Professional independence of midwives

dr Grażyna Bączek
In Poland, midwives can provide independent care for a woman in healthy pregnancy and during regular childbirth and confinement, prescribe some medications and perform ultrasound examinations. - The law gives us the opportunity to act independently, but the health care system does not yet see, respect and use it - says Grażyna Bączek, PhD, Head of the Gynaecology - Obstetrics Didactics Department at MUW, Director for Nurses and Midwifes at St. Sophia’s Specialist Hospital in Warsaw.

In recent years, the profession of midwife has gained a reputation, also because the system of teaching midwives has changed. What does university education give to the students and midwives?

Until 2000, the education of midwives in Poland was executed as a post-secondary 2.5-year medical course. Then, due to our country's accession to the EU, it was necessary to adapt the educational paths to EU standards. The education of midwives was transferred to the university level in the form of three-year first degree studies and two-year second degree studies. As a result, the rank of the midwife profession has changed. Doctors, pharmacists, midwives, nurses, paramedics, physiotherapists, etc. study at one university. Each responds to different needs of the patient. It is also worth emphasizing that midwives also have doctoral studies and post-doctoral (habilitation) procedures on their educational path. We have a large group of midwives with post-doctoral degree, midwives with the title of university professor (although not at the Medical University of Warsaw) and one midwife with the title of professor.

After graduation a midwife starts working in a profession that is becoming more and more independent - what does it mean? 

The midwives were in fact quite independent from the very beginning. Let us analyse two acts of 1840 and 1906. Both of them include detailed description of the profession and the criteria that must be met in order to be able to perform it. In those years, the midwife was often the only medic in the country. She was the person to go to when childbirth was approaching, as well as in any matter related to health. Today this independence is defined in the Act on the profession of nurse and midwife. A midwife can provide care for a pregnant woman, a woman giving birth, a postpartum woman and a new-born, as well as a gynecologically ill woman, a senior woman and a girl during the time of puberty (education and care in the field of reproductive health). We have to emphasize, that our independence concerns providing care for a woman who is fully healthy. When we observe irregularities, we work in team with a doctor. 
Pregnancy is not an illness, so is it the midwife's responsibility to provide care for healthy pregnancy?
Yes, it is stated in the act on the profession. We also have the "Organizational Standard of Perinatal Care" in the rank of the Regulation of the Minister of Health and in this document the midwife is listed as one of the persons who can provide independent care for a woman during healthy pregnancy and during regular childbirth and the postpartum period. This means, that she can e.g. identify pregnancy, monitor it, perform ultrasound examinations, educate women, prescribe certain medications. Unfortunately, competences are not yet fully recognized and used by the health care system, and therefore unavailable to patients. 

In Poland when a woman gets pregnant she goes to the doctor. Why not to the midwife?

I think that there is more than one reason. But most important one is the matter of availability of such health service. Providing care for the pregnant by a midwife is a service that is difficult to access or even unavailable in the Polish health care system. We have had such service in the system for several years, but only as part of Primary Health Care. Practice shows, that women prefer to get the pregnancy care in other centres - specialist outpatient care, hospital outpatient clinics, private doctor’s practices (i.e. outside the reimbursement system) - but not in PHC. 
Providing pregnancy care should not be linked to a specific place in the system or form of professional practice, but to the midwife's profession and competences in general.
The organization of healthcare should follow the patient – her expectations and preferences. According to this approach to pregnancy care, a woman who gets pregnant, but also a woman who is planning a pregnancy, should have a choice within the reimbursed care: I want to get pregnancy care at a doctor’s or I want to get pregnancy care at midwife’s. I wish we could have such two options in the system. After choosing one of them, the woman learns the criteria, rules and course of care from one of the two professionals. She also makes the decision she can change (or she has to change if any difficulties requiring doctor’s care occur). I think such option is inevitable for many reasons and will be real in close future.

How does it work in other countries? 

In France I visited many times the universities educating midwives, as part of the Erasmus + program. In addition to teaching classes for French students of Obstetrics, I had the opportunity to observe and participate in various forms of professional practice. There, when woman gets pregnant, she may go either to the general doctor, to gynaecologist or to the midwife. And ca. 50% of French women choose the third option. We should also notice that French midwives are far more independent. For many years they have been prescribing certain medications (including antibiotics after performing antibiogram) and perform the ultrasound examinations (in Poland, we can theoretically perform ultrasound, because we acquire such competences in the course of education at second degree studies, but the system does not allow us to do so yet). In Scandinavia, the midwife's independence is even more highlighted. The midwives there are a very strong professional group and are very strongly integrated with the health care system. The pregnant women mostly go to them.
Is the strong position of the midwives connected with the fact, that there are many home births in Scandinavia?

Partly yes, however this independence is well established by many years of functioning in the system. There are indeed a lot of home births there, just like in the Netherlands. But we must remember that their popularity is conditioned by culture. Their health systems have adapted to this procedure and treat it as one of the possible forms of care. Care that is based on the application of specific eligibility criteria for childbirth, supervision and compliance with the procedures set out by law. Only then such childbirth is safe. We cannot forget that only a healthy woman without any risk factor can give birth at home. 
In Poland, home births also take place, albeit rarely.
This is not a significant number and the decision is always made by the woman. There are many reasons for such a choice - the desire to give birth at home, intimate environment, difficult experiences from previous deliveries or reluctance to the hospital environment and its rules. Home births are only possible as a private service. The pregnant woman signs a contract with the midwife for such a service and must pay for it. A home birth accompanied by a professional – a midwife is not reimbursed by the health care system. Of course, the qualification procedure for such a birth and the rules of care are strictly defined in the standard of care, based on international documents regulating this form of perinatal care.

