Midwives as researchers

10 World Health • 50th Year, No. 2, Morch-Aprill997 Midwives as researchers Ulla Waldenstrom A home birth in a remote area of Mongolia Immediately after birth, the baby finds the breast and starts suckling. Photo WHO/ UNICEF / R. Lemoyne. Agrowing number of countries have transferred their mid-wifery education into the university sector, thus enabling midwives to complete their training with an academic degree. In addition to having the clinical skills needed to care for women during childbirth, these new university-trained mid- wives have an understanding of the basic principles of research. They have had the opportunity to develop their critical thinking skills, to under- stand the importance of keeping abreast of new knowledge and to base their practice on evidence. Most of the midwifery graduates will become good research consumers, and some will continue their aca- demic careers into Masters and Doctoral studies, carrying out their own research. Conducting research is increas- ing! y a part of midwives' profes- sional careers. An important question is whether midwifery research contributes to our knowl- edge about childbearing and mater- nity care, or whether the research at present being carried out by doctors and other professionals is sufficient. My response is that midwifery research does indeed produce new data that can be of great value for the Midwifery research has an important role to play in meeting the general goals of maternity care: safety, satisfaction and low costs. Its greatest contribution will be to meet the second of these goals. care of pregnant women and for the improvement of maternity services. The fact is that midwives' sphere of practice differs from that of doc- tors and other health workers , and therefore midwives ask different questions. Compared with obstetrics and the practice of doctors, mid- wifery has a stronger focus on the normal process of pregnancy, labour and birth and on emotional well- being and support, especially during labour. Areas of midwifery research Several research projects undertaken by midwives have questioned proce- dures that might be seen as "medical- izing" pregnancy and birth, thus unnecessarily jeopardizing the nor- mal process. Midwives have been involved in projects to evaluate the routine use of episiotomy (a cut in the perineum to widen the birth canal). It is generally accepted in medical practice that no intervention should be carried out unless it clearly benefits the person receiving it. Research begun by midwives has shown that there is little evidence of such benefit in the case of routine World Health • 50th Year, No. 2, March Aprill997 Home visiting. Continuity of care helps to ensure a normal process of pregnancy, labour and birth. Photo WHO/H Anenden. episiotomy. Other midwifery re- search projects have looked at the routine administration of the drug oxytocin to reduce blood loss at birth, the dorsal position during labour and birth, breastfeeding at fixed intervals and the length of hospital stay after the birth. Midwives have also been instrumen- tal in introducing and evaluating alternative methods of pain relief (such as relaxation techniques and immersion in water), alternative birth positions, support in labour, and midwifery models for the continuity of care from early pregnancy to the period after birth. Other important areas of mid- wifery research are women's experi- ences of pregnancy, birth and early motherhood, experiences of father- hood, reactions to negative experi- ences in pregnancy and childbirth, and satisfaction with the care that is provided. Besides the evaluation of different clinical procedures and studies of satisfaction and emotional well-being, midwifery research covers cultural, ethical , educational and professional issues. Effect of medication The effect of the drug pethidine in labour has been extensively studied. We know that the medication gives some pain relief during labour, but also that it affects the baby. A new interest in pethidine during labour has evolved from midwives' interest in breastfeeding. Anne-Marie Widstrom and colleagues found that a baby placed skin-to-skin on its mother's chest during the first hours after birth exhibits an innate ability to find the mother's breast and start suckling. Another midwife, Eva Nissen, investigated the hypothesis that pethidine negatively affects the baby's breastfeeding reflexes and thus its capacity to reach the breast. She found that infants exposed to pethidine had delayed and depressed sucking behaviour and that a smaller proportion of these babies started to suckle compared with those who were not exposed to pethidine. These findings probably contributed to a reduction in the use of pethidine in Sweden from 45 % to less than 10%. Research aimed at evaluating new models of care, characterized by continuity of care and in some mod- els by the restricted use of medica- tion and technology, has been carried out by doctors as well as by mid- wives. Most studies have been descriptive, but during the last few years the results of at least seven randomized controlled trials have been published. In more than half of these trials , the chief investigator was a midwife. The studies showed that the alternative models were associ- ated with less use of pain relief, less artificial stimulation of labour, less electronic fetal monitoring, fewer episiotomies and fewer operative deliveries compared with standard care. No differences were observed in perinatal mortality, and satisfac- tion with care was increased. 11 Compared with other professional groups in maternity care, the midwife is probably the care provider who spends the largest proportion of her time in a supportive role. This may explain why midwifery research often addresses issues of satisfaction and emotional well-being. Studies of mothers' satisfaction with birth suggest that pain has a negative impact. Paradoxically, however, there is no scientific evi- dence that pharmacological pain relief has a positive effect on the general birth experience when as- sessed after the birth. Social support in labour seems to be a more power- ful positive factor. Studies of women's birth experiences illustrate the complexity of the phenomenon and the importance of individualized and sensitive care. Many important questions remain to be answered. There are still major areas of midwifery practice which are not evaluated, procedures that have been carried out for decades without any evidence of their effec- tiveness. New medical technologies are still being introduced without sufficient evaluation, whether from a medical point of view or from the standpoint of patients in terms of satisfaction and psychological out- comes. Long-term follow-up of different procedures is very rare. We still have limited knowledge about women's experiences of preg- nancy, birth and early motherhood in different cultures and the factors that influence those developments, or about the impact of the various procedures, medications and tech- nologies we use in maternity care. In summary, midwifery research has an important role to play in meeting the general goals of mater- nity care: safety, satisfaction and low costs. Its greatest contribution will be to meet the second of these goals. • Ulla Waldenstrom is Professor of Midwifery at La Trobe University's Graduate Clinical School of Midwifery and Women 's Health , Car/ton, Victoria, Australia.