MIDIRS Midwifery Digest

www.midirs.org

Midwifery Digest June 2011, volume 21, number 2

research/education midwifery pregnancy labour & birth postnatal infant nutrition neonatal & infancy worldwide maternity services news & views

CONTENTS See page 137 for explanation of symbols.

housekeeping

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contents

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editorial

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diary

142

hot topic

143

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Using the birth environment to increase women’s potential in labour

research/education

149 Scattering leaves and making soup: a midwifery student’s experience of formulating a personal philosophy

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A review of student midwives’ conduct and support through supervision

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A reflection on reflection

157

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Action research: a process to facilitate collaboration and change in clinical midwifery practice

160

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midwifery

161

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Fat as deviancy: providing ethical midwifery care to women of all sizes in the UK

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An experience of miscarriage from a spiritual perspective

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Compassionate midwifery: review of a study day for midwives

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Informed choice: web-based midwifery

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Auscultation — the action of listening

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contents

pregnancy

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NICE clinical guideline: hypertension in pregnancy — the role and responsibilities of midwives

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Hypertension in pregnancy

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Offering antenatal sickle cell and thalassaemia screening to pregnant women in primary care: a qualitative study of GPs’ experiences

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Reducing the rate of preterm birth through a simple antenatal screen-and-treat programme: a retrospective cohort study

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Exploring pregnant women’s views on influenza vaccination and educational text messages

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labour & birth

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Exploring carers’ views and attitudes towards the use of water during labour and birth

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Care pathways for critical care in childbirth: a viable proposition?

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Use of complementary and alternative medicine during pregnancy and delivery

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Identifying women requiring maternity high dependency care

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Influences on decision making among primiparous women choosing elective caesarean section in the absence of medical indications: findings from a qualitative investigation

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postnatal

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Postnatal care: exploring the views of first-time mothers

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Institutional processes and individual responses: women’s experiences of care in relation to cesarean birth

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Postpartum urinary retention after vaginal delivery

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Prevalence of postpartum urinary incontinence: a systematic review

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Postnatal women’s experiences of management of depressive symptoms: a qualitative study

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infant nutrition

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Encouraging breastfeeding: a relational perspective

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A call for clarity in infant breast and bottle-feeding definitions for research

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Is my baby getting enough breast milk?

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Media coverage of infant feeding studies: informed choice or promotional opportunity?

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neonatal & infancy

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‘Leaving footprints on our hearts’ — how can midwives provide meaningful emotional support after a perinatal death? Part 2

235

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Probiotics decrease the incidence of NEC and death — so why aren’t we using them?

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Monitoring technologies in the neonatal intensive care unit: implications for the detection of necrotizing enterocolitis

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The association between clubfoot and developmental dysplasia of the hip

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worldwide maternity services

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What is a quality maternity service? Reflections after an elective placement in Bhotechaur, Nepal, supported by the Iolanthe Midwifery Trust

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Wales to Ethiopia: a midwife’s perspective

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Saving mothers’ lives: the reality or the rhetoric?

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Variation in rates of caesarean section among English NHS trusts after accounting for maternal and clinical risk: cross sectional study

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Variation in caesarean delivery rates

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Improvements to the newborn bloodspot screening service are required to meet national standards

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news and views

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263 Book reviews

263

Did you miss it?

264

News from MIDIRS

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All your own work

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Author index

271

Subject index

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Midwifery Digest is printed on paper which is totally Chlorine Free and produced from pulp originating from sustainable forests.

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hot topic

hot topic hot topic Using the birth environment to increase women’s potential in labour Denis Walsh, Kathryn Gutteridge

The current climate of maternity services is exciting, raising many challenges for midwives. The launch of Midwifery 2020: delivering expectations calls for midwives to maximise their influence and seek innovative solutions to implementing practice. One of the suggestions from this document has indicated that midwives should develop more midwife led care services. This article will explore the concept of an optimum environment for a midwifery-led unit (MLU) and how this can be achieved in a climate of financial savings.

comfort and usually adopted upright positions that would relieve their discomfort or accommodate the birth of their babies (Kitzinger 2000).

Common and everyday birthing tools, which midwives have come to know and love, started their usefulness in women’s homes. These included low wooden birthing stools and ropes that would be secured to beds or beams used for pulling on during labour.

Midwives would sit at the front of upright women waiting to receive the baby into their hands (Coppen 2005).

Historical context omen have used their surroundings W to achieve comfort and control during labour and birth, as childbirth texts have shown, over many decades: ‘Women all around the world moved freely during labor, changing positions frequently as a method for managing the pain associated with labor contractions and cervical dilation. They ate and drank as they pleased within the cultural confines of what was considered acceptable, nourishing and safe for the mother and baby. They were attended by other women whom they knew well, in a place that was familiar to them —

usually in their home or in the home of a female relative. They labored and birthed in upright positions using instinctive knowledge to expand the size of the pelvis, capitalize on gravity, and to maximize the efficiency of the abdominal muscles needed for pushing.’

(Davis-Floyd & Cheyney 2009) It is only in the past 100 years that birth has become institutionalised in the western world and with that has come a more medical birthing environment (Walsh 2010). Prior to that, as far as we can tell, women were with companions they trusted in an environment that was usually home.

They would move around to suit their

Whilst there are many midwives who are confident and used to being with women throughout their natural labour there is no doubt that for some midwives and many obstetricians, hearing and seeing a woman progressing through such a labour stirs their fears and emotions. Wagner (2001) used a phrase ‘fish can’t see the water they swim in’ to refer to birth attendants, who have experienced ‘…only hospital based, high interventionist, medicalised birth [and] cannot see the profound effect their interventions are having on the birth.’ (Second paragraph of paper presented at Homebirth Australian Conference 2000).

However, even in this context there has been, over the past 30 years, a turn towards acknowledging that the birth environment may profoundly affect women’s labour and birth. Fannin (2003) has written about the humanisation of the birthing space

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research/education research/education research/education

Scattering leaves and making soup: a midwifery student’s experience of formulating a personal philosophy

* Donna Wixted

s a second year student midwife at Bournemouth University (BU), I am required to provide antenatal, intrapartum and postnatal care for a woman and her baby within the student caseloading model of care (NMC 2009). As the pioneer of student midwife caseloading, BU has developed a comprehensive academic caseloading unit that supports students in preparing for this initiative.

Prior to beginning caseloading practice I must successfully complete the final assignment of this unit to consolidate my learning. This assignment must demonstrate my understanding of safe practice and my knowledge of the processes involved in planning, prioritising and evaluating women-centred care that is underpinned by my personal philosophy of care (Rawnson et al 2008). This article reflects on my experiences of developing and articulating my personal philosophy of care, and discusses the challenges I encountered in trying to express it in a meaningful way so that it captured my core beliefs and values. It also explores how this journey can provide a powerful learning platform for future practice.

A

VandeVusse (1997) and Walker (2006) both state that the process of devising a personal philosophy of care allows the student to focus on the direction of their own practice while identifying where their beliefs intersect with those of midwifery. Personal philosophies should be unique and, as explored by VandeVusse (1997) and Walker (2006) can take the form of artistic pieces of work that give substance to individual beliefs and values. In this context, in our preparatory seminars we were encouraged to utilise a variety of media with which we felt comfortable, for example story-telling, poetry, drawing or painting, in order to bring our philosophies to life. In this way, we were able to distance the development of our philosophies from academic constraints, which provided the freedom for each of us to develop our own unique personal philosophy.

art, science, personal and ethical knowledge. The boundaries between these four patterns overlap and blur and each midwife will combine the patterns of knowing into a framework that is unique to them (Clarke 2002).

