Mateja presented her experience as a midwifery student on an exchange in Northern Norway, where she gained experience in a freestanding midwifery unit.
Introduction
Northern Norway covers almost half of the Norwegian territory and is 5.6 times the size of Slovenia. It is inhabited by 470,000 people, which is only 9.4% of Norway’s total population. The population density is 5.2 inhabitants/km2. Sparse population, long distances, low birth rates, harsh weather conditions, winter darkness, and a shortage of healthcare personnel have always posed a challenge for the healthcare system in Northern Norway, especially in terms of ensuring quality, acceptable costs, and logistics (Norum, et al., 2013).
Quality is ensured through national standards and a decentralized model of perinatal care, as this is the only way to provide timely access to healthcare. Based on risk factors, pregnant women are categorized into three levels. At the primary level, there are freestanding midwifery units with 40–500 births per year, where women with a low risk of complications can give birth. The secondary level consists of maternity hospitals with 500–1500 births per year, intended for all women with low or medium risk. The tertiary level includes obstetric-gynecological departments of university clinical centers with more than 1500 births per year, which, among others, accept pregnant and birthing women with the highest risk of complications (Holt, et al., 2001; Norum, et al., 2013).
There are a total of 15 birthing units in Northern Norway. Of these, six are freestanding midwifery units, which represent an important pillar of healthcare. This article presents in more detail the operation of the Alta unit, which is the largest and has the longest tradition. At the secondary level, there are seven hospital departments for gynecology and obstetrics, where an obstetrician-gynecologist is available 24 hours a day, along with the possibility of a cesarean section and a neonatal unit without respiratory support (Norum, et al., 2013). The gynecologist is not present in the department but is called by the midwife in case of an emergency or professional dilemma (Et trygt fødetilbud – Kvalitetskrav til fødselsomsorgen, 2010). At the tertiary level, there are two specialized hospitals that offer better access to pediatricians and a neonatal intensive care unit (Et trygt fødetilbud – Kvalitetskrav til fødselsomsorgen, 2010).
The purpose of this article is to place the Norwegian midwifery-obstetric care model within existing perinatal care systems, present the continuous midwifery care of pregnant and birthing women in the freestanding Alta unit, show birth outcomes in a decentralized healthcare system, and reflect on the quality of said care and possible alternatives.
The Model of Continuous Midwifery Care in Norway
Continuous midwifery care is a treatment model where the midwife is the lead professional who plans and provides care for the woman from the beginning of pregnancy through the postpartum period. The midwife and the woman establish a partnership in which the midwife takes responsibility for assessing the woman’s needs, plans the monitoring of her condition, and refers her to other specialists if necessary. Usually, in the continuous midwifery care model, midwives care for healthy women with healthy or low-risk pregnancies. In some care models, including Norway, midwives care for all women from a specific geographic area and are the lead professionals for women with uncomplicated pregnancies and births; however, they continue to provide midwifery care to women with medical or obstetric-gynecological complications in collaboration with other specialists (gynecologist, family doctor, physiotherapist, internist, etc.). This represents a shared care model, where responsibility is distributed among different healthcare workers (Sandall, et al., 2013). In Norway, continuous midwifery care is provided by a group of midwives (team midwifery) in collaboration with a family medicine specialist. At least twice a year, both professional profiles organize a professional meeting together. A gynecologist is involved only in case of complications during pregnancy (Et trygt fødetilbud – Kvalitetskrav til fødselsomsorgen, 2010).
Freestanding Midwifery Units
There are almost twice as many freestanding midwifery units in Norway as in Sweden and Finland. The reasons for this are difficult geographic and weather conditions, high population dispersal, the historical development of the regions, and the desire of families for decentralized care. Freestanding midwifery units can be located separately or within maternity hospitals. General requirements that a freestanding midwifery unit must meet are: (1) in-house education at least once a month; (2) emergency training twice a year; (3) proximity to an emergency medical team and a written precise protocol for calling them; (4) supervision by an obstetrician-gynecologist from the maternity hospital at least twice a year and a pediatrician at least once a year, who review intervention outcomes and re-evaluate the appropriateness of the criteria for selecting the place of birth and the procedures performed; (5) thorough documentation of births and transfers during and after birth; (6) and supervision of the technical equipment’s integrity in the department. Each freestanding midwifery unit must provide the following equipment and procedures: (1) resuscitation of an acutely ill mother; (2) neonatal resuscitation; (3) CTG machine; (4) phototherapy; (5) TEOAE device; (6) pulse oximeter; (7) supply of medications; (8) systematic inspection and maintenance of medical equipment; (9) organized newborn examination (Et trygt fødetilbud – Kvalitetskrav til fødselsomsorgen, 2010).
