Midwifery students hit the nail on the head with the chosen theme “Home Birth” at the 3rd Student Midwifery Forum, organized on May 31, 2016, at the Faculty of Health Sciences in Ljubljana.

The first lecture by Asst. Prof. Dr. Irena Rožman, BA in Ethnology and Sociology, was presented by her husband, obstetrician-gynecologist Asst. Aleš Pišek, MD, Spec. Obs-Gyn, whom I was delighted to listen to twice. Ms. Irena is an extraordinary woman; she has written excellent articles, and she is also the author of the book “The Stove Has Collapsed – Birth Culture in the Slovenian Countryside in the 20th Century.”

Her lecture also included a quote from English literature about the difference in character between an independent midwife vs. a midwife working in a hospital.

“The nature of an independent midwife’s work: Her working hours are flexible, undefined, and adapted to the needs of the woman in labor. She cares for the woman during pregnancy, knows her needs, wishes, health status, family situation, etc.

The nature of a midwife working in a hospital:the working hours are fixed, her work is more routine than that of a midwife helping a woman give birth at home, she works directly under a doctor’s supervision or instructions, she doesn’t know the woman in labor, and she helps several women at once.

One of the slides also featured the motto of community midwives, which actually applies to all midwives, though there is usually (too) little of it in a hospital environment… either from the staff or the women in labor: “Patience, patience, and more patience.” Labor needs its own time to unfold as intended, and a midwife must recognize pathology and react appropriately.

Špela Urbanc and her partner shared their birth story with us – why they decided to have a home birth for their second child and what was so different from the first time. You can watch their story HERE.

Independent midwife Jasna Gumze, BSc Midwifery, presented her work. That is, the work of an independent midwife practicing in Slovenia. When and how her visits take place, and what they include. She prefers women to contact her after 12 weeks of pregnancy, which is a period of well-being. Generally, she makes 2 visits. During the high-demand period 3, and during the birth preparation period 4 visits. These are followed by the birth and postpartum visits. She highlighted the wish for Slovenian legislation to be regulated so that the midwife who attended the birth could also register the child and perform screening tests. Her website: http://babicajasna.si/kontakt/

Good prerequisites for labor

” Primipara (a woman giving birth for the first time):

• From 36 weeks onwards, the baby descends into the lower uterine segment, with the head engaged in the pelvic inlet.
• In the 10th lunar month, the leading fetal part fills the upper part of the pelvic cavity halfway.
• Longitudinal lie.
• Head turned towards the sacrum. It is flexed in the 1/a or 2/a position.
• Cervix centered.
• Sagittal suture oblique.

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

• Baby in an indifferent posture (not flexed), high up. It only enters the pelvis with pre-labor contractions or labor contractions.
• Longitudinal lie (does not only mean cephalic presentation).
• 1st or 2nd fetal position.
• Cervix slightly open, portio shorter, wider, does not disappear completely..
• Sagittal suture transverse (head not yet flexed).”

Asst. Aleš Pišek, MD, Spec. Obs-Gyn, then presented his lecture. I would like to highlight certain parts. Firstly, the character traits of independent midwives compared to midwives employed in hospitals. Dear women, please read carefully… and think about it, especially when you decide to give birth in hospitals with a high volume of births.

His personal opinion: “The central person of the birth is the woman giving birth. We, the healthcare professionals, are her companions. We are obliged to respect her as an individual and take into account her decisions, needs, and wishes. We are her advisors, helpers, and performers of medical procedures that prove necessary during labor and to which the woman agrees. We have the necessary professional knowledge and access to medical technology to perform these.”

Pišek also highlights the “Wisdom of Teamwork,” which Zala touches upon later:

“Midwives:

• They are directly present with the woman and stand by her side throughout the labor (my addition: although they might not be able to be physically with her the whole time!).
• They monitor the progress of labor and detect any deviations from the norm.
• In case of deviations, they act together with the doctor.
• If there are no deviations, they help the woman deliver the baby and care for it.

Doctors:

• We introduce ourselves and our colleagues to the woman and her companions.
• Upon admission to the hospital, we examine the woman and the documentation on the course of the pregnancy. We also ask about her wishes and plans. Based on all this, together with the midwife, we agree with the woman on the course of the labor (Is it really like that?!).
• We congratulate her after the birth (if everything goes well, we midwives are also most satisfied that everything went smoothly). “

It is also important that he highlighted “What influences the views of obstetricians” and, ultimately, midwives who have been in the hospital system for a long time:

” Historical memories: historical memory is an important factor that allows us to objectively compare the current state with the past and helps us understand the factors that led to the currently established obstetric practice during development.

Personal experiences: Obstetricians working in hospitals gain experience from day one until we retire. We also encounter tragic events such as the death of a mother and/or child, and experience relief when we manage to prevent the worst. At the same time, we realize how little it takes for the unexpected to happen.”

Maternal mortality is certainly one of the quality indicators. The best:worst ratio is 2,054 (Sudan) : 2 (Estonia) per 100,000 live births for 2010 (SOURCE: CIA World Factbook, link)

BIRTH SAFETY: “When talking about the safety and benefits of home birth, it should be emphasized that we are discussing home birth in environments where access to medical knowledge and technology is available, and communication and transport are well-organized. The historical memory that something can go wrong during labor is gone, and any unfavorable outcome is usually attributed to medical error by the affected parents.

Given that today, pregnant women, partners, and the general public perceive an unfavorable birth outcome as completely unacceptable and impossible, we medical professionals are looking for ways to bring the possibility of an unfavorable outcome as close to zero as possible.”

