This essay will examine the care provided in a woman’s case taken from a reflective journal. It will focus on issues pertinent to current midwifery practice that may have influenced the delivery of care.
In accordance with guidelines laid out by the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC), all names have been changed throughout this essay for the purpose of confidentiality (UKCC 1987).
The scenario that will be examined in this essay concerns a series of post-natal visits in the community to first time parents ‘Tom’ and ‘Kim’. The visits were made by a student, while her mentor observed, but did not participate in care provision directly. Kim had been discharged from hospital two days after an uncomplicated vaginal delivery. Her new son ‘Joshua’ was healthy and bottle feeding with no problems at discharge. Both Tom and Kim had a degree of learning difficulties.
On the first visit, Tom and Kim appeared to be coping well with their new baby. Despite this, the couple’s neighbour contacted the health-centre with some concerns regarding the couples feeding methods. When the student returned to the couple’s home and discussed feeding in depth with Tom and Kim it became clear that they were not preparing feeds safely for the baby. Kim had been preparing feeds with salt water as she believed this to be sterile, and after sterilisation, Tom had been rinsing feeding equipment with tap water. Joshua appeared to be suffering no physical ill effects as a result of this. The student explained why this was unsafe, and explained the correct methods for these procedures, however Tom and Kim had some difficulty in remembering and carrying out these preparation techniques, but were both keen to do the best for their baby. The student produced a written guide to preparation of a feed, which Kim seemed to find easy to follow.
The student discussed the situation with her mentor, and it was felt appropriate to involve the couple’s health-visitor. Using a team approach, the student and midwife visited the couple daily until 28 days, and the health visitor also visited to offer further support and guidance. The couple were pleased to accept continued support, and appeared to be doing extremely well with continued support at the point of discharge.
The student chose this episode for reflection, as she was pleased with the positive outcome following a supportive team approach. She felt that this demonstrated a good example of midwifery care, and had helped Kim and Tom increase their confidence in their own parenting skills. However, she was also concerned that the situation had arisen at all, and felt that this potential problem could have been identified sooner, either ante-natally or sooner after delivery, and she felt she may have let Tom and Kim down by not identifying the feeding problems at the first post-natal visit.
Reflection is a valuable tool for self-examination and improvement (Atkins 1995). The process of reflection maybe unique to the individual, but the outcome is to clarify and learn from experiences. In this case, the student chose to discuss the incident with her mentor, and write a short piece on what happened, how this made her feel, and an exploration of what may have been done differently. Written reflection is a valuable part of a midwife’s portfolio as a demonstration of her ability to learn from past experiences, and as such is recommended by the UKCC (1997).
A less subjective way of assessing care delivery which may be integrated into reflection, is to examine the policies and guidelines that the midwife is expected to adhere to, and determine whether care met or deviated from these expected standards.
In an immediate context, the student must consider her hospital policy on infant feeding (Surrey & Sussex Healthcare NHS Trust 1999). The policy states that breast-feeding should be promoted at all times, and that bottle-feeding should only be used with medical indication and with the mother’s informed consent. In this case, no medical indication for artificial feeding existed. Kim had chosen to bottle-feed, and had therefore given her consent, but it is difficult to establish whether this was truly informed consent. The student did not inform Kim about the benefits of breast-feeding, merely educated her in bottle-feeding, however it should be noted that by the first meeting Kim had already been bottle-feeding for two days. For a choice to be truly informed, a mother must be fully aware of the advantages and disadvantages of each of the options open to her (Robertson 2000) and should be provided with un-biased evidence based information to help her come to her own decision (Newburn 2000). This was not the case with Kim, and although she found some information difficult to understand, she was able to understand information presented carefully to her. It is vital that the principles of informed consent are applied to those with learning difficulties, and unless deemed incapable of this, every effort to provide information to the client should be made (UKCC 1996).