Clarke (2002) provides a comprehensive framework of what is included in each of the four patterns and how each is connected. Within this framework, art involves communication, story telling, aspects of femininity and empathy; science includes academic research, guidelines and policy; ethical knowledge encompasses the practitioner’s learnt morals from childhood along with personal experience regarding issues such as beneficence and, lastly, personal knowledge includes personal reflection and knowledge gained through getting to know a woman and gaining an understanding of her life world.

When formulating our personal philosophies we were encouraged to consider aspects of this framework in order to build a dynamic and credible philosophy.

In order to reflect on my feelings surrounding the completion of this task, I have used a shortened version of Gibbs reflective cycle (Gibbs 1988, cited Jasper 2003:77) (Figure 1). Reflection is an important tool in midwifery clinical practice and to this end is used widely in Figure 1

For a midwife to develop a rounded philosophy, Kelly (1997, cited Clarke 2002:84) identifies the need to incorporate four patterns of knowing, which encompass MIDIRS Midwifery Digest 21:2 2011

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A review of student midwives’ conduct and support through supervision

A review of student midwives’ conduct and support through supervision

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Dorothy Patterson, Carolyn Moorhead

© Norman Pogson, Fotolia

Introduction tudent nurses and midwives accessing pre-registration midwifery training within universities are different from their peers studying in other disciplines. They have the same rights and responsibilities as other students, but are being prepared to enter a profession which carries with it a high level of responsibility and one which expects certain standards of professional behaviour (Karstadt 2009). Throughout training students will receive information on what is acceptable conduct and behaviour and what the public expects from a professional nurse or midwife.

Although students are not registered by the Nursing and Midwifery Council (NMC) it is expected of them that they conduct themselves professionally at all times in order to justify the trust that the public places in the nursing and midwifery professions. To assist and provide clarity, the NMC, the UK regulator for nursing and midwifery, has published guidance setting out certain standards of personal and professional conduct expected of nursing and midwifery students in

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order for them to become fit for practice (NMC 2009a). The affiliated university will also set out certain guidelines for conduct and behaviour that is expected. In addition to this, as part of the education and training programme for student midwives, they are supported by the statutory midwifery supervisory framework. It is envisaged that interaction between the student and the supervisor of midwives (SoM), at this early stage of the student’s career, will provide a clear understanding of the role of supervision and the support which is available in midwifery practice (Steele 2009). The aim of this paper is to discuss the attributes of attaining a professional qualification, what is expected for the professional behaviour of student midwives and to explore the direct and indirect relationship between supervision of midwives, midwifery education and student midwives.

Supervision of midwives and students Student midwives qualify and register to practise once they have successfully completed an approved midwifery course (NMC 2004). During their course they are supported, guided, and assessed in their learning in clinical practice and in the higher education institution (HEI) by midwife mentors, practice teachers, and midwife teachers, whilst a host of other members of the maternity services and educationalists contribute to student learning. The NMC (2007) set clear standards as to the means by which a midwife becomes a mentor, practice teacher or midwife teacher and how a student midwife should be supported throughout the period of their midwifery course. Such support facilitates the transmission of knowledge, skill, attitudes and attributes from one generation of

midwives to the next, aiding learning in an effective and efficient way so that care to women can be provided by knowledgeable, compassionate practitioners that match the professional expectations required.

At the point of registration, and in order to practise, each midwife is allocated to a SoM (NMC 2004) whose role is to support them by providing continuous, professional advice to enable safe and effective midwifery practice, thereby ensuring women and their families are the recipients of good, evidence-based and sensitive care. Since the aims of both mentoring support and supervisory support are similar, the question arises — does the SoM have a role that benefits the student midwife?

Although student midwives are not specifically mentioned in the NMC’s (2006) report Standards for the preparation and practice of supervisors of midwives, a closer look at the NMC’s (2004) Midwives rules and standards, rule 12, shows that the NMC clearly links the two and expects the Local Supervising Authority (LSA) to ‘enable students to be supported by the supervisory framework’ and, in rule 16, the LSA reports to the NMC, ‘evidence of engagement with higher education institutions in relation to supervisory input into midwifery education’.

Also, the NMC standards for preregistration midwifery education (NMC 2009c) expect students to practice within The Code (NMC 2008a) and enhance their own self development by engaging and utilising the statutory supervisory framework. Statutory supervision of midwifery certainly has a place in the development of student midwives and newly qualified midwives to nurture the fresh approach and enthusiasm they bring to their embryonic career (Kitson-Reynolds

A review of student midwives’ conduct and support through supervision

Characteristics of a profession alongside the professional status of midwifery Several papers on professionalism refer to the social contract that professionals now have with society demonstrating the relationship which the professional has with society and what society expects from professionals (Symon 1996, Sills 1998, Cruess et al 2010).

The desired characteristics of a profession are referred to as having (1) a unique body of knowledge, (2) a code of ethics, which regulates practice, (3) the ability to work autonomously (Freidson 1970, Maloney 1986, Pyne 1998). Davies (2007) defines the difference between an occupation and a profession as the latter possessing elements of a monopoly in the provision of professional services and having the right to self-regulate.

Professional monopoly is referred to

by Martimianakis et al (2009) as ‘boundary work’ which marks the political attributes of professionalism, where a professional group has the power to influence government policy by their expert knowledge, their regulatory status, their education and their vitalness to the well-being of society. Symon (1996) argues that midwifery in the recent past did not fulfil the criteria of full professional status due to being a female dominated occupation and coming from a feminist perspective which refers to professional groups as dominant and usually male. This ‘gender division of labour ’ (Manley 1995:980) poses a hindrance to professional status for groups that are female dominant.

SoMs can promote and nurture developments within the profession as they are appointed to be professional leaders and visionaries, and Warwick (2007) notes that qualities such as upholding professional values, visibility (being seen at the coal face) and optimism can steer the profession into the future where the strength of supervision is that it is based in national regulation, not employment (Warwick 2009). A high level of midwifery supervision visibility is important, for instance, in the development of Midwifery 2020 and the review of the NMC’s (2004) Midwives rules and standards, to ensure that the profession remains focused on the needs of women and that midwifery is being best equipped to deal with their needs. To achieve these SOMs need to be the transformational leaders described by Daft (2002) who have a strong sense of vision for the profession, who can communicate the need for changes within the profession and motivate others to believe in the need for change and to develop and empower midwives into future leaders.

Students, as a result, should be able to see clearly where midwifery stands within society and within health services, and take confidence in the fact that the midwifery profession, in conjunction with women, is deciding and directing its own future. The midwifery profession can socialise students into a profession that is equipped for the future, without disregarding the creativity and individuality that new recruits can bring.

In order to succeed, however, SOMs have to overcome and prevent the barriers of learned helplessness that occurs with powerlessness, authoritative and controlling hierarchal organisations and patriarchal dominance that suppress professionalism (Maresh 1986) so that they can empower midwives, student midwives and more importantly women and families in their care.

A unique body of knowledge An extensive theoretical knowledge base is stated to be essential for defining aspects of professionalism

(Etzioni 1969, Friedson 1970).

University education provides exposure to theoretical knowledge and complex skills. It displays power of access to professionalism by controlling entry into the profession as a licence to practice can only be obtained by completing an accredited course of study (Yam 2004). Nixon & Power (2007) state that control in education and changes in the form and structure of professional educational preparation programmes is significant and central to professional identity.