What are the Birth Centres?

Birth Centre is an alternative for women wanting a natural and non-medicalized birth, but their sense of safety is ensured only by direct availability of hospital procedures. There are two types of birth centres. Free-standing - quite popular in Western countries and hospital-based, or actually in-hospital. The example of the second one is the Hospital Birth Centre at St. Sophia’s Specialist Hospital, where I work.
It is a separate space in the hospital organization managed by a midwife and run by midwives. We have three rooms arranged as home rooms. Of course we have all the necessary medical equipment, but it is well hidden to create a friendly atmosphere and to reduce stress. Births proceed in their natural rhythm, without unnecessary medicalization, but under the watchful eye of an experienced midwife who monitors their course in accordance with obstetric and standards of care. When irregularities occur, a doctor is called and together they decide on further treatment. A woman who during childbirth decides, that she would like to have analgesia, can go to the delivery ward at any time and continue childbirth there using the available means. So on the one hand we have home conditions - intimacy and silence, and on the other - safety - just a few minutes and the patient can be transported to the operating theatre. Of course, only women with a low risk factor can be qualified for childbirth at the Birth Centre. The evaluation takes place during qualification visits also performed by midwives. Births in the Birth Centre account for approx. 8% of all natural births. Of course, all care is provided under the contract with the National Health Fund.

We are talking about healthy births, which theoretically should be the largest number, but when we look at the statistics, in Poland in 2021 we had 40 percent pregnancies ended with caesarean section.

In Poland, as in most countries, we have a three-level perinatal care system. First-level hospitals are dedicated to pregnant women with low risk factor. Patients with an average risk factor are referred to second-level hospitals. Patients diagnosed with the highest risk factor are referred to a third-level hospital. Of course women with healthy pregnancy may go to any of them and give birth in a chosen facility. However, analysing the clinical picture of patients in individual hospitals, we may conclude, that the highest percentage of caesarean sections should be observed in a third-level hospital. 

Where you treat the most difficult cases?

Yes. Where it is necessary to use specialized procedures, where specialized equipment for mothers and new-borns is required, where women in conditions threatening their health and the health of their children are admitted. So the high percentage of caesarean sections would be justified. The reality, however, differs from rational predictions. The highest rates of caesarean section are observed in first-level hospitals with a low birth rate. In hospitals where, by definition, healthy women without risk factors should be giving birth to healthy full-term babies, we observe 60-70% of caesarean sections. 

Why is this happening?

This issue concerns people from many circles, I myself participated in many debates on this subject. A few years ago, this trend was even the subject of interest of the Supreme Audit Office. The problem is also being analysed in the government's Demographic Strategy 2040 project. In my opinion, achieving a lower percentage of caesarean sections in Poland requires responsible, integrated and bold decisions in the medical (both science and education), educational, legal, economic and political areas. These disturbing data are the result of many circumstances - medical practice, legal practice, women's access to reliable health education, and finally the division and administrative subordination of hospitals and maternity wards in Poland. It is worth noting that the lowest percentage of caesarean sections is in the aforementioned Scandinavia. Why? Is it because the pregnancy care there is provided by the midwives? Or perhaps it is because effective prenatal education is implemented? And the midwives have time (as part of the reimbursement) to conduct a few or a dozen or so hour-long visits, to explain what a regular childbirth looks like, dispel any fears of their patients? Or maybe the strong position of the midwife integrated with the health care system somehow contributes to such a state?

The St. Sophia’s Specialist Hospital, where you work and which closely cooperates with the Medical University of Warsaw, introduced a model of care coordinated by a midwife. What does it mean?

In practice, under the project a midwife accepts a woman with a new-born to the ward, assesses their health, monitors all parameters during the stay, carries out orders, educates the patient or helps in solving current problems. She also orders necessary tests, certain medications or consultations, if necessary. Finally, the midwife plans the patient's discharge, prepares the components of the discharge and prepares the patient to go home. If she notices irregularities during the stay, she asks a doctor for consultation. However, if the patient's condition is normal, there is no need to involve the doctor in this process. 
The project is in progress, it is evolving, we are improving it. At the beginning, the scope of midwife's care included patients after natural deliveries only. Our experience allowed us to extend care to a group of patients after planned, uncomplicated caesarean sections.
The key to success is, above all, cooperation between the doctor and the midwife. The leaders in the project are young midwives (second degree with specialization, with the EMBA title). Together with the resident doctors, they build a real therapeutic team.

We are talking about the increasing independence of midwives, do you think that midwives in Poland will have such a strong position in the health care system as, for example, in Scandinavia, how long will it take?

I am certain, they will. Midwives in Poland will independently and comprehensively take care of pregnant women in healthy pregnancies as part of insurance cover, in various forms of professional practice. We are in the process that will lead to this. This is a matter of a couple of years. I can see the potential of Polish midwives, their commitment and constant readiness for professional development. I see the potential and energy of our students and graduates, it cannot be stopped. They will achieve it. I can also see huge benefits from such a solution for women, for the promotion of reproductive health and for the health care system (also in the economic sphere).


Interviewed by Iwona Kołakowska
Photo by Marcin Szumowski
University Communication and Promotion Office