At the 3rd Student Midwifery Forum, held on 31 May 2016 at the Faculty of Health Sciences in Ljubljana, midwifery students really hit the nail on the head with their chosen topic, “Home Birth.”

The first lecture by Assoc. Prof. Dr. Irena Rožman, Univ. Grad. Ethnology & Sociology was presented by her husband, obstetrician-gynecologist Assist. Aleš Pišek, MD, specialist in gynecology and obstetrics, and I was truly delighted to listen to him not once but twice. Mrs. Irena is an extraordinary woman; she has written excellent articles, and she also authored the book “The Stove Collapsed – The Culture of Birth in the Slovenian Countryside in the 20th Century.”

Her lecture also included a quote from English literature about the difference in the character of an independent midwife versus a midwife who works in a maternity hospital.

“The character of an independent midwife’s work: Her schedule is flexible, not time-bound, and adapted to the needs of the birthing woman. She cares for the woman already during pregnancy, knows her needs, wishes, health status, family circumstances, etc.”

The character of a midwife who works in a maternity hospital: the schedule is fixed; her work is more routine than that of a midwife who helps a woman give birth at home; she works directly under a doctor’s supervision or according to their instructions; she doesn’t know the birthing woman, and at the same time she assists several women in labour.”

One of the slides also included the motto of community midwives, which actually applies to all midwives, but in the hospital setting there is usually (far) too little of it… either from staff or from the birthing women: “Patience, patience, and patience again.” Birth needs its time to unfold as it should, and when pathology occurs, the midwife must recognise it and respond appropriately.

Špela Urbanc and her partner shared their birth story with us—why they decided to have their second baby at home and what was so different compared to the first time. You can read their story HERE.

Independent midwife Jasna Gumze, BMid presented her work—what it’s like to be an independent midwife working in Slovenia. When and how her visits take place, and what they include. She would like women to contact her after 12 weeks of pregnancy, which is a period of well-being. In principle, she does 2 visits: 3 visits during the more demanding period and 4 visits in the preparation-for-birth period. Then come the birth and postpartum visits. She highlighted her wish for legislation in Slovenia to be arranged so that a midwife who attended the birth could also register the baby and carry out screening tests. Her website: http://babicajasna.si/kontakt/

Good prerequisites for birth

” First-time mother (a woman giving birth for the first time):

• From week 36 onwards, the baby descends into the lower uterine segment, with the head engaged in the pelvic inlet.
• In the 10th lunar month, the presenting part fills the upper part of the pelvic cavity up to halfway.
• Longitudinal lie.
• Head turned towards the sacrum. Flexed—1st or 2nd position.
• Cervix centred.
• Sagittal suture oblique.

Multiparous woman (a woman who has given birth at least once):

• The baby is in an indifferent attitude (not flexed), high. It enters the pelvis only with pre-labour contractions or labour contractions.
• Longitudinal lie (does not mean only a cephalic presentation).
• 1st or 2nd fetal position.
• Cervix slightly open, the vaginal portion shorter, wider, and does not disappear completely..
• Sagittal suture transverse (the head is not yet flexed).”

Assist. Aleš Pišek, MD, specialist in gynecology and obstetrics then presented his lecture. I’d like to highlight certain parts of it. First, the personality traits of independent midwives compared to midwives employed in a maternity hospital. Dear women, please read carefully… and think about it, especially when you decide to give birth in maternity hospitals where there are many births.

His personal view: “The central person in birth is the woman giving birth. Healthcare professionals are her companions. We are obliged to respect her as a person and take into account her decisions, needs, and wishes. We are her advisers, helpers, and providers of medical procedures that, during birth, prove to be necessary and that the birthing woman agrees to. To carry these out, we have the necessary professional knowledge and access to medical technology.”

Pišek also highlights the “Wisdom of teamwork,” which Zala also touches on a bit later:

“Midwives:

• Are directly present with the birthing woman and stand by her throughout labour (my addition: even if they may not be able to be physically with her the whole time!).
• Monitor the course of labour and detect possible deviations from normal.
• In case of deviations, they act together with the doctor.
• If there are no deviations, they help the woman give birth and care for the baby.

