According to WHO (2016), midwifery-led continuity of care models in which a known midwife or small groups of known midwives support a woman throughout the antenatal, intrapartum and postpartum continuum, are recommended for pregnant women in settings with well-functioning midwifery programs. The phenomenon of women-centered care has been acknowledged as a maker of quality in maternity service and it has become a midwifery concept with implied significance aiming to provide a clear theoretical foundation of women-centered care for midwifery as an evidence-based practice. The illustrated theory, of women-centered care is used in relation to midwifery care because it emphasizes a strong midwifery-specific focus on the pregnant woman holistically. This means that the midwife focuses on the woman, and communicates with the woman`s family and other health professionals about the care of the pregnant woman.
Therefore, the concept of women-centered care is a process of partnership, interdependence, and interconnectedness where the woman is the center of care in any maternity or birthing unit. Thus, the relationship between the woman and the midwife serves as an opportunity for cooperation between the woman and the midwife. This enables personalized care to develop a rapport and trust, so that, the woman feels in control by actively allowing the authority of decision to a person the woman trusts to make decisions; advocating for the woman with concrete knowledge of woman-centered care. The relationship offers an opportunity to validate the boundaries for both parties while at the same time picking up other limitations that may affect their responsibilities. The woman`s most common partner is the midwife during the journey of the mother throughout the continuum of pregnancy to motherhood. The midwife takes the woman through the transition of womanhood to motherhood acting as a facilitator, mediator and coordinator. As (Eur. J Midwifery, 2018) stated, the childbearing woman is at the center of care. The focus of woman-centered care stresses the dynamic and reciprocal character of the woman-midwife relationship. This highlights that the midwife`s role as a communicator, collaborator, and leader is truly essential for providing woman-centered care.
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Fijian Midwifery Models Used In The Past
Fiji is a country that is well known for its strong cultural identity and it also has great exposure on western culture and this explains the reason why it has adopted the change. The concept of the midwifery care model has changed over time and it has had a dramatic shift. It has been transformed from a common event overseen by a local midwife or a traditional birth attendant (TBA). This was a common process practiced in the past and mostly mysterious since it lacked scientific understanding, to an occasional event overwhelmingly overseen by obstetricians to maximize health outcomes. This particular transition is unique to the Fijian culture especially when the western culture predominates on so many aspects of life in Fiji and one of which is the drastic shift of the midwifery care model used in the past to the current phenomenon used today.
The midwifery model that was used in the past was the traditional birth process before the western culture moved in with a more medically managed birth process guided by a professional midwife to a doctor. The different methods of delivery used in the past compared to that of the current delivery practice. The positioning of delivery in the past, most women prefer to squat or stand during labor and delivery (Ivamere Ravutu), the woman finds it comfortable due to the gravitational pull allowing for easy birth and there is less tear and trauma. In the past, the focus is more on the pregnant woman and not so much of the unborn child. During a complicated delivery, the focus is more on the woman than to the unborn child. The traditional birth attendant prefers to save the woman and not the unborn child in a complicated delivery. Henceforth, the mortality and morbidity rate is high in the past since aseptic techniques were not used. The woman may be the center of care; the holistic approach was not present to support the woman in all the dimensions of life.
The management of pain during labor and childbirth is different in a Fijian woman from an Indo-Fijian woman. Fijian mothers preferred the extensive traditional caring patterns of the community and of relatives during pregnancy and childbirth to medical care. They learned from where infants come, pregnancy, labor, and delivery when still very young. Their natural view of childbirth, the social and kinship support systems, and community prenatal care readied them for delivery. Thus they could anticipate the pain of childbirth.
Current midwifery model
The current midwifery model used is more of a collaborative model where the medical officers take the leading role in the care of the woman.
Five Current Midwifery Practices in Fiji That Compromise Women-Centered Care
The midwife is the responsible and accountable professional who works in partnership with women and families to give the necessary support, care, and advice during pregnancy, labor, birth, and throughout the puerperium period; to conduct birth on the midwife`s own responsibility, and to provide care for the newborn and infant. This care includes preventative measures, promotion of normal birth, detection of complications in the mother and child, accessing medical care or other appropriate assistance, and caring out emergency measures (Fiji Nursing Council, 2017, pg.1). Current practice has subsequently shown that the responsibilities and care provided by the midwife is altered and compromised due to underlying reasons; one of which is the limited resources and the other is the outbreak of the COVID19. Discussed below are current midwifery practices within the current midwifery model in Fiji which compromises the care of the woman.