Less than 10% of all births in Norway occur in freestanding midwifery units. This represents a challenge for the Norwegian healthcare system – how to maintain qualified staff if some units have only about 50 births per year, meaning an individual midwife handles very few births. They are aware that births must be supplemented with different types of midwifery skills training. They organize simulation exercises and exchanges where a midwife works in a larger maternity hospital for a short period. Additionally, they constantly assess whether an individual midwifery unit meets quality standards (Et trygt fødetilbud – Kvalitetskrav til fødselsomsorgen, 2010).
The organization of midwifery-obstetric care is one of Norway’s pressing issues, as they are caught between the possibilities offered by medical and technological progress and the care for healthy, uncomplicated pregnancies. In obstetrics, giving birth in larger maternity hospitals is associated with a higher prevalence of interventions in low-risk women and questionable benefits for the newborn (Engjom, et al., 2014). A British study also confirms that there are no significant differences in perinatal outcomes between women who gave birth in a freestanding midwifery unit and those who gave birth in a maternity hospital (Hollowell, et al., 2011).
The World Health Organization recommends 5 institutions per 500,000 inhabitants, including one tertiary-level institution (Monitoring Emergency Obstetric Care, 2009). Similarly, national guidelines in Norway emphasize the need for decentralized care with the aim of providing women with safe, high-quality care close to home (En gledelig begivenhet, 2008).
Midwifery Care in the Alta Freestanding Unit
Alta is the administrative center and the most populated municipality in the Northern Norwegian county of Finnmark, which includes three perinatal care institutions: the Alta midwifery unit and two secondary-level obstetric-gynecological departments in Hammerfest and Kirkenes. About 20,000 people live in the municipality of Alta, which places the Alta midwifery unit in the category of the largest in Norway. Nevertheless, it is worth mentioning that about 60,000 children are born annually in Norway, with only about 100 in Alta (Fødselsomsorgen i Alta kommune med tilhørende poliklinisk virksomhet, 2014). The Alta freestanding unit employs 8 midwives, is also led by a midwife, and the institution enjoys a high reputation throughout Norway. It is located in the local health center. Midwives play a key role in ensuring a safe pregnancy, birth, and postpartum period, as they have neither their own obstetrician-gynecologist nor a pediatrician. Pregnant and birthing women with complications are sent for additional check-ups and birth to Hammerfest, which is 240 kilometers away. High-risk birthing women are redirected to the Tromsø University Clinical Center.
A healthy pregnant woman decides for herself whether she will be monitored during pregnancy by a midwife, her family doctor, or shared by both. If she is healthy and has no problems in pregnancy, they see no medical advantages in her visiting a gynecologist. Only in case of problems does her midwife or general practitioner refer her to a gynecologist. The basic program includes 8 check-ups during pregnancy until the due date and one ultrasound between 17 and 19 weeks. The ultrasound can be performed by an obstetrician-gynecologist or a midwife with one year of additional training in ultrasound diagnostics (Er du gravid?, 2005; Informasjon om ultralyd i svangerskapet, 2005).
In the Alta midwifery unit, the rooms for pregnancy care, the delivery room, postpartum stay rooms, kitchen, and living room for birthing and postpartum women with their families are all in the same department. Two midwives are on duty during the morning. One handles pregnant women, while the other, in addition to handling pregnant women, is also on call for the birthing and postpartum part of the unit. In the afternoon and at night, midwives can be at home and are on call according to an agreed schedule. The exception is days when the midwifery unit is caring for families in the first days after birth (Fødselsomsorgen i Alta kommune med tilhørende poliklinisk virksomhet, 2014).