Midwifery theory is essential for safe and effective practice as it challenges midwives to develop skills in critical thinking and to develop the ability and skill to discuss and debate research findings (Baird 2007). The SoMs are well situated as having a unique body of knowledge and are capable of performing the role of expert leaders.

Osborne (2007:555) states that ‘for many supervisors their work places them firmly at the forefront as the providers of support and wisdom in a developing workforce’.

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2005). Kitson-Reynolds (2005) claimed that the SoM is misunderstood and under-utilised when it comes to student midwives but, more recently, McKenzie (2009) noted that, without exception, all the LSAs had been able to report to the NMC a diversity of means by which supervision of midwifery worked with midwifery academia and practice to support and improve the learning experiences of student midwives across the UK.

Student midwives can be faced with difficult practice situations, which can be excellent learning opportunities if addressed in a supportive way. Difficult situations can also invoke anxiety, which interferes with learning (Chamberlain 1997). Timely support from a SoM can reduce uncertainty and apprehension during occasions such as complaints or tricky practice issues (McGuinness 2006). By demonstrating to the student that the SoM is a valuable mechanism for advice and guidance, students can learn the benefits of this support. Whilst involvement of a SoM can blur issues and there is the danger of overlap with the mentor teacher and the potential for conflicting advice, they might be able to offer a more objective perspective that advocates on behalf of the woman. They can be another voice to add to any debate, and can focus specifically on practice issues rather than institutional or educational ones.

Licqurish & Seibold (2008) found that student midwives appreciated being mentored by midwives who are caring and supportive, willing to share knowledge, fair in assessment, able to

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A review of student midwives’ conduct and support through supervision reflect or debrief on practice and offer a woman-centred approach to care.

These qualities are also reflected in good supervision of midwifery (NMC 2006). Nevertheless, mentors are well placed to provide this support, with a good working relationship and good appreciation of local issues. SoMs, on the other hand, can also be positive professional role models for students to emulate.

Despite the fact that the aim of midwifery education is to fully prepare students to practise autonomously at the point of registration, students themselves have identified a theory and practice gap (Baird 2007). This means they do not always have contact with or direction from midwives who are inherently confident and accountable in making decisions and basing care on the best evidence available (Fowler 2008). The SoM can be a practice-advisor/guide through difficult circumstances which can be addressed locally by guided reflective thinking. In addition, the SoM is well placed to challenge practices that are out-dated and students have been shown to welcome such support (NMC 2005). SOMs can be directly involved in developing the environment that facilitates reflective midwifery decision making, asking prudent questions and handling the ‘situation’ rather than the individuals (Ralston 2005). The SoM can be the positive role model demonstrating behaviours and knowledge considered optimal for the role of the midwife, bringing midwives to the stage of being able to move appropriately within and outwith policies and protocols (Fowler 2008).

Midwifery education has undergone extensive change in recent years in terms of location, commissioning and accountability (Baird 2007). It has ‘evolved from a model of informal apprenticeship’ to standardised training within HEI (Baird 2007:400).

The NMC (2009b) endorsed degree education for midwifery as mandatory and the introduction of direct entry midwifery education continues to provide a new dimension to midwifery where nurse training is no longer a prerequisite, thus widening the gate for

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entry into the profession (Nixon & Power 2007) .

Statutory supervision directly impacts on midwifery education by the collaboration that occurs between supervision and midwifery educational institutions. The Local Supervising Authorities Midwifery Officers’ (LSAMOs) Forum (2009) has set a strategic goal to be involved with curriculum development, validation and quality assurance aspects of midwifery education. Having the SoM involvement in such work ensures that there is freedom within the curriculum for development of accountability that will prepare midwives for registration and ensure that evidence-based practice remains at the forefront of midwifery education which includes pre- and post-registration education. A reassuring report from the LSAMO’s forum (2008) comments that all LSAs can ‘robustly’ meet the requirements of rule 16 (NMC 2004) and show evidence of engagement with HEIs to ensure evidence-based practice (LSAMO 2008).

A further strategic goal of the LSAMO Forum (2009) expects collaboration between SoMs in practice and HEIs to ensure that students are exposed to the positive benefits of supervision. This can be done both in tuition and in practice where the role and responsibilities of the SoM can be explained and students can witness and be involved in active or theoretical case supervision activities.

Supervisors also have a responsibility to ensure standards for education and practice are met in the clinical environment (Steele 2009). This has the advantage of benefiting the whole organisation, not just the student midwives. Any concerns about practice conditions in the clinical learning environment that may adversely affect student learning should be reported to the NMC, particularly if those concerns are in relation to the learning environment and ability of mentors to support students. If students are facing difficulties in clinical practice, this may be reflective of the general work ethic and approach and could, potentially, have a detrimental effect on women

and families. Finally, the LSAMO audit clinical placements and the student and user perspective are reflected in these audits (LSAMO 2008, LSAMO 2009). So supervision of midwifery is concerned that the student experience is positive.

The art and craft of midwifery is viewed as an essential component, as is theory where the philosophy of midwifery is centred on normality and is based on the needs of the woman (Davies 2007). Midwifery being practice and skill based does not sit comfortably within the stipulations of professionalism that is referred to by Friedson (1970) as formal and empirical knowledge. Midwifery professionalism may be best defined by Shaw (1983) who describes nursing practice as combining the art of caring with a pragmatic application to science. Schön (1987) describes two views of professional knowledge, the technical rational type referring to tasks being broken into component parts or skills and mastery of skills and, secondly, the professional artistry which is concerned with not only how a task is done but also what the end result is. Therefore, it relates to conduct which is concerned with beliefs, attitudes, assumptions and values and not just with behaviour (Fish & Twinn 1997). De Cossart (2005) states that the artistry professional refers to the autonomous practitioner making their own decisions, using professional judgement and all within a moral code of ethics which can be effectively supported by utilising the framework of statutory supervision.

To promote the role and activities of a new SoM, this could be communicated transparently by adding the supervisory title to any work correspondence/professional signatures etc. Given that student midwives access protocols and policy documents throughout their course, they should then be able to identify supervisory involvement. Since women and families should easily be able to contact a SoM in their area (NMC 2009c), the same information should be available to student midwives, and clinical areas are known to use information leaflets, websites or notice-

A review of student midwives’ conduct and support through supervision boards to advertise the contact details of SoMs.

Figure 1. A framework to support student midwives in development of conduct through statutory supervision

Code of ethics

research/education

The guidance for nursing and midwifery students sets out the personal and professional conduct that is expected of them in order to be fit for practise (NMC 2009a). Guidance for students is based on strict standards set out in the professional code of conduct for registered nurses and midwives which is the foundation of good practice and the key to safeguarding the health and wellbeing of the public (NMC 2008a). The White Paper Trust Assurance and Safety (Great Britain, Secretary of State for Health 2007) issued guidance on how regulators should engage with students in training, stating that education providers should encourage attitudes and behaviour which constitutes professional conduct throughout pre-registration programs and that students should be aware what is required of them from the outset of the course (Great Britain, Secretary of State for Health 2007).

They also suggest that students should be registered with the regulator at the commencement of training and, subject to fitness, to practice panels within the university if their conduct is in question. Being fit for practice is having the skills, knowledge, good health and character to perform the role safely and effectively and to be deemed worthy of entry to the register (NMC 2009a). Prior to this, decisions would have been made between the practice area and institutions using The Code (NMC 2008a) as guidance which provides more clarity and transparency throughout the process (Karstadt 2009). Baker (2009) promotes The Code for nursing and midwifery students stating that it facilitates engagement at an early stage between the NMC and students rather than at registration and provides closer links between educational institutions, the regulator and employers. Supervision of midwives supports this through involvement in curriculum planning, ensuring that professional values and nursing and midwifery regulation are included in the curriculum and

ensuring that students can access help and support when needed.