Firstly, the midwife protects, promotes, and supports breastfeeding, promoting the WHO United Nations Children`s Fund's ten steps to successful breastfeeding. The midwife facilitates and respects the woman`s choice regarding infant feeding (Fiji Nursing Council, 2017, pg.3). From my experience as a maternity nurse at the Labasa Hospital, which is also known as a Baby-Friendly Hospital; it initiates and supports breastfeeding as a mode of feeding for neonates and newborn. Undoubtedly, through this practice; the preference and the woman`s choice of feeding are compromised. Since not all mothers want to breastfeed their children full time and most mothers are working mothers. They prefer other means of feeding their newborn and thus, the freedom of choice is restricted because of the hospital protocol.
Secondly, the midwife is able to support the woman and her family through the birth crisis and refer appropriately to the woman`s needs (Fiji Nursing Council, 2017, pg.3). Due to the pandemic COVID19, there is not so much focus on the family since there are restrictions of visitors to the hospital, social distancing and curfew hours thus; there are limitations in the midwife`s involvement with the family.
Thirdly, the midwife supports the woman and her family, and their informed and educated choice regarding family planning and refers the patient appropriately and without judgment (Fiji Nursing Council, 2017, pg.3). In some cases today, the decision of the woman on having a family planning or not is decided by the midwife. These are women with high parity and high-risk cases, midwives and doctors have to decide on the method of family planning that better suits the mother.
Fourthly, the midwife communicates information to facilitate decision-making by the woman and provides learning opportunities appropriate to the woman`s needs (FNC, 2017, pg.3). In the current clinical setting, the major language used is English. Since Fiji is a multi-racial country, the barrier is there between the midwife and the mother. The information is conveyed but it is how the mother receives and interprets the message which is a major drawback in the care of the mother leading to an unsuccessful and complicated pregnancy.
Lastly, the midwife has a full understanding of cultural differences and individual preferences of each woman and her family (FNC, 2017, pg.3). The new era of midwifery lack an understanding of cultural differences and preferences. Nowadays,
Professional, Ethical and Legal Obligations
Professional
The current Fijian model of midwifery care is more into a collaborative model where medical intervention always comes first and the medical officers take the leading role. The ICM Models of Midwifery Care (2014) and the ICM Philosophy of Midwifery Care (2014) is not in alignment with the Fijian current Midwifery Model whilst the Fiji Scope of Practice for Midwifery (2017) guides the practice of midwives in Fiji.
The two given ICM models elaborated above differ from the current Fijian midwifery model used in our clinical settings today. The ICM Philosophy of Care (2014), focuses on the physiological processes of delivery. With the current practice used in Fiji, physiological processes are not taken into consideration. For instance, if a mother who is long overdue with an age of gestation of 41 weeks walks into the birthing unit and has not experienced any regular contractions, the medical officer orders for a syntocinon augmentation or a folleys induction to augment labor for the pregnant woman. Thus, the midwife`s request to allow another one to two hours for the pregnant woman to go through the physiological process of labor is hindered. Hence, the criteria of ICM Philosophy of Care (2014) are not met.
Ethical
Pregnancy and childbearing is a profound experience, which carries significant meaning to the woman, the family members and the community (ICM Philosophy of Midwifery Care, 2014). In relation to the current midwifery practice, the focus is prioritized to the woman and the unborn child whilst the close family members and the community are not much involved in the continuity of care of the woman. This is solely due to the outbreak of the pandemic COVID 19 since there are restrictions of visitors to the hospitals to prevent the community and the public from acquiring infection or bringing in infection to the maternity unit causing detrimental harm to the woman and the unborn child. Therefore, it is ethically unacceptable and the above-mentioned philosophy of midwifery care is compromised.
Today, the current practice do not allow midwives to encourage and support for non-intervention in normal labor since the care offered is more of medical intervention. Thus, there is no consultation of the midwife`s second opinion on the holistic care of the woman.
Legal
The scope of practice for Fiji registered midwives (2017), is in place to guide and protect the midwives and their practice in Fiji. The Fiji Nursing Council is the main governing body of the Fiji Registered Midwives. Criteria 1.2: fulfills the duty of care pertaining to midwifery practice and works within the defined scope of practice (Scope of Practice for Fiji Registered Midwives, 2017). The midwife is responsible and accountable for his own actions within the clinical setting which is the maternity unit. The midwife must follow all the legal requirements in all aspects of documentation which includes; recording, collecting and safekeeping all the information relating to the duty of care.
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