In Alta, a woman has an average of 11 check-ups during pregnancy. All check-ups can be done by a midwife; these are at weeks 8–12, 12–16, 17–19, 24, 28, 32, 34, 36, 38, 39, and 40. The check-ups at 28 and 36 weeks can be taken over by the pregnant woman’s personal doctor if she so wishes. In Norway, the expected date of delivery is set at 40 weeks and 2 days of gestation. In the 41st week and in case of a post-term pregnancy, the woman has a check-up at the secondary level in Hammerfest (documentation sources, 2014). A midwife examines an average of 12 pregnant women per day. 30 minutes are scheduled for each consultation, and 60 minutes twice during the pregnancy. Parent classes take place individually during the pregnancy check-ups. General topics the midwife discusses with the pregnant woman include nutrition, smoking, alcohol, medications, drugs, breastfeeding, the start of labor (contractions, rupture of membranes, bleeding), the course of labor, a tour of the delivery and postpartum rooms, Vitamin K, birthing positions, labor pain relief, fears and expectations, birth, the course of the postpartum stay, and neonatal tests (documentation sources, 2014). In addition to regular work in the midwifery unit, some midwives have their own clinic for young women at least once every fortnight, where they perform chlamydia tests, advise on contraception, and prescribe it. They also visit schools to teach young people sexual education.
High-risk pregnant women are not allowed to give birth in Alta, while healthy pregnant women can freely decide whether to give birth in Alta or Hammerfest. Regardless of the chosen place of birth, every pregnant woman starting labor with contractions or ruptured membranes is always first examined by a midwife from the Alta unit (Et trygt fødetilbud – Kvalitetskrav til fødselsomsorgen, 2010). For emergency transport, 3 ambulances are available at the Alta health center, and in the Northern Norway region, 11 aircraft are on standby (6 planes, 2 emergency medical helicopters, and 3 rescue helicopters) (Norum, et al., 2013).
Selection criteria for birth in a freestanding midwifery unit vary in different parts of Norway. In Alta, the following can give birth: (1) a pregnant woman without chronic illnesses, previous C-section, or other uterine surgeries, (2) multipara, (3) primipara aged 35 or less (only since 2012), (4) normal pregnancy, (5) fetus in cephalic presentation, (6) no diagnosed disease that could cause complications, (7) previous healthy pregnancies and births, (8) labor starts spontaneously at gestation from 36 + 0 to 41 + 3 days, (9) contractions start spontaneously and remain normal until the end of labor, (10) women who previously gave birth with the help of vacuum or forceps and there is no suspicion that this could happen again, (11) estimated fetal weight < 4500 g or no IUGR, (12) pre-pregnancy BMI < 27, (13) weight gain during pregnancy < 20 kg, (14) absence of diabetes mellitus or gestational diabetes, (15) absence of polyhydramnios or oligohydramnios, (16) 24 hours since spontaneous rupture of membranes, (17) no active Group B Strep infection, (18) the mother is not addicted to alcohol or drugs, does not have Hepatitis B or C, (19) no congenital diseases or anomalies in the family history. In agreement with the obstetrician-gynecologist in Hammerfest, the following can also give birth in Alta: (1) pregnant woman 18 years old, (2) pregnant woman with a pre-pregnancy BMI up to 30, and (3) pregnant woman with non-specific psychological or psychosocial problems. A midwife can suggest a hospital birth even if none of the mentioned criteria are cited (Et trygt fødetilbud – Kvalitetskrav til fødselsomsorgen, 2010). < 24 hours, (17) no active Group B Streptococcus infection, (18) the pregnant woman is not addicted to alcohol or drugs, does not have hepatitis B or C, (19) there are no congenital diseases or anomalies in the family history. In agreement with the obstetrician-gynecologist in Hammerfest, a pregnant woman < 18 years of age, (2) a pregnant woman with a pre-pregnancy BMI up to 30, and (3) a pregnant woman with non-specific psychological or psychosocial problems can also give birth in Alta. The midwife can suggest delivery in a hospital, even if none of the mentioned criteria are met (Et trygt fødetilbud – Kvalitetskrav til fødselsomsorgen, 2010).