Professional regulation Midwifery is contained within The Nursing and Midwifery Order 2001.

The Order requires the NMC to set rules and standards for midwifery practice and also for the function of statutory supervision of midwives (NMC 2004).

There is also an obligation for the regulator to police the performance of its members and to put the interest of the public above that of its own members (Davies 2007).

In order to support student midwives to meet the guidance on professional conduct there is a need for direct contact between a student midwife and a SoM. Students rely on mentors to help develop their self-confidence, and development of competence is a career-long event (Steele 2009); hence there is a strong support mechanism in place for student midwives. However, the Midwives rules and standards (NMC 2004) say that students should be ‘supported by the supervisory framework’; therefore, for a student to be fully conversant with supervision of midwifery and to be prepared for supervision at the point of registration it would seem sensible that the student has some direct access to a SoM. Early

introduction of the students to the foundational principles of supervision and, if possible, introduction to a SoM enables a developing relationship to form and enables students to understand the role and thereby be proactive in its use (Steele 2009).

On the other hand, it is not known what students expect from supervision that is over and above the support provided by midwife mentors and midwife teachers.

The NMC (2008b) reports that some students are being individually allocated to a SoM, whilst others experience group/cohort allocation, so there is clear evidence that students are being supported by the supervisory framework; however, this is in addition to a supervisory caseload and has workload implications for the SoM. Supervision drop-in clinics are an efficient, practical means of meeting with students, ensuring their needs are met (Kitson-Reynolds 2005). Some Trusts have produced information packs on supervision which are given to midwifery students and allocated a SoM to specifically look after midwifery students.

Autonomy in midwifery practice It has already been stated that the expectation is, on registration, that

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A review of student midwives’ conduct and support through supervision midwives are autonomous practitioners and will take on full responsibility for providing care to women during pregnancy, labour and in the postnatal period (World Health Organization 1996). In order to assist students to learn how to make autonomous decisions regarding normal childbirth, the NMC (2008b) states that students should be actively involved in caring for and supporting women giving birth in a number of various settings and have recently introduced the concept of students taking a caseload from the commencement of training rather than in the final year. Also, during training student midwives may have an elective component as part of their program, and much could be gained in terms of autonomous practice by visiting countries where a social model of birth exists, such as in Holland, Scandinavia and New Zealand (Baird 2007).

Student midwives can be supported and nurtured to develop into autonomous practitioners by SoMs offering appropriate advice in the clinical area, by performing as a positive role model and being available to students as a resource (Steele 2009).

Final discussion Midwifery professional regulation has made provision for student midwives to be well-supported throughout their education with a range of specifically tailored means of support (Figure 1).

However, following conversations with midwifery students who have not been provided with the name of a SoM for support, it could be alleged that universities and NHS Trusts in some instances have failed to recognise the value of statutory supervision of midwives in supporting students in practice. From the discussion it is recognised that supervision of midwifery can be a valuable source of support to midwifery students.

Supervision provides a valuable link between HEIs and practice, it demonstrates to midwifery students the relevance and importance of professional conduct, accountability and autonomy in midwifery practice.

The allocation of time to midwifery students from an already stretched midwife and SoM can be challenging; however many supervisors have found

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innovative ways of meeting the needs of students through drop-in supervisory clinics, group supervision and packs providing information on supervision.

There is potential for overlap and overkill for students and SoMs alike where time is unflexible but efforts into some areas will reduce time needed in others. The earlier a student understands the role of supervision, the sooner they can utilise it for their own professional conduct and engage with it in a positive manner.

Dorothy Patterson, midwifery teaching Fellow, teaches pre- and post-registration midwifery education, Queens University, Belfast. SoM appointed by Public Health Agency, Northern Ireland. Email: Dorothy.patterson @qub.ac.uk Carolyn Moorhead, midwifery teaching Fellow, supervisor of midwives (PHA, NI), teaches pre- and post-registration midwifery, module co-ordinator for preparation of SoMs, Queens University, Belfast. Email: c.moorhead @qub.ac.uk.

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Local Supervising Authority Midwifery Officer’s Forum UK (2008). Modern supervision in action. London: NMC. Local Supervising Authority Midwifery Officer’s Forum UK (2009). Strategic direction and priorities 20082011. United Kingdom: LSAMO Forum.

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Martimianakis MA, Maniate JM, Hodges BD (2009).

Sociological interpretations of professionalism. Medical Education 43(9):829-37.

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Nursing and Midwifery Council (2004). Midwives rules and standards. London: NMC. Nursing and Midwifery Council (2005). Report on the Nursing and Midwifery Council’s extraordinary visit to the maternity services at Northwest London Hospitals NHS Trust. London: NMC. Nursing and Midwifery Council (2006). Standards for the preparation and practice of supervisors of midwives.

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London: NMC. Nursing and Midwifery Council (2008a). The Code : standards of conduct, performance and ethics for nurses and midwives. London: NMC. Nursing and Midwifery Council (2008b). Supervision, support and safety: analysis of the 2008-2009 local supervising authorities’ annual reports to the Nursing and Midwifery Council. London: NMC. Nursing and Midwifery Council (2009a). Guidance on professional conduct for nursing and midwifery students. London: NMC. Nursing and Midwifery Council (2009b). Standards for pre-registration midwifery education. London: NMC. Nursing and Midwifery Council (2009c). Support for parents: how supervision and supervisors of midwives can help you. London: NMC. Nursing and Midwifery Order 2001. (SI 1997 1580).

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midwifery midwifery Fat as deviancy: providing ethical midwifery care to women of all sizes in the UK

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he human body needs fat, so while adipose tissue acts as a compact fuel, storing and releasing energy, subcutaneous fats work to maintain thermostasis, and structural fats, such as cholesterol and phospholipids, are necessary for cell structure and function (Kapit et al 2000). There are also strong socio-cultural and emotive labels attached to the word ‘fat’, including perceptions of fatness, overweight and obesity. Being fat is viewed as a form of deviancy from accepted social norms within western capitalist society (Bordo 2003). The dominant obesity paradigm informing UK midwifery practice is based on the body mass index (BMI) which is a rough equation that calculates weight divided by height but not percentage of body fat. The predominant message is that women with a BMI above 30 are at greater risk of maternal and fetal/infant morbidity and mortality than women with a BMI of 18.5–29 (DH 2008, Bick 2009, WHO 2010).

A counter-discourse, rooted in feminist, body-positive traditions, reclaims the word ‘fat’ as a positive adjective, talks about women being ‘fat and proud’ (Cooper 2007) and propounds the concept of Health at Every Size (HAES UK 2010). The Nursing and Midwifery Council (NMC) (2009) emphasises woman-centred care and individual practitioners being responsible for ethical and legal conduct. There is an argument that the practice of pathologising body size is incompatible with the provision of ethical midwifery care and that only by employing a holistic approach can this be achieved.

By considering the impact of these

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serious flaws in the evidence supporting the obesity epidemic movement and that this powerful concept has its roots in politics, economics, society and culture.

Midwifery writers such as Bick (2009) and Irwin (2010) call for midwives to address the so-called obesity epidemic.

