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Scope of Midwifery Practice: Response from CPHVA Scotland

 

The Community Practitioners and Health Visitors Association (CPHVA) recognise that there is a need for midwives and health visitors to work more closely together within not only the postnatal but also the antenatal period. Currently, there is little systematic collaboration between the groups in practice. Both groups are employed by different trusts, with midwives also rotating within teams between the acute & primary care setting. This does not lend itself favourably for the continuity if care or the development of relationships within primary care teams.

 
Clearly, Glasgow is keen to initiate the extension of midwifery scope of practice, however, there appears to have been little formal consultation? The Board are requesting that Health visitors submit a reasoned and evidenced response to the proposed changes, late on within the decision making process. However, there does not seem to be any clear evidence base behind the intention to extend the scope of midwifery practice? The added benefits to the family in the face of these reorganisations are also ambiguous, especially given that the midwifery episode is a relatively brief one within a woman’s life-span
 
Given the emerging public health and social inclusion agendas, midwives have a significant contribution to make to affect health outcomes positively. If the scope of midwifery practice is extended where will the midwife ‘sit’ in relation to the family as a whole? For example, in cases where a sibling is being difficult because of a new birth, or where there is a dependent adult within the household. These are instances where a health visitor would deal with the gamete of requirements as part of a whole package of inter-related events. Given the potential scope that exists within the community setting it is likely that midwives will require additional education and training to undertake an extension of practice.
 
Where will the midwifery responsibility stop? In instances where postnatal depression has been detected, utilising the appropriate tool, will the midwife continue the listening and supportive visits for the client? Alternatively, will it be the case that health visitor intervention at this critical and sensitive stage will be required demanding that the mother and family re-establish trusting relationships with yet another health professional.
 

Health visitors maintain that early contact is crucial in the client relationship and that the delay in hand over may compromise this.

 
Research from Durdle & Davis substantiate this observation, their findings demonstrating that if a health visitor (through their personality and approach) establish positive relationships with a client by 3 months following birth, that the mother will actively seek health visitor assistance there after. Such an outcome, in terms of client independence, must be welcomed.
 
The early postnatal period is an important time for risk assessment, particularly in corporate caseloads, and forms a large part of the assessment period for mother & baby interactions and child protection risk. The CPHVA is currently investigating evidence from the NSPCC in relation to this. Midwives would require education and training relating to this.
 
There is also no evidence within the proposal of user views. It appears that the agenda is being driven form a professional perspective. Clearly it is necessary to critically evaluate the optimum requirements for the delivery of midwifery and health visiting services, and how they interact, looking at the positives & the drawbacks from the professional and client viewpoint. I believe that a forthcoming national Review of Maternal Health Services aims to do exactly this.
 

There is evidence of similar initiatives involving the extension of the scope of midwifery practice, for example, in Hereford, where clients are visited by midwives until six weeks postpartum and then offered a universal health visiting service. The rational, in part, for this was I believe to improve breastfeeding rates. However, whether this outcome was achieved is not clear. Birmingham, also, is currently redesigning postnatal care and the CPHVA are in the process of gathering information from work carried out related to this.

 

I understand, also, that in some areas a different approach has been taken with health visitors attending women earlier within the postnatal period, i.e., at 6 days post-partum. Perhaps this may be a consideration if positive patient outcomes are the focus for change.

 
If the proposal to extend the scope of midwifery practice is to proceed it would free health visitors to undertake the development of their public health role and community based work.
 
There should be strong consideration of the opportunities that exist for midwives and health visitors to work jointly to plan interventions with base within the primary care setting, and to develop skills training not available within the current delivery design.
 
The CPHVA is in the process of establishing a joint working group in partnership with the RCM. We would be delighted to inform Glasgow of the outcome of work undertaken in due course.
 
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