Indications for transfer during labor are (1) spontaneous rupture of membranes > 24 hours without well-established contractions, (2) abnormal fetal presentation, (3) fetal head not fixed despite good contractions, (4) stained amniotic fluid in the early stage of labor, (5) abnormally heavy bleeding, (6) need for continuous monitoring of fetal heart rate due to threatening fetal asphyxia, (7) need for epidural analgesia, (8) need for contraction stimulation (except when the fetus is already on the pelvic floor and there is no suspicion of dystocia), (9) labor arrest, and (10) signs of infection. Artificial rupture of membranes in the early stage of labor is not allowed. Midwives have all the necessary medications for labor pain relief and for preventing postpartum hemorrhage; they also decide on their application independently. All deviations from the protocol must be explained and documented. After birth, the postpartum woman is transferred in case of (1) retained placenta with or without major bleeding, (2) III and IV degree tears, deep vaginal tears, cervical rupture, (3) abnormal bleeding after birth (> 500 ml), atony or bleeding from birth injuries, and due to other indications. The newborn is transferred in case of (1) suspected illness, (2) insufficient breathing, (3) deformity, injuries or fractures, (4) jaundice, and other indications (Et trygt fødetilbud – Kvalitetskrav til fødselsomsorgen, 2010).
The atmosphere in the midwifery unit is very pleasant. The relationship between the midwife and the woman is a partnership; they respect each other mutually. Both during pregnancy check-ups and during labor, the woman can have as many companions with her as she wishes. Midwives assess the presence of family members as a positive contribution to the experience of pregnancy, birth, and the postpartum period. One midwife is present at the birth, and during the second stage of labor, an additional second midwife (during the day) or a nurse from other departments of the health center (at night) is also present. During labor, they adapt to the individual needs of the woman. After the initial examination, the birthing woman is assigned a room where she will also stay with her partner after the birth. Eating and drinking before and during labor is encouraged. Intravenous cannulas are not placed preventatively.
For pain relief, birthing women have access to unlimited movement, a warm tub in the first stage of labor, acupuncture, warm compresses for the perineum, massage, aromatherapy, music, nitrous oxide, and morphine. Usually, the birthing woman moves from her room to the delivery room only when pain relief is needed or in the second stage of labor. Birth in Norway is not treated as a sterile event. The perineum is protected with a traditional grip, as women give birth in all positions. The third stage of labor is managed physiologically, except in cases of bleeding or a difficult birth. After birth, they wait for the umbilical cord to stop pulsing, leave the newborn on the mother’s belly for at least an hour, and encourage spontaneous latching for breastfeeding. All midwives in Norway sew 1st and 2nd degree perineal ruptures themselves. Routine procedures for the newborn include measuring, weighing, and intramuscular application of Vitamin K.
The postpartum woman can go home with the newborn as early as 3 hours after birth or stay for up to four days. Family medicine specialists examine the newborn twice before discharge. In case of early discharge from the midwifery unit, the mother and newborn return after 48 hours, when saturation is measured, the TEOAE test is performed, and blood is taken from the heel for 28 screening tests according to the principles of atraumatic care. In case of early discharge, the newborn is examined for the second time then. Six weeks after birth, the mother goes for a check-up with her chosen personal doctor.
Discussion
The discussion presents research results and a review of clinical documentation showing the quality and importance of the freestanding midwifery unit in Alta. In the years 2007–2011, the municipality of Alta had a higher birth rate than the rest of Norway. As many as 60% of residents gave birth in Alta, 35% in Hammerfest, and 5% in the Tromsø maternity hospital. Since 2010, the number of pregnancy visits in Hammerfest and specialized clinics in Alta has been increasing due to stricter criteria, rising obesity, and an increase in gestational diabetes. In 2012, 30% of pregnancy check-ups were performed in Alta, 40% at the secondary level in Hammerfest, 12% at the tertiary level in Tromsø, 16% with private specialists, and 2% elsewhere. The number of visits and births in the Alta midwifery unit has remained stable since 2002 (Fødselsomsorgen i Alta kommune med tilhørende poliklinisk virksomhet, 2014).
In a study conducted by Engjom et al. (2014), they found that in Norway over the last 30 years (1979–2009), the number of obstetric institutions fell from 95 to 51. Consequently, the proportion of women who are more than an hour away from the nearest midwifery or obstetric institution rose from 7.9% to 8.8% in the years 2000–2010. The risk of an unplanned birth outside an institution rose from 0.4% in 1979–1983 to 0.7% in 2004–2009. Maternal mortality rose from 1.7% in 2000 to 2.2% in 2009. Regional differences increased. The proportion of women living within two hours of the nearest obstetric care rose from 21% to 28% in Northern Norway. Consequently, the risk of maternal mortality in the north increased significantly. They concluded that due to the partial centralization of midwifery-obstetric care, maternal mortality did not decrease as initially expected and planned. The risk of birth outside a midwifery-obstetric unit has even doubled in the last 30 years.