Many influential sectors of UK society promulgate the warning of a global obesity epidemic. Western media interest in obesity has itself reached epidemic proportions, with coverage increasing by nearly 300% in five years (Echo Research 2010). In 2008 the UK government pledged £372 million towards tackling the ‘lifestyle disease’ of obesity, as ‘one of the biggest threats to our health’, by promoting healthy lifestyles for the achievement of healthy weight (DH 2008:iii). Similarly, the NHS describes obesity as a growing, self-inflicted disease (Raynor et al 2005, NHS Choices 2010).

The obesogenic society can be understood as a structural concept, where individuals are subject to society’s norms. Obesogenic society discourse blames people’s ‘overweight’ on a society where overeating of empty calories and under activity is facilitated by a socio-economic environment. It is an ideology to which the World Health Organization (WHO 2010) and the UK Department of Health (DH) (2008) partly subscribe. However, the DH’s Healthy weight, healthy lives strategy also highlights lifestyle. State involvement in shaping lifestyle choices reflects what Guthman (2009) describes as a ‘neoliberal governmentality’ — one where citizens are now governed through their own socially regulated choices rather than directly by the state. Concepts of consumer choice, personal responsibility and individual empowerment are key themes in the obesity epidemic discourse and government obesity policy.

Connections have also been drawn between neoliberal governmentality and neoliberal economics.

A minority of commentators, from fields as diverse as midwifery (Deery & Wray 2009, Wickham 2009), medicine (Robison 2005), dietetics (Aphramor & Gringas 2009), epidemiology (Campos et al 2006), geography (Evans 2006, Guthman 2009) and sociology (UCLA 2005), are convinced that there are

Weight loss is big business. Weight Watchers International made nearly $14 billion revenue in 2009 (Weight Watchers International 2009). Bordo (2003) argues that capitalism uses advertising to play on emotional needs and insecurities in order to simultaneously sell diet-related

contrasting models, some of the praxis available to midwives for implementing ethics in this area can be evaluated.

The UK context: westerncapitalist culture and body size

midwifery

Clara Miriam

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An experience of miscarriage from a spiritual perspective

An experience of miscarriage from a spiritual perspective

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Sharon Moloney

hortly before my daughter turned one, I weaned her so we could begin trying for another baby. I had loved breastfeeding Caitlin — the intimate sensuality, the fulfilment of nourishing her from my own body, the moments of blissful reverie. I could have happily continued breastfeeding her for another year at least. But my sensitivity to the lactation hormones meant that my fertility had not returned at all. Nearing my 41st year, I didn’t have the luxury of time on my side and in the end, the yearning for another child won out over my love of breastfeeding. Within ten days of weaning, I had ovulated.

Two cycles later, I was pregnant and my husband and I were jubilant. We happily booked into the Brisbane Birth Centre where my daughter was born. Despite my delight, there was nevertheless an undercurrent of apprehension, a low-grade anxiety that with the benefit of hindsight seemed like an anticipatory knowing of what was to come.

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There were some small signifiers that all was not well.

The pregnancy test was equivocal. It took a long time for the blue line to appear and it was much fainter than last time. The morning sickness was awful and still going strong at 11 weeks, whereas in previous pregnancies it was over by eight weeks. Apart from that, the pregnancy seemed fine. My husband and I had begun reading from The Book of Weeks (Roxburgh et al 1996), a detailed description of the baby’s weekly growth and development. At 12 weeks, our baby was the size of my thumb and fully formed with all rudimentary organ systems in place and sexual differentiation complete.

I had begun to feel the first gentle flutters and my heart swelled with love for this new little person. Inwardly I spoke to my baby often. My husband and I were full of hopes about the future — a loved, longed-for sibling for our daughter and a very welcome addition to our family.

We had just bought our first home and were about to move in. Life seemed to be smiling on us.

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In Australia miscarriage is the birth of a baby before 20 weeks’ gestation and when it is such a very premature birth, there is no chance of the baby’s survival. Although a common event estimated to occur for one in four pregnancies, it is often an unacknowledged and a deeply mourned loss. Women have always miscarried and in times past, they would probably have sat together and talked about their experiences. However, in our current social climate with its unease about any kind of death, we seem to have lost the emotional skills to support each other through miscarriage. This uncomfortable silence has the effect of implying that the death of a baby so early in pregnancy is of no major importance. My own experience of miscarriage highlights this anomaly. When my third baby died at 12 weeks, it had a profound impact on me. That baby’s life, although very brief, was hugely significant. This story was written in his memory. I hope that breaking the silence and sharing my experience, will validate other women’s experiences of miscarriage and also help midwives to better support and understand mothers who miscarry.

Then a shadow crossed our horizon. Midway through the 12th week of pregnancy, a dark brownish stain appeared.

The stain continued on and off for two days. Worried, I called my midwife and visited my GP, who both assured me that some spotting early in pregnancy didn’t necessarily signal miscarriage. Wanting to believe them, I carried on with life as usual, not overly concerned.

After two days of spotting, the dark brown stain turned into a bright red flow. Now deeply concerned, I kept hoping and praying it would stop, still not wanting to believe that I would miscarry. By now our baby had become very precious to us. As the hours passed, the flow got heavier accompanied by waves of painful cramping in my cervix. I lay down on our bed, a growing disquiet in my heart. Groceries were needed, so my husband took Caitlin off to do the shopping so I could rest quietly. As I lay there in the silence, the realisation that I was losing my baby became undeniable. Yes, I had weaned Caitlin and this new little soul had come to join us without delay; but the writing was on the wall. As the reality dawned, tears started streaming down my face. What happened next is difficult to put into words.

Midwives sometimes talk about the special atmosphere in the room when a baby is born — an almost palpable sense of some greater power that infuses the whole space.

Although powerful, this special quality is also fragile, easily shattered by brusque words or insensitive attitudes.

Something of this nature occurred in our bedroom that day. The veil between visible and invisible worlds thinned and became permeable. The house grew very still and I felt an overwhelming awareness of an awesome loving Presence permeating the physical space. The room still looked the same, yet my consciousness was imbued with a vivid awareness of the divine rupturing into time and space, filling the room with grace. I felt the depth of my love for this tiny baby who was leaving us so soon. At the same time and strange as it may seem, I also felt this MIDIRS Midwifery Digest 21:2 2011

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An experience of miscarriage from a spiritual perspective soul’s love for me and it moved me deeply. I intuitively sensed that my baby was male and I thanked him for coming to spend this short time with us. Although his body was thumb-sized, the magnitude of his spirit infusing the room seemed as vast as the night sky. I told him I wished he didn’t have to go and how sorry I was that he was leaving. In reply, there came back to me a sense of reassurance, of needing to trust the universal processes of life and death, that all was as it should be, despite appearances. This communication softened my distress and enabled me to yield to the inevitability of the loss.

As I did so, the cramping intensified and I knew I was in labour.

When my family returned a short while later, I breathed through the sensations just as I had in labour with my previous births. Then I ‘heard’ a distinct pop inside me followed by a small gush of fluid as my waters broke.

I hurried to the toilet where I passed a dark mass of clotted blood and tissue into the water. Peering down into the red, murky depths, we wondered whether to try to retrieve the dark mass which had by now become obscured.

Ten minutes later, I passed another mass of tissue and more dark blood, this time catching it in a plastic container. We looked intently, trying to find a tiny human form in the dark red blood. There was a miniature placenta and membranes but it was so soaked with clotted blood, it was difficult to determine what exactly was there.

Although the cramping had stopped, the heavy bleeding continued. Concerned, I phoned my midwife who told me to come into the hospital and that I would probably need a D and C (dilatation and curettage). At the hospital, the nurse asked for our ‘products of conception’ and took the plastic container away to be examined. ‘Products of conception’ — what a strange turn of phrase, so clinical and dehumanising after what I had just experienced.