It should be noted that the hospital policy (Surrey & Sussex Healthcare NHS Trust 1999) states it is audited bi-annually, and updated accordingly, however, the most recent copy available is two years old, and limited references are given within the policy, which may imply the policy is not appropriately evidence based. In places it appears contradictory, for example suggesting initially that women should be allowed the un-biased information required to make a truly informed feeding choice, then suggesting that only positive breast-feeding information and negative artificial feeding information is made available. The policy also states that no instruction on bottle-feeding is to be given ante-natally as this is thought to undermine confidence in breast-feeding. This bias towards breast-feeding may have been a contributing factor in Kim’s lack of education on feeding technique. It states that women who have made an informed choice to bottle-feed should be offered instruction on a one to one basis post-natally, however this is not routine practice within the hospital. The hospital use pre-prepared bottles that require no sterilisation, which may mean teaching requirements are not immediately obvious to hospital staff. The hospital policy is based on recommendations laid down by the UKCC and baby friendly policy detailed by UNICEF and the World Health Organisation (WHO).
Despite the hospital policy’s dismissal of antenatal bottle feeding education, research demonstrates that one aspect of parent-craft many prospective parents are keen to explore in more depth is that of infant feeding (Britton 1998, Hoddinott and Pill 1999, Frossell 1998, Newburn 2000, Department of Health 1993). In particular, recent concerns have been raised about the lack of support offered to women that bottle-feed their babies (Kaufmann 1999). Adequate antenatal education may have prevented the unsafe practices that Kim and Tom were using, or may have identified a possible need for further assistance after delivery.
The baby friendly policy produced by the United Nations Children’s Fund (UNICEF) and the World Health Organisation (WHO) on which the hospital policy was based suggests 10 key recommendations (UNICEF UK Baby Friendly Initiative 1998), and in summary suggest that women are provided with positive information about the benefits of breast-feeding, with support and encouragement being offered to help mothers breast-feed exclusively. These guidelines were primarily introduced to reduce high rates of infant mortality in third world countries, but have since been adopted by many developed nations. The 10 steps in the initiative were based on the International Code of Marketing of Breast-milk Substitutes also produced by the World Health Organisation (The International Baby Food Action Network (IBFAN) 2001), which also states that while infant formula should not be promoted, parents that have made an informed decision to use artificial milk should be provided with adequate information to do this safely. This was also re-iterated in Changing childbirth (Department of Health 1993) and Maternity care in action (Maternity Services Advisory Committee 1982). These documents, while emphasising the benefits of breast-feeding, also emphasise the importance of informed choice in feeding, and educating parents in the safe use of artificial breast-milk substitutes. This aspect of the code has often been overlooked in hospital policies, and other aspects of the code have been misinterpreted by midwives (Martyn 1998), which has resulted in unsafe bottle-feeding practice in new mothers due to poor education (Kaufmann 1999), and feelings of guilt in mothers that choose to bottle-feed their babies (Battersby 2000).
The UKCC is currently the key governing body for all nurses, midwives and health visitors, and this includes students of midwifery. It is the body responsible for identifying and monitoring standards of practice within the midwifery profession. This has a huge impact on care delivery. As a student midwife, accountability for actions is a complex matter (UKCC 1992), however, the student acted appropriately by informing her mentor of the situation and discussing a course of action with her. This demonstrates that she acknowledges her own limitations, which ensures safe practice. The interaction demonstrates a good example of clause 6 of the Code of Professional Conduct (UKCC 1992b), which emphasises the importance of working in collaboration with other members of the healthcare team. The student also followed UKCC guidelines (UKCC 1992a) by clearly introducing herself as a student to Kim and Tom, and keeping accurate records throughout.
Accurate record keeping is a vital element of ensuring quality care of the client. Records are a key aspect of interdisciplinary communication, and errors or omissions may affect the future care that is provided by other health care professionals (Byrne 1999). With this in mind, the student kept an accurate record of all interactions with Kim and Tom, and as a student, her mentor countersigned each entry in accordance with UKCC guidelines on accountability (1992a). Poor record keeping is often demonstrated in cases of litigation (Byrne 1999, Mason & Edwards 1993), and the only evidence of the quality of care provided by the midwife is in the records kept, so it is also vital for her own protection that the midwife records events fully and accurately.