Among candidates suitable for birth in a freestanding midwifery unit, 1.1% of women in Norway gave birth unplanned outside an institution in the years 2002–2011. In Alta, however, the percentage of unplanned births outside an institution is very small; it is 0.5% both for women who meet the criteria for birth in Alta and for all birthing women combined. Premature births (before the 35th week of gestation) in Alta were 1.9% in the years 2002–2011, while in Norway they were 2.6%. In Norway, maternal morbidity was 2%; among candidates for birth in a freestanding midwifery unit, it was 1.3%. In Alta, the total maternal morbidity was as high as 2.7%, but among candidates for birth in the midwifery unit, it was 1.5% (Fødselsomsorgen i Alta kommune med tilhørende poliklinisk virksomhet, 2014).
An Apgar score below 7 at 5 minutes after birth was recorded in 1.6% of all newborns in Norway and 0.7% of newborns born to mothers who met the criteria for birth in a midwifery unit in the years 2002–2011. In the north, the total was 1.8%. Among newborns born in Alta, the percentage of newborns with an Apgar below 7 at 5 minutes was 0.8%. An Apgar below 4 at 5 minutes was recorded in 0.6% of newborns both in Norway and in the municipality of Alta. At the national level, 0.3% of newborns among candidates for birth in a freestanding midwifery unit had an Apgar below 4, while in Alta it was 0.4%. The percentage of newborns with a birth weight < 2500 g was 3.7 in Norway in the years 2002–2011. In the north, it was 3.6%, and in Alta, 3.2%. Among candidates for birth in a freestanding midwifery unit, 0.7% of newborns in Norway had a birth weight < 2500 g, in Northern Norway 0.8%, and in Alta 1%, which is slightly higher than elsewhere (Fødselsomsorgen i Alta kommune med tilhørende poliklinisk virksomhet, 2014). One reason for the higher percentage of low birth weight could be the fact that Northern Norway has a significantly higher percentage of pregnant smokers compared to the whole country (26.9% vs. 18.5%) (Norum, et al. 2013).
Perinatal mortality was 0.5% both in Norway and in Northern Norway in the years 2002–2011. Among newborns born to women who met the criteria for birth in a freestanding midwifery unit, perinatal mortality was 0.2% both in Norway and in the north of the country. In the same period, mortality in the first month of life was 0.2% in Norway and 0.2% in Northern Norway; among candidates for birth in a midwifery unit, it was 0.05% in Norway and 0.1% in Northern Norway. In Alta, fewer than five cases were recorded in a decade, which is not even meaningful to show in percentages (Fødselsomsorgen i Alta kommune med tilhørende poliklinisk virksomhet, 2014).
The Alta midwifery unit has a comparable percentage of unplanned births outside an institution, serious maternal morbidity, premature births, Apgar scores, birth weight, perinatal mortality, and neonatal mortality to the rest of Norway. It operates in accordance with national guidelines and has good results (Fødselsomsorgen i Alta kommune med tilhørende poliklinisk virksomhet, 2014). Additionally, they offer users care in their home environment, continuity of care, and trust, which are important components of high-quality care during pregnancy and birth (Guidelines for Antenatal Care, 2005).
Conclusion
From what has been written, it is evident that perinatal healthcare in Northern Norway and the freestanding midwifery unit in Alta are of satisfactory quality and that the benefits outweigh the risks of decentralized midwifery-obstetric care for pregnant and birthing women. In the projection to 2030, the municipality of Alta anticipates a further population increase, which will also lead to a rise in the number of pregnant women. Additionally, there will be more obesity, diabetes, associated illnesses, and women will choose to have children at a later age. From this, they conclude that the number of births in the Alta midwifery unit will neither significantly increase nor decrease (Fødselsomsorgen i Alta kommune med tilhørende poliklinisk virksomhet, 2014).
The midwives in Alta want to maintain their independence; however, they advocate for getting their own obstetrician-gynecologist specialist, to whom they could send pregnant women with complications, saving them effort, time, and money. In the coming years, they will also extensively expand and modernize their facilities.
Written by:
Mateja Kusterle, Prof. of English and Spanish, 3rd-year midwifery student
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