As we waited for my turn in theatre, my daughter kept calling me over and over, ‘Mum, mum’. For the previous two weeks, she had clung to me like a limpet, upset if I disappeared out of her sight, as though she knew something was wrong. At nightfall, I was wheeled away on the trolley into a cold, sterile-looking theatre with its stainless steel adornments and surgical gadgetry. I don’t remember a thing after the injection.

Back in the ward, I was told they did find more ‘products of conception’ during the procedure. It sounded so technical and matter-of-fact. I felt confused about what had actually happened and whether my baby’s body was in that plastic container or not. No one explained anything. Several days later, I called pathology for the results — ‘placenta and gestational sac measuring… No fetal tissue found’. Slowly as the days passed, I began to put the pieces together myself. It was my baby who had passed into the toilet with that first gush of dark clotted blood. After the enormity of what had happened in the bedroom just a short while earlier, the knowledge that my baby’s burial had been down the toilet distressed me deeply. I thought of his warm little body hitting the cold 168

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water, of his vast presence being flushed down a pipe used to carry away excrement. It seemed so ignominious and undignified. I deeply regretted not having tried to retrieve his body to bury in the soft earth.

While the resonance of that extraordinary visit from on high has always remained with me, it did not spare me the human reality of grief. My acute distress in the days immediately following the miscarriage gave way to the long haul of grieving. I was shocked at how few people were able to talk about it; no one wanted to know. When I phoned a friend whose toddler was the same age as Caitlin, she quickly changed the subject and started chatting about what was happening in her life. The women in my mother’s group either didn’t know what to say or made unhelpful comments: ‘Oh well, you still have Caitlin.’ ‘Its nature’s way, there must have been something wrong with it.’ ‘At least it happened early, before you became attached.’ I so wanted someone to acknowledge the significance of my baby’s life and my acute feelings of grief and loss. Prior to my miscarriage, I worked part-time as a fertility educator in a maternity hospital and one of my tasks was to give information to mothers on the postnatal ward. Unable to bear being in such close proximity to newborn babies, I had to resign a few weeks later. Having just moved into our first home, we now had only one income to finance the mortgage.

Some months later, I began attending the SANDS (Stillbirth and Neonatal Death Support) meetings, a peer group of other parents who had also experienced the loss of a baby. Each month, we met in someone’s home and sat around the kitchen table sharing tea and nice things to eat.

While our toddlers played together, we told our stories about the death of our babies. People listened attentively and there was permission to speak. My raw feelings of grief and loss were welcome. I realised that all of my feelings were normal, an appropriate response to the loss of my baby. Some of the stories were heart-wrenching.

My experience of miscarriage was not deemed a ‘lesser’ loss; it was simply accepted as my experience.

In honour of my baby, I created a special place in our garden with a statue and two flowering shrubs. I also compiled a memory box with the pregnancy test, the fertility chart, and the congratulations cards about the pregnancy, the condolence cards and other memorabilia.

From time to time I open this precious box and go through all the treasures and remember this special being that touched me so powerfully. I created a small plaque with his name, date of birth and date of death, and hung it up on the wall along with our other family pictures.

Even though I miscarried over 14 years ago, my body knowledge of this experience has never disappeared. Each year, when the anniversary comes round, I get hyper sensitive. It is always a poignant time. In her book Woman: an intimate geography, Natalie Angier writes: ‘Stray cells from a growing fetus circulate through a woman’s body during pregnancy… scientists have found

An experience of miscarriage from a spiritual perspective fetal cells surviving in the maternal bloodstream decades after the women have given birth to their children… A mother, then, is forever a cellular chimera, a blend of the body she was born with, and of all the bodies she has borne. Which may mean nothing, or it may mean that there is always something there to remind her, a few biochemical bars of a song capable of playing upon her neural systems of attachment, particularly if those attachments were nourished through a multiplicity of stimuli, of sensorial input’ (1999:319).

All around the world and down the ages, women have borne these intimate experiences of life and death, and supported one another through them. It is what women do — conceive, grow babies, give birth to them, breastfeed and care for our infants, and support one another.

Sometimes babies die, whether in early pregnancy or full term. That is the nature of life. In the past, women were usually the ones who readied the body for burial. When death like birth was moved away from its social context in the home and into the public sphere of the hospital, we began to lose this firsthand knowledge about how to negotiate these pivotal rites of passage, their physicality and the emotional terrain that accompanies them. Now, we live one step removed from the process, particularly in Western culture, and we have lost the emotional skills for dealing with these stark realities. But we need to remember them again; they are part of our female heritage.

As a community, we need to acknowledge the experience of miscarriage as an aspect of our existence that is worthy of attention and discussion. We need an appropriate vocabulary to talk about it, one that does not dehumanise the event or distance caregivers from those they are caring for. The nurse who looked after me during my D and C was warm and caring, but some of the language

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Reading these words, I understood that my deep emotional response was not just cerebral. It had a physical substrate, fuelled by the cellular remnants of my baby’s presence circulating in my bloodstream, like a lullaby echoing around inside me. This mystery is part of the awesomeness of what it means to be female. As women, we are capable of bearing new life inside us. When a baby dies in utero, we carry the footprint of that baby’s death inside the intimate contours of our bodies. It is a dark privilege that is both a double-edged sword and an initiation into realms of existence not commonly acknowledged.

considered normal by medical staff was jarring to me. The technical language, social silence and cultural discomfort about miscarriage represent a disservice to women and a lack of respect for the deceased babies. Their lives, however short, matter and our lives are impoverished by ignoring that impact. Not every woman who miscarries is rent with grief; it is a uniquely individual experience coloured by her social context, her pregnancy intention, her depth of attachment to her baby, her family circumstances and so on. Yet, in my professional work as a therapist, I have often witnessed relief and tears after validating a woman’s deep and hidden grief in response to her baby’s death in early pregnancy.

My spiritual experience at the time of my tiny baby’s death contains important lessons about life — about the spiritual realities veiled inside the pregnant belly, the sacredness of what is going on beneath the surface, the presence accompanying that ‘bundle of cells’, which is infinitely more than the physiological apparatus. This spiritual perspective does not spare us the harsh reality of grief and loss — but it brings deep meaning and humanity to the experience. In telling the story of my miscarriage, my hope is that midwives and the wider community may be inspired to consider the experience of miscarriage in a different light.

Sharon Moloney PhD is a women’s health practitioner and therapist, with a background as a fertility/childbirth educator, pregnancy/birth counsellor and hypnotherapist.

She has a private practice working with couples and individual clients on a range of reproductive and other issues. Her doctoral research explored women’s experiences of menstruation and birth as spiritual phenomena.

Correspondence to: Sharon Moloney, PhD. Independent Scholar & Women’s Health Therapist. 56 Illuta Street, Rasmussen, Queensland, 4815, Australia. Email: sg_moloney@bigpond.com

References Angier N (1999). Woman: an intimate geography. New York: Virago Press.

Roxburgh T, Boehme S, Usher J (1996). The book of weeks. Melbourne: William Heinemann Australia.

S Moloney. MIDIRS Midwifery Digest, vol 21, no 2, June 2011, pp167–169.

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pregnancy pregnancy NICE clinical guideline: hypertension in pregnancy – the role and responsibilities of midwives

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Helen Crafter, Dianne Garland

pregnancy

In 2010 The National Institute for Health and Clinical Excellence (NICE) released its guideline for the management of hypertension in pregnancy. This article relates to the information contained in the full guideline. Also available are Hypertension in pregnancy: quick reference guide, a short version, and Understanding NICE guidance: high blood pressure in pregnancy for women using NHS services. All Trusts should now be incorporating the NICE guidance into their local guidelines. Since publication, two amendments have been made to the text and these are taken into account below.