Record keeping is essentially a risk management issue (Mason & Edwards 1993), which comes under the area covered by clinical governance. Clinical governance may be defined as:
"... the coalescence of activities undertaken by practitioners individually, collectively and organisationally, within an interdisciplinary forum, which together – within a single mechanism – produce clinical effectiveness and promote quality services." (Royal College of Midwives 1998 p1)
This is a vast area, but essentially, the issues it encompasses include risk management, clinical audit, evidence based practice, statutory supervision, and standard setting, monitoring and evaluation (Royal College of Midwives 1998). It ensures effective practice from both the individual and the organisation in which she works.
Although not strictly a supervisory issue, the interaction between the student and the mentor was representative of the role of the supervisor in many respects. It is the role of the supervisor to advise and support midwives, and to ensure good practice by monitoring standards, for example in record keeping (South Thames Local Supervising Authority Consortia 1997). Annual supervisory meetings allow this.
Clinical audit and evidence based practice appeared to be poorly demonstrated in the hospital policy, as mentioned previously. The policy was based on the The evidence surrounding bottle feeding education can be contradictory in places (Frossell 1998, Minchin 2000, Robertson 2000, Battersby 2000), so it is difficult to determine whether she followed a research based approach. The hospital policy is based on recommendations laid down by the UKCC and baby friendly policy detailed by UNICEF and the World Health Organisation (WHO), but does not appear to take into account any research independent of this source, which may affect whether the policy is meeting the needs of the clients it is put into place to serve.
Many wider issues affect the role of the midwife in a care provision situation. The word restriction of this essay limits a full discussion, but it is important to acknowledge influences such as the human rights act (as discussed by Dimond 2000) and in particular article 8 which emphasises the importance of an individuals right to respect for their private life. Although as we have acknowledged, Kim’s choice to bottle-feed may not have been fully informed, this demonstrates that her choice should be respected. A failure to do this would be a breech of her human rights.
The Children’s act also must be mentioned in reference to the midwife’s role (Department of Health 1992). It states that once a child in need is identified midwives should:
"... work with parents to enable them to care for their children to the best of their ability by enhancing their knowledge and understanding of child care and development ..." (Department of Health 1992 p4)
This should be done with the co-operation of other members of the health care team to ensure the child’s needs are met. In this case, Joshua was identified as a potential child in need, and by co-operating with other health professionals and working closely with the parents, both Joshua’s and his parent’s needs were met.
On analysis, the student felt that she could have done more to meet the educational needs of Kim and Tom required for them to make a fully informed choice about feeding. She acknowledges that this may have been difficult as a feeding pattern had already been established, but a more concerted effort on her part should have been made. It was unfortunate that Kim and Tom’s learning needs had not been identified earlier, and it remains a contentious issue as to whether group antenatal education in bottle-feeding may have solved or identified some of these problems sooner. It was identified that the hospital policy may require revision in some areas, and an audit of current methods would help to achieve this. On a wider scale, more definitive research into the requirements of antenatal education in feeding practices may be called for.
On a positive note, the multi-disciplinary approach to care was felt to be a positive experience, and met guidelines from the UKCC and Changing Childbirth (Department of Health 1993). It was felt to be a satisfying experience to work with Kim and Tom towards a common aim, and the student felt great progress had been made prior to the cessation of midwifery led care at 28 days.
So many factors influence care delivery in midwifery, that it is impossible to discuss them all fully within the word limitation of this work, and some areas that warrant a full discussion have only been briefly mentioned here. The author feels strongly that although the primary issues that emerged from the scenarios (feeding methods, informed choice, parental support) have been strongly influenced by major works such as the Baby friendly initiative (UNICEF UK Baby Friendly Initiative 1998), it is important not to forget the basic guidelines that apply to midwives in any given situation, such as those detailed by the UKCC. The author also feels that although midwives must work within these guidelines, one of the biggest influences on how care is delivered may be the individuality and personality of the midwife herself, and it is the midwife that analyses and interprets policies and guidelines into her own approach to care.