Doctors:

• Introduce ourselves and our colleagues to the birthing woman and her companions.
• On admission to the maternity hospital, we examine the birthing woman and the documentation on the course of pregnancy. We also ask about her wishes and plans. Based on all this, together with the midwife we agree with the birthing woman on the course of labour (Is that really so?!).
• We congratulate her after the birth (if everything goes smoothly, we midwives are also happiest that it all went smoothly).”

It’s also important that he highlighted “What influences obstetricians’ attitudes” and, last but not least, also midwives who have been in the hospital system for a long time:

“Historical memory: historical memory is an important factor that enables us to objectively compare the present situation with the past and helps us understand the factors that, over the course of development, led to today’s established obstetric practice.

Personal experience: Obstetricians who work in maternity hospitals gain experience from the first day until we retire. We also encounter tragic events such as the death of the mother and/or baby; we feel relief when we manage to prevent the worst. In doing so, we realise how little it takes for the unexpected to happen.”

Maternal mortality is certainly one of the indicators of quality. The ratio best:worst is 2054 (Sudan) : 2 (Estonia) per 100,000 live births, for 2010 (SOURCE: CIA World Factbook, link)

BIRTH SAFETY: “When we talk about the safety and advantages of home birth, it should be emphasised that here we are talking about home birth in settings where access to medical knowledge and technology is available and where communication and transport are organised. The historical memory that something can go wrong during birth is no longer present, and parents affected by any adverse outcome generally attribute it to medical error.

Given that nowadays pregnant women and partners, as well as the wider public, perceive an adverse birth outcome as completely unacceptable and impossible, we medical professionals are looking for a way to bring the possibility of an adverse outcome as close to zero as possible.”

Pišek said many important things in his lecture. It’s definitely worth highlighting “The chalice of the Last Supper of all-powerful studies,” the gist of which is that any study can give us the result we want to present. In other words: “Scientific studies are good servants but bad masters,” says Pišek. “When they are carried out in a scientifically and methodologically appropriate way, they help us compare procedures, choose the most appropriate one, and monitor its effectiveness. But when we expect them to make that choice for us, or when we want to see only what fits our ideas, they often become an end in themselves.”

“In an environment where favourable conditions regarding communication, transport, and access to medical knowledge and technology make it possible to achieve adequate and comparable birth safety at home, the right to choose the place of birth seems logical and self-evident to many.”

“When it comes to home birth, the task of the medical profession—both midwifery and medical—is to define professional criteria for such a birth within its legally defined competences. When the professional criteria are clear, it is then the task of health policy to decide whether it will ensure conditions that make it possible to carry out such a birth according to the defined professional criteria. We can expect, however, that given the complexity and high expectations, this process will be neither short nor simple.”

We should also form our own opinion about this article: Planned home birth: a review article (Takač, Serdinšek, 2016)

In December 2015, the Professional Educational Council and the Executive Board of the Association for Perinatal Medicine of Slovenia adopted a joint opinion on home birth:

“Until all conditions for a relatively safe home birth for low-risk pregnant women are met in Slovenia, any home birth is risky for the health and life of the woman and the newborn, as has also been shown in recent years.

Instead of introducing home birth as the first measure to meet pregnant women’s wishes, it would be better to first introduce midwife-led care for normal birth, a midwifery unit, or a birth centre (my addition: YES, LET’S DO IT!!). The professional basis for midwife-led care of a normal pregnancy and midwife-led birth, i.e., management of normal birth, has already been adopted by the Extended Professional Board for Gynecology and Obstetrics of the Ministry of Health of the Republic of Slovenia in the form of a clinical pathway with appropriate documents. The Ministry of Health should propose and implement the appropriate legal basis for providing midwife-led care for normal pregnancy and normal birth. In this way, midwives would gain the necessary practical knowledge and skills, and thus also the possibility of attending home births under accepted safe conditions. For independent management of home births, a midwife would need to independently manage between 100 and 150 births per year. With home births alone in Slovenia, this is not possible. Therefore, home births could be attended by midwives who would otherwise also be partly employed in midwifery units or a birth centre. Slovenia has 14 maternity hospitals, among which some could also be designated as a midwifery unit or a birth centre. For this purpose, the Ministry of Health of the Republic of Slovenia should carry out analyses, hold discussions with maternity hospitals and professional associations, and find a joint solution with maternity hospitals.”

