of the birth and prior to going to the hospital.
Definition of maternal request Caesarean section
Even though the Nordic countries today still have a CS rate below that of many industrialised countries, a recent steep rise in numbers has given cause for concern. Delivery by CS on maternal request has been blamed for a larger part of the rise, but the extent of these requests has only been registered sporadically. At Skejby Hospital, Denmark three midwives, Lone Sorensen, Charlotte Sollid and Trine Uldbjerg, have worked to establish a credible picture of the number of 'maternal request' CS deliveries.
The definition identified is: 'a Caesarean section performed without obstetric personnel having counselled against vaginal delivery'. From March 2003 till March 2004, 1106 sections were carried out, of which 407 were elective, among these 181 on maternal request. CS on maternal request is rarely performed on primiparae. Nine out of 10 of the multiparae wanting a CS with no obstetric indication gave 'previous birth experience' as their reason.
Over 50% of this group were women who had had a previous CS delivery, either elective or emergency. Women with previous CS are thus more likely to choose this mode of delivery in a later birth.
An increasingly common attitude among obstetricians and in professional literature seems to be that the risk of a planned Caesarean is comparable to that of a normal vaginal delivery; because the risk is similar, woman's choice of birth has been introduced as a factor in the decision, said Lone Sorensen. She put the question to us, whether the midwife's task is to promote normal delivery? Or should she rather support the woman in whatever choice she makes?
Pregnant and birthing women in Denmark do not have a real choice. They cannot choose to have a midwife whom they know and trust with them during delivery. They cannot even be certain in advance that they will have a midwife present throughout the birth, said Lone Sorensen, warning against the state of perinatal care in some Latin American countries with up to 80% Caesarean sections.
Approach to reduction of Caesarean section rate
Ingibjorg Jonsdottir, ward midwife at the hospital of Akureyri in Iceland, described how the staff in her unit had wanted to reduce the number of Caesarean deliveries. The 10 Robson groups were used to classify the women, and the staff concentrated on three of those groups in particular: Group 1: Primiparae, singleton, cephalic presentation, >37 weeks, spontaneous labour; Group 2: Primiparae, singleton, cephalic presentation, >37 weeks, induction/elective CS; Group 5: Multiparae, former CS, cephalic presentation, >37 weeks. By giving optimal support and treatment to the women in these groups, the total CS frequency on this small Icelandic delivery ward has been reduced from 24.9% to 18.8% in the period 1999 to 2003. The largest reduction in CS frequency was found in group 1. Ingibjorg underlined the importance of paying great attention and care to the primiparae in order to secure a successful vaginal delivery. This will avoid placing them for future deliveries in group 5, a group that has a high complications rate; instead, they will be in group 3 where women with previous vaginal delivery, are registered, and where 98% of the deliveries happen without complications.
The staff in this Icelandic delivery ward made their own partogram for, respectively, primips and multips and took particular care to define the onset of labour accurately in order not to start the partogram too early. Special care was taken to avoid protracted labours. Several trials have shown that slow progress is perceived negatively by the women and therefore there was no reluctance to stimulate labour by oxytocin, if necessary. In this way the CS rate was successfully reduced from 18% to 9% for group 1. Ingibjorg Jonsdottir concluded that this achievement will work positively to reduce the rate of operative delivery when these women turn up to have their next child.
Report by Lillian Bondo, president, Danish Association of Midwives; Kit Dynnes Hansen, vice president, Danish Association of Midwives; Anne Marie Kjeldset, editor, Danish Midwifery Journal
Lillian Bondo, LIB@jordemoderforeningen.dk
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|Author:||Bondo, Lillian; Dynnes, Kit; Kjeldset, Anne Marie|
|Date:||Jul 1, 2004|
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