As a midwifery postgraduate student in Hangzhou Normal University, I was lucky to have an opportunity to witness and report briefly on the groundbreaking development of the first midwife-led normal birth unit (MNBU) in Hangzhou City, east China. It is an international project to promote normal childbirth and Chinese midwifery. The collaborators are from Hangzhou Normal University, University of Edinburgh and Hangzhou First People’s Hospital.
This project was based on previous studies of Chinese rates of caesarean section and the development of Chinese midwifery (Cheung et al. 2005a, 2005b, 2006a, 2006b; Cheung, 2009a). In the above studies, the marginalisation of Chinese midwifery since 1990s was identified, and this has led to a sudden high caesarean rate of over 60% (Zhang, 2005), especially in urban areas. In order to make some changes, the first MNBU was planned and set up in Hangzhou (Cheung et al, 2008).
The host hospital of the project is one of the best locally. There are 59 midwives in the hospital and 23 of them participated. Until the end of May 2009, more than 500 women had used the services of the MNBU since March 2007.
The project’s achievementsIn China, midwives are only allowed to provide intrapartum care in labour rooms of hospitals according to the national healthcare legislation. They have to work under the supervision of the charge nurses and obstetricians in the hospital (Chinese Ministry of Health, 1985). Midwifery care is prohibited in the community setting, because it is regarded as a serious hazard to women and babies to carry out delivery services at home (Chinese Ministry of Health et al, 2006). Therefore, Chinese midwives do not have the opportunity to play the full role in the birth process as defined by World Health Organisation (WHO) (Fraser et al, 2003). In spite of the harsh policy, the first MNBU was established successfully by the motivated midwives in Hangzhou against the odds.
The MNBU service was offered to healthy pregnant women from 37 to 41 weeks’ gestation. A healthy woman could choose the MNBU service by herself. Once she made the decision, midwives would arrange a series of antenatal classes for her and the birth companion of her choice. When she was in labour, the woman could enjoy the special ‘two-to-one care’ in the MNBU, which means that she could have her birth companion with her and be looked after by her midwife in the labour room. With such a model, the woman could be well supported physically, emotionally and psychologically, which facilitated the midwifery philosophy of ‘women-centred’ care. So the midwives in the hospital called this MNBU a ‘homely birthplace’, because the unit created a warm and harmonious birth atmosphere which clients really appreciated.
Midwives could use their professional skills fully in the MNBU and thought the unit would be a new way forward for Chinese midwifery. They were happy to work in it, and felt that they could have a better understanding of the concept of holistic care for the healthy woman in the model of 'two-to-one care'.
The concept of ‘two-to-one care’ was developed from the western one-to-one midwifery model (Page, 2003). ‘Two-to-one care’ pays attention to the role of midwives and it also emphasises the role and the positive participation of birth companions. The birth companion is required to accompany women to attend the pre-birth educational courses and to make the birth plan together with women and midwives. Moreover, this new 'two-to-one care' promotes the mutual cooperation among midwives, women and birth companions during the labour and birth.
The rate of normal birth reached 87.6% in the MNBU (Cheung et al, 2009b), so it has met WHO’s standard that caesarean rate should not surpass 10-15% in every country. The caesarean rate in the standard care of the obstetricians-led unit in the host hospital still remained at approximately 42% (Cheung et al, 2009b). So the difference in the two birth units highlights that midwives can provide better care for healthy women.
However, there were still some problems with the skills and practices of midwives in the MNBU service. For example, the episiotomy rate in this unit was still 77.9%, although this figure is lower than the standard care of 94.2% (Cheung et al, 2009b). It was certainly much higher than that of England, which has maintained at 12% to 14% over the recent decade (Richardson et al, 2007). It reveals that the MNBU needs further improvement in China. Midwives should continue to make an effort to raise the standard of service quality in the MNBU.
The clients’ experienceSome Chinese reports showed that the care of the MNBU increased women's satisfaction in childbearing and improved the relationship between the couples considerately (Yang Q et al, 2008).
Some women who used the service also put their stories onto their own websites or blogs to share the experience in the MNBU with others. They were happy to be able to have their birth companions with them and appreciated the care provided by midwives in the labour. The experience of the women is similar to those who received midwifery care in other countries (Page, 2003; RCM, 2008).
I had an opportunity to attend an informal meeting with some birth companions of the MNBU to listen to their stories. They reported that after being with their partners during the birth, they felt their relationship and affection strengthened. However, midwives may need to arrange more separate educational sessions to help birth companions clarify their role and enable them to provide better support.
The MNBU service can encourage family participation and empower women, as well as providing women with appropriate care in China. The development of the first MNBU in China is a big step forward for Chinese midwifery. The achievement of the project shows that Chinese midwives are able to make changes and to play their role in looking after healthy women. They also prove that they can offer healthy women better care than doctors.
The author would like to thank her supervisors, Professors Cheung Ngai Fen, Professor Fu Wei, Professor Wang Xiaoli and Zhou Hong and Professor Mander Rosemary for their teaching and guidance.
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