NICE offers the following definitions of hypertensive disorders in pregnancy which will now be adopted throughout the NHS:

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Chronic hypertension is hypertension that is present at the booking visit or before 20 weeks or if the woman is already taking antihypertensive medication when referred to maternity services. It can be primary or secondary in aetiology.

Gestational hypertension is new hypertension presenting after 20 weeks without significant proteinuria.

he advent of a NICE guideline for hypertension in pregnancy is a welcome addition to the midwife’s toolkit as it clearly explains how with best practice existing cases of hypertensive conditions can be better managed, and there is greater opportunity to identify those women who are at risk of potential harm from hypertension associated with pregnancy. It also highlights the continuing need for midwives and other health professionals to be observant, vigilant and proactive in their care. The guidance brings a broad range of evidence together in a single document, and while acknowledging a lack of evidence in many areas, there are a number of research recommendations which will help fill some gaps in knowledge in the future.

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The full guideline presents a large amount of information in the form of clinical pathways which are visually attractive and can offer clarity in terms of care management. Details of how the guideline was developed and the reviews of the evidence behind it are available at http://guidance.nice.org.uk/CG107/Guidance/pdf/English.

Pre-eclampsia is new hypertension presenting after 20 weeks with significant proteinuria.

Severe pre-eclampsia is pre-eclampsia with severe hypertension and/or with symptoms, and/or biochemical and/or haematological impairment.

Eclampsia is a convulsive condition associated with pre-eclampsia.

HELLP syndrome is haemolysis, elevated liver enzymes and low platelet count.

Mild hypertension is characterised by a diastolic blood pressure of 90–99mmHg, and a systolic blood pressure of 140–149mmHg. Moderate hypertension is characterised by a diastolic blood pressure of 100–109 mmHg, and a systolic blood pressure of 150–159mmHg. Severe hypertension is characterised by a diastolic blood pressure of 110mmHg or greater, and a systolic blood pressure of 160mmHg or greater.

(NICE 2010) MIDIRS Midwifery Digest 21:2 2011

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labour and birth labour and birth Exploring carers’ views and attitudes towards the use of water during labour and birth

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Dianne Garland Carers were very willing to voice their questions, experiences and concerns when in a face-to-face situation; I was naturally interested to see if this was the wider view amongst other carers.

Constructing the survey

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the views of those offering to care for women who wish to labour or give birth in water

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background information as to how they gained their existing knowledge about water use in labour

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what is available to women within the services or care context in which they work

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the understanding of the benefits or otherwise of this choice for women.

labour & birth

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uring 2009, whilst rewriting my book Revisiting waterbirth: an attitude to care (Garland 2010), it became apparent that although there is a reasonably large amount of evidence regarding clinical outcomes for water birth, one area of study sorely lacking was information about midwives’ and other carers’ views and attitudes towards using water in practice. Through my work on the use of water for labour and for birth, I have access to a number of professionals and non-professionals who attend my courses or contact me for information and I felt it would be appropriate to ask them about their understanding of the use of water in labour by completing a short survey. The questionnaire was either available at one of my study days, online or posted out on request.

This was not a research survey or an audit of practice, but an initial enquiry into:

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To compile the questions for use in the survey, I drew on three pieces of research as a guide to what questions to ask to help respondents identify with the ideas of most interest to me. The need for more information about the use of water within the maternity services was also supported by a report from the Healthcare Commission (2008) which identified that while 95% of Trusts claimed to be able to access facilities for women to use water in labour, it appeared from the information obtained that only 11% of women reported having used a birth pool, with even fewer (3%) giving birth in water (Healthcare Commission 2008:36).

The report also highlighted the lack of appropriately trained midwives attending women who wanted to use water for labour and/or for birth.

Key background literature A study by Meyer et al (2010) explored the experiences and perceptions of certified nurse-midwives in Georgia, USA. A convenience sample of 119 nurse-midwives attending the local chapter of American College of Nurse Midwives (ANCM) (similar to a Royal College of Midwives (RCM) branch in the UK), were invited to take part in a survey to which 45% responded. The majority of midwives had some experience of water birth through self-education or clinical practice but only half of those who responded used water in their practice. The greatest benefits for mothers were seen as relaxation and reduced use of other analgesia. The midwives’ greatest concerns were regarding maintenance of water temperature, physical stress on the midwife and inability to see the perineum. The midwives’ main support for water birth appeared to focus on the benefits for the mother, with less worry about the risks.

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postnatal postnatal ‡

Postnatal care: exploring the views of first-time mothers S Bailey Government policy has highlighted the provision of a postnatal service that responds to women’s physical, psychological, emotional and social needs. This paper presents the results of a small in-depth qualitative study that aimed to explore the views of first-time mothers with regard to the level of support they would have liked to receive from health visitors during the postnatal period, focusing on the theme of health visitor contact.

Homogenous sampling was used to identify seven firsttime mothers. Data was collected from semi-structured

interviews and analysed using a thematic network approach. Four organising themes were identified — health visitor contact, emotional adjustment to motherhood, infant feeding and other support.

Although the first-time mothers valued the postnatal support provided by the health visitor highly, there were varying levels of satisfaction with the frequency and pattern of health visitor contacts. The findings also raise issues about the perception of need and the value of home visiting during the postnatal period.

The provision of postnatal care and support is a long established part of the health visitor’s role. However, it is only in recent years that postnatal service provision has come to the forefront of government policy. Recent publications highlight the importance of providing new mothers with a postnatal service that responds to their individual physical, psychological, emotional and social needs, acknowledging the role of the health

visitor in providing woman- and baby-centred care (Department of Health/DH 2004, National Institute for Health and Clinical Excellence/ NICE 2006, HM Government 2006).

For many first-time mothers, the postnatal period marks a time of emotional and social change as they are simultaneously confronted with the demands of caring for their new baby and adjustment to their new role.

Adaptation to motherhood can be complex and affect all aspects of the

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postnatal

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Introduction

new mother’s life (Wilkins 2005). It has been suggested that the addition of a newborn baby to a family brings with it more profound changes than any other stage of the family life-cycle (Nystrom & Ohrling 2004). It is common for new mothers to experience feelings of anxiety and uncertainty as they adapt to their new role, and it is imperative that new mothers feel supported during this period. NICE guidelines for routine postnatal care (2006) propose that postnatal care is pre-eminently about the ‘provision of a supportive environment in which a woman, her baby and the wider family can begin their new life together’ (Demott et al 2006:8). Correspondingly, the Child Health Promotion Programme (DH 2008) places a major emphasis on supporting the transition to parenthood, especially for first-time parents. Health visiting service provision during the postnatal period has needed to develop in response to policy and guidance (NICE 2006, DH 2006b, DH 2007), which has emphasised the importance of consulting with and involving patients and service users in the development of healthcare initiatives (DH 2005, DH 2006a).