Pišek said many important things in his lecture. It is definitely worth highlighting the “Chalice of the Last Supper of Almighty Studies,” the summary of which is that any study can give us the result we want to show. So: “Scientific studies are good servants but bad masters,” says Pišek. “When they are scientifically and methodologically appropriately executed, they help us compare procedures, choose the most appropriate one, and monitor its success. But when we expect them to make this choice for us, or when we only want to see what fits our ideas, they often become an end in themselves.”

“In an environment where favorable conditions regarding communication, transport, and access to medical knowledge and technology allow us to achieve appropriate and comparable birth safety in the home environment, the right to choose the place of birth seems logical and self-evident to many.”

” Regarding home birth, the task of the medical profession, both midwifery and medical, is to define professional criteria for such a birth within their own legally defined competencies. Once the professional criteria are clear, it is the task of health policy to decide whether it will provide conditions that allow such a birth to be carried out according to the defined professional criteria. However, we can expect that this process, given its complexity and high expectations, will be neither short nor simple.”

We must also form our own opinion about this article: Planned Home Birth: A Review Article (Takač, Serdinšek, 2016)

The Professional Education Council and the Board of Directors of the Association for Perinatal Medicine of Slovenia adopted a joint opinion on home birth in December 2015:

“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 been shown in past years.

Instead of introducing home birth as the first measure to meet the wishes of pregnant women, it would be better to first introduce midwifery-led management of normal birth, a midwifery ward, or a birth center (my addition: YES, LET’S DO IT!!). The professional basis for midwifery-led management of normal pregnancy and midwifery-led birth or 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 relevant documents. The Ministry of Health should propose and implement the appropriate legal basis for the implementation of midwifery-led management of normal pregnancy and normal birth. In this way, midwives would gain the appropriate practical knowledge and skills, and thus the possibility of managing 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. This is not possible only by managing home births in Slovenia. Therefore, home births could be managed by midwives who would also be partially employed in midwifery wards or a birth center. There are 14 maternity hospitals in Slovenia, any of which could also define itself as a midwifery ward or a birth center. The Ministry of Health of the Republic of Slovenia should conduct analyses, interviews with maternity hospitals and professional associations, and find a common solution with the maternity hospitals.”

In my opinion, what is written is very positive and realistic, but is there interest? I’m all for it.

Andrej Vojnovič, BA in Law, spoke about the legislation. A midwife who successfully completes her education is allowed to manage a home birth. Certainly, the biggest “gem” of the law was about registering the child or verifying the mother’s identity:

Rosemarie Franc, BSc Midwifery, presented the 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, BSc Midwifery
• Asst. Prof. Dr. Ana Polona Mivšek, BSc Midwifery
• Anita Prelec, RN, MSc (UK)
• Senior Lect. Teja Škodič Zakšek, BSc Rad., BSc Midwifery, MSc (UK)
• Andrej Vojnovič, BA in Law

Here, the most criticism was directed at the provision that an independent midwife may not use medication at home. However, we must know that the document is not permanent; it will be revised and expanded in the future. Primarily, the goal of the working group is for it to be adopted at all. Additional training for midwives in Slovenia for planned home birth together with a supervisor is planned, and training for midwives in the fields of pharmacology and neonatology will be refined. The document has been written and coordinated with the Extended Professional Board 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 labor
• Environmental criteria for planned home birth
• Basic equipment, tools, materials
• Birth registration
• Documentation of the birth
• Transfer to the hospital and reasons for transfer
• Care for the mother and newborn in the home environment

Another lecture very dear to me followed, given by Zala Pušnik, BSc Midwifery, who works in Carinthia, Austria, as an independent midwife for home births. She never considered working differently (in a hospital environment). After finishing her studies in Russian and Media Communications, she decided to study midwifery as well. After graduating from the Midwifery College in Klagenfurt, she completed the necessary internship (1 year) with a mentor who is also an independent midwife, serving as her assistant. Through this, she learned and trained for independent work. She also teaches at the Midwifery College in Klagenfurt, trains young midwives in practice, and their curriculum includes a mandatory internship with an independent midwife for every student, so they can see how their work is done, even if they later get employed in a clinical setting. She spoke about the wrong image people have of independent midwives, e.g., how much she actually has left from one birth that costs, for example, 2,500 EUR, which includes all preventive check-ups during pregnancy, the birth, and postpartum visits that end after 1 month, when the mother and newborn are somewhat 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. Pediatricians there come to the home to see the baby, and some also perform ultrasounds. This is a way of life; you are available 24/7 and you really need to have a partner and family by your side who understand this. She is a mother of four. She also says that in a birth that starts at home and ends in the hospital, we midwives “get the short end of the stick.” And when a birth that started in the hospital spontaneously ends with a C-section, we also get the short end of the stick. Maybe I missed it, but in Zala’s lecture, it seemed really important for the first time that she pointed out that in all of this, it’s not about us, the midwives and doctors. Who is right and who is not. It’s about the women and the newborns. And because of that, we must find compromises, and above all, appropriate communication, so that we can carry things out at a high level of safety and quality. They have meetings and encounters with clinic heads at least once a year to coordinate potential complications and misunderstandings, so that everyone can work smoothly, and the care is high-quality and safe. Zala’s website: http://www.zala-hebamme.at

Birth photography: Adriana Aleksić (Month of May) was also the official photographer of the forum. She told us how she actually got involved with births, how she does her work, and what is important in it. Her photos and videos impress me every time.

THANK YOU!