In my opinion, it’s written very positively and realistically, but is there interest? I’m all for it right away.

Andrej Vojnovič, Univ. Grad. Law spoke about legislation. A midwife who successfully completes her education is allowed to attend a home birth. By far the biggest “gem” in the law was the provision on registering the child, i.e., verifying the mother’s identity:

Rosemarie Franc, BMid presented a lecture by Anita Prelec, RN, MSc (UK), who presented the work of the working group for new guidelines for planned home birth. The working group consists of:

• Rosemarie Franc, BMid
• Assoc. Prof. Dr. Ana Plona Mivšek, BMid
• Anita Prelec, RN, MSc (UK)
• Senior Lecturer Teja Škodič Zakšek, BSc Radiology Eng., BMid, MSc (UK)
• Andrej Vojnovič, Univ. Grad. Law

There was the most criticism here about the provision that an independent midwife at home must not use medicines. However, we need to know that the document is not something fixed; it will be revised and upgraded in the future. First and foremost, the working group’s goal is for it to be adopted at all. Additional training for midwives in Slovenia for planned home birth is being planned together with a supervisor; training for midwives in pharmacology and neonatology will be further developed. The document has been written and aligned with the RSK and the Association for Perinatal Medicine, and they are still waiting for a response from the Ministry of Health.

The document consists of:

• Introduction
• Evidence-based midwifery practice
• Regulation and legislation in Slovenia
• Risk factors for complications during birth
• Environmental criteria for planned home birth
• Basic equipment, aids, materials
• Birth registration
• Keeping birth records
• Transfer to a maternity hospital and reasons for transfer
• Care of the postpartum woman and the newborn in the home setting

This was followed by another lecture I really enjoyed, given by Zala Pušnik, BMid, who works in Carinthia, Austria, as an independent midwife attending home births. She never considered working differently (in a hospital setting). After completing studies in Russian and media communications, she decided to study midwifery as well. After finishing the College of Midwifery in Klagenfurt, she completed the required internship (1 year) with a mentor who is also an independent midwife; she was her assistant. Through this, she learned and trained for independent work. She also teaches at the College of Midwifery in Klagenfurt, educating young midwives in practice, and in their curriculum each student is required to do a placement with an independent midwife so they can see how the work is done, even if they later work in a clinical setting. She explained how wrong a picture people have of independent midwives—for example, how much she actually keeps from one birth that costs, say, EUR 2,500, which includes all preventive check-ups during pregnancy, the birth, and postpartum visits that end after 1 month, when the mother and newborn are also somehow ready to leave their nest. After the birth, she also registers the birth, performs screening tests, advises on breastfeeding, and everything else that belongs to the postpartum period. In their system, paediatricians come to the home to examine the baby; some also perform ultrasound scans. It’s a way of life—you’re available 24/7, and you really need a partner and family who understand that. She is the mother of four children. She also says that when a birth starts at home and ends in the maternity hospital, midwives “draw the short straw.” And when a birth that started in the maternity hospital ends spontaneously with a caesarean section, we also draw the short straw. Maybe I missed it, but in Zala’s lecture it felt truly important to me for the first time that she pointed out that this is not about us—midwives and doctors—who is right and who is not. It’s about women and newborns. And because of that, we need to find compromises, and above all, appropriate communication, so we can carry things out at a high level of safety and quality. In their system, they have at least annual meetings with heads of clinics to align on possible complications and misunderstandings, so everyone can work smoothly and care remains high-quality and safe. Zala’s website: http://www.zala-hebamme.at

Birth photography: Adriana Aleksić (Month of May) was also the forum’s official photographer. She told us how she actually got involved with births, how she does her work, and what matters in it. Her photos and videos always move me.

THANK YOU!