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infant nutrition infant nutrition ‡

Encouraging breastfeeding: a relational perspective F Dykes, R Flacking 1. Introduction

The BFHI was developed by WHO and UNICEF to reverse the medicalisation of infant feeding that occurred during the twentieth century to include rigid determination of the frequency and duration of feeds, separation of mothers and babies and unnecessary supplementation of breastfeeding with infant formula.6-8 It aimed to restore the relational aspects between mother and

infant nutrition

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Despite the WHO recommendations that babies should be breastfed exclusively for six months and thereafter for up to two years and beyond this pattern of feeding is far from the global norm. Although breastfeeding is triggered through biological mechanisms which have not changed with time, the perception of breastfeeding as a phenomenon is variable, as it not only reflects cultural values of motherhood but is also negotiable from the perspective of the individual. This paper argues that relationships are central to encouraging breastfeeding at an organisational, family and staff parent level. This shifts our conceptualisations away from the primary focus of breastfeeding as nutrition which, in turn, removes the notion of breastfeeding as a productive process, prone to problems and failure.

Breastfeeding is universally acknowledged as providing health benefits to both mothers and infants.1 The Global Strategy for Infant and Young Child Feeding,2 provides an international, evidence-based guide to protecting, promoting and supporting breastfeeding and to optimising practices in relation to infant and young child feeding. The Global Strategy aims to ‘improve — through optimal feeding — the nutritional status, growth and development, health, and thus the survival of infants and young children.’2,p6 Central to this is the recommendation that infants should be exclusively breastfed for the first six months of life and thereafter receive nutritionally adequate and safe complementary foods with breastfeeding continuing for up to two years of age or beyond. The Global Strategy refocuses, internationally, attention towards policy and practice on the feeding and well-being of infants and young children, by calling for a renewed commitment to the WHO International Code of Marketing of Breastmilk Substitutes,3 the Innocenti Declaration on Protection, Promotion and Support of Breastfeeding4 and the Baby Friendly Hospital Initiative (BFHI).5

baby, staff members and parents and to provide additional support for women once they left hospital. Key aspects include provision of health professional education, providing appropriate antenatal information, encouraging skin-to-skin contact between mother and baby, providing health professional support with lactation to include those mothers separated from their babies, avoidance of giving unnecessary breast milk substitutes, keeping mothers and babies together, encouraging flexible, baby-led breastfeeding and offering mothers peer support once discharged from hospital. Research has identified that implementation of the BFI has a positive impact on breastfeeding rates9-17 though there are continuing challenges in achieving successful implementation.18 Whilst initiatives like the BFHI are crucial, when we ask ourselves the question, ‘how can we encourage women to breastfeed and to do so exclusively and for longer?’ Our starting point needs to centre on, why, given the overwhelming evidence of the value of breastfeeding for mother and child, do so few women initiate and continue to breastfeed in many communities across the globe? This can only be answered by focusing upon the cultural issues related to breastfeeding.

There is a growing body of research that illuminates the ways in which maternal dietary and infant feeding practices relate substantially to local cultural norms and constraints.19-22 Therefore, we cannot simply recommend interventions without thoroughly exploring the socio-cultural

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neonatal and neonatal andinfancy infancy ‘Leaving footprints on our hearts’

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— how can midwives provide meaningful emotional support after a perinatal death? Part 2 Judith Stolberg

After exploring concepts around grief in relation to culture and the specific nature of birth, death and parenthood in my first article, featured in the March edition of MIDIRS Midwifery Digest, this second article focuses on midwives’ communication and interpersonal

skills, as well as their experience of caring for bereaved parents. This article concludes with an exploration of basic palliative care principles which might offer a new approach towards the improvement of perinatal bereavement support.

distress (Kohner & Henley 2001). Good practice guidelines have been developed in conjunction with bereaved parents to assist practitioners in this situation, in particular how to manage the more clinical aspects of perinatal loss and to facilitate grieving through rituals and memory making (Schott et al 2007).

Building a relationship and communicating with bereaved parents

MIDIRS Midwifery Digest 21:2 2011

neonatal & infancy

© Vibe Images, Fotolia

idwives might encounter women and their families at any stage of a perinatal death and the quality of care will ‘shape and colour’ parents’ memories to the extent that they can either relieve or aggravate their

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Reluctance or fear on the carer’s part to fully engage with the parents can create barriers to communication, thus leaving the parents feeling abandoned and unsupported (Lundqvist et al 2002, Down & Simons 2006). Hence, the development of a trusting relationship based on mutual respect and genuineness is paramount to the provision of individualised and inclusive care which can help to instil confidence in the parents and their ability to cope. This relationship provides the foundation for the parents to explore their feelings and requires the midwife to be able to accept their intense emotions and to treat both parents and their baby with sensitivity, dignity and respect (Moulder 1999). Empathy and self-awareness are crucial components in achieving a shared understanding of the bereaved family’s perspective without losing a necessary professional distance (Norfolk et al 2007). Practitioners must be aware of so-called micro skills to facilitate effective communication through posture, proximity, gestures, eye contact and tone of voice while being able to engage the parents by using open questions and reflecting back or paraphrasing the actual words and feelings expressed (Egan 1998). Sometimes touch can convey a sense of understanding and caring when words seem trite 235

worldwide worldwide maternity services maternity services *

What is a quality maternity service?

Reflections after an elective placement in Bhotechaur, Nepal, supported by the Iolanthe Midwifery Trust Alison Norris people in Kathmandu explained how for a month after giving birth, women were kept from all work except tending their baby. In contrast, Tamang people living around BHC expected women to resume heavy physical work soon after labour and this, combined with multiple pregnancies closely spaced, contributed to a high rate of uterine prolapse (Rajbhandari & Pradhan 2009).

Bhotechaur Rural Community Health Services Centre, located in the foothills of the Himalayas, Nepal.

Nepal is a small country, sandwiched between India and China. Its terrain and its cultures vary hugely. In the mountainous west the only form of transport may be walking, physical access to health services is very difficult and a harsh environment means many families rely on money sent home by workers abroad. In the middle hills, where BHC is based, farmland is richer but infrastructure problems remain. The Eastern Terai, where 50% of people now live, is the edge of the Ganges plain, the wealthiest part of the country and strongly influenced by India. There are more than 70 ethnic and caste groups (Bhattachan & Pyakuryal 1996), each with their own attitudes to and traditions surrounding childbearing. For example, Newari

worldwide maternity services

women’s health volunteer explained ‘I love the women in this village and I don’t want them to die in childbirth,’ when asked why she had taken on her role.

This response was typical of the dedication and vocation of staff I met at all levels in the maternity service in Nepal, in the capital Kathmandu and in the Bhotechaur Rural Community Health Services Centre (BHC) where I spent most of my three week midwifery elective.

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In the United Kingdom (UK), after a long history of colonialism and misinformation, it is hard for us to get a clear picture of life in a low income country. My placement was set up through ACTIONAID Nepal, and staff organised for a female university student to act as an interpreter. This is essential for a non-Nepali speaker, and I would have understood little without her dedicated support. I know I arrived with romanticised preconceptions about the strength of community and traditional wisdom supporting natural labour. I was unaware of many cultural and religious distinctions. I was unprepared for local traditions that made it bad luck for anyone to look at a woman’s vagina. I was shocked by widespread domestic violence, stemming from sexism and the stresses of poverty. However, I found it equally important not to underestimate the intelligence, resourcefulness and skills of local people. It may not be the case everywhere, but the staff I met were determined to offer as safe and effective a health service as possible given significant challenges in terms of resources, infrastructure and the social and political context. In this article I hope to convey a sense of the health professionals and volunteers I met as colleagues, keen to learn but also with a wealth of experience to share which brought insights that, for me, illuminated practice in the UK.

The context — challenges facing maternity services in Nepal Maternal mortality in Nepal remains high, though encouraging progress has been made to reduce rates since a Nepal Department of Health initiative, the Safer MIDIRS Midwifery Digest 21:2 2011

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