1. MIDWIVES WORKING FOR MIDWIVES – THEIR EXPERIENCES AND CHALLENGES Dr. Diana du Plessis In Association with Philips Avent 2012

2. Philosophy of Woman-centered care Gives priority to the wishes and needs of the user. Embraces the midwifery-led care of women with a normal pregnancy, labour and post-natal period. Confidence in the body’s natural abilities

3. Woman-centered care:  Childbirth: a normal life experience Most pregnant women have the potential to have a normal and safe pregnancy and to give birth without medical intervention

4. Midwives are private primary care givers Work in close collaboration with medical practitioners who share the same philosophy of childbirth

5. Private maternity obstetric unit in Johannesburg Private midwives and MOU midwives work collaboratively Provide intrapartum and postpartum care  Low-technology care  Homely and relaxed atmosphere.

6. The private midwife Has to apply for “birthing rights” Must provide proof of obstetric back-up Self-employed practitioner or in partnership Provides antenatal care, Progress the client intrapartum and Provide some post partum care Work independently and in close collaboration with the midwives appointed by the MOU

7. MOU midwife Assists the private midwife during labour and birth and nurses the client post-natally

8. Problem statement Numerous studies on the effectiveness of birth centers but minimal research was found on the experiences of midwives and private midwives working together in an MOU in collaborative partnership. From personal observation, it appears that the relationship between the private midwife and MOU midwife changes when these two sets of practitioners provide “split-services”

9. Research questions What are the experiences of midwives working for private midwives during labour, birth and the postpartum period in a private Midwife Obstetric Unit in Gauteng? How can the midwives be assisted to deliver collaborative maternity care?

10. Results: Theme 1. Positive experience Identify with the values and aims of the MOU Felt supported in their efforts to treat the laboring women with dignity and respect Practiced as peers and colleagues Had the opportunity to improve their knowledge and skills

11. “I agree with the ethos of this place; we should not interfere with labour and birth”.

12. Positive continue Expanded on the reasons why they left the traditional hospital systems:  Not treated with dignity and respect;  “I just could not fight the system”.  “I left government, because they treated the women so badly”  “I left them (the private hospital group) because the women are all conned into caesareans, and I had to stand there and defend the doctor”.

13. Positive continue Felt appreciated if their opinions were sought by the private midwife. “It [working in collaboration] makes it easier to work together as a united group” “Better than working for a doctor”. They valued the opportunity to share ideas and experiences with one another.

14. Theme 2: Staff midwives expressed negative sentiments Role conflict

15. 2.1 Role conflict and accountability “……Midwife X called for obstetric back-up too late…….. I was called in as to provide an explanation and to write a detailed incident report. I already felt bad that [the incident] happened, all of a sudden I felt it was my fault.”

16. 2.2 Role conflict: responsibilities Staff midwives felt being taken advantage of “We are supposed to be a team, to help and support each other but I know that midwife A induces clients in her consulting room. By the time the client arrives in full labour, the midwife pretends that the client went into normal labour. By withholding information, she puts me at risk” “By the way, is an induction part of the private midwife’s scope of practice?” “When I complain about this issue, my concerns are ignored”.

17. Role conflict: staffing Frustration when agency places an inexperienced or disinterested staff member. “We were so busy and then I had to work with an inexperienced agency staff member, it was really difficult. But if I complained …. She will just take her bag and go”

18. 2.3 Role conflict and the private midwife “[She] acted like a gyne and only pitches way later. I’m required to progress a woman I have never even seen before. How is this different from government? …. She gets the money for the delivery, yet I have to do the progressing!”

19. 2.3.1 Lack of Professional Conduct The private midwives were not necessarily seen as leaders or experts Late arrival “I had two fresh c/sections, and the rooms were all full. When the lady arrived without calling her midwife, I had to stop everything and progress her.”

20. Role conflict continue Felt not valued: “I gave her some advice when the woman was pushing for a long time, but she said afterwards I was interfering and overruling her authority. I thought we were colleagues and was merely trying to help … I mean, I am not inexperienced!” “I have the impression that there is a gap between us; my opinion just does not count”.

21. Role conflict continue Quality of the relationship with the private midwives:  Entry to the room restricted  But then requested to suture a tear “I refused to do that, it’s her responsibility and I told her to phone the back-up gyne if she is not up to it.” “I also take responsibility if I suture…. Why can’t she do it herself? I’m not good enough to be present during the birth, why do I have to do the dirty work? How do I know what happened?”

22. 2.4 Role conflict: Undermining the ethos of the MOU Interference in the normal process of labour  Inductions;  medicalization in stead of non- pharmacological methods;  ROM  IV infusion (short line) inserted regularly, especially when the labour is progressing slowly. “push the boundaries and got away with it…..

23. 2.5 Role conflict & client No relationship with the client Had to remain in the background Felt left out “…I felt unwelcome and disappointed” and “I didn’t know if she noticed I was actually there”

24. Role conflict continue Reluctant to report “….we are evaluated by the private midwife…. I don’t want to be seen as a negative person”

25. 2.6 Communication barriers The private midwife’s professional notes were often not available, written or accessible. No antenatal records. Incomplete private midwife’s records Staff midwives had to “find” the relevant information and complete the patient files. “Why must I guess the amount of blood loss during the second stage or complete her partogram? It remains her responsibility!”

26. Theme 2.7: Workplace boredom

27. Workplace boredom Provide help and support during the second stage of labour and nurse the woman in the post partum period. Some liked being absorbed into the system Others: Stagnating and their skills were eroding. Expressed the need to start an own private practice or to travel internationally to gain more experience. “I really miss being the actual midwife, but I don’t want to be in private practice either. What do I do?”

28. The End Mutually beneficial Quality Maternity Care Partnership