A manifesto for PNEI in midwifery

Midwifery care as a reference model for the whole society

In most countries, at all resource levels, healthcare systems are based on post-modernist social and cultural paradigms, which have been conceptualised as risk prevention (Beck, 1986) and acceleration (Rosa, 2013). The concept of acceleration describes the technical-, digital- and economic-process-triggered social changes which lead to accelerated work- and life rhythms (Rose, 2013). Such accelerated rhythms are then transferred to maternity care, with evident effects on pregnancy-, but first and foremost labour-, birth- and baby management. The risk prevention and acceleration paradigms contextualize and set out social norms for healthcare and for its subcategory: maternity care. Soo Downe, a midwife and researcher in salutogenesis applied to maternity, claims that this has led to both damages and benefits to the mothers’-, the babies- and their families’ health (Downe, 2010).

The principle of sustainability in midwifery

The first paradigm of maternity care is that the long, sometimes very long term or even transgenerational perspective must not be left out of consideration. Assisting a woman, a family, during the reproductive period, certainly implies paying attention to wellbeing and risk factors, but also pursuing two clear, long-term purposes: reinforcing the parenting skills (which will spread across a lifetime) and supporting the new generations’ physical and psychological health. This could be referred to as transgenerational risk prevention. For example, the healthcare view based on the immediately measurable outcome, has led to an epidemic of caesarean sections in out industrialised world, particularly in Italy, the country holding the european record. Integrated medicine has shown how the impact of a caesarean section on the baby’s microbiome can affect the future adult’s Body Mass Index (BMI) and metabolism in the very long term (Mueller, 2015). Psychoneuroendocrinoimmunology has shown that the stress experienced by a woman during pregnancy and childbirth may generate a cascade of long-term effects on the baby’s and the future adult’s immune and relational competence (Buckely 2016, Schmid 2021, Van Dijk 2012, Hendler 2011).

Mind-body connection is essential

Once the desire for a healthcare system characterised by a long-term and transgenerational perspective is established, the points to pursue become clear:

Physical health cannot be separated from mental health and from the “health perception”, therefore paying attention to a person’s past is as important as primary and secondary prevention;
The power to make choices regarding the own health is a factor of health itself (Ottawa Charter for Health Promotion 1985);
The ability to choose gives a sense of control over life, thus strengthening the sense of competence and, as a consequence, coping abilities.
Since the notion of stress and wellbeing is subjective, and since the response to stressors is individual, medicine needs to listen to the individual’s real needs and custom assistance and care according to them. The ability to communicate without judgements, prejudices, regulations, obligations, dramatisations, minimisations, is a competence that every healthcare-worker should possess. Every person is their history and their environment, the healthcare system is in itself an environment for those who resort to it;
If a healthcare system aims to be a good environment, listening, dialogue and support to the choices require a trust relationship: such a relationship can be formed only through a relational healthcare; and since creating stable relationships requires time, assistance continuity becomes a health-creating factor.

The 5 C’s of Midwifery

Midwifery Care is the first healthcare model that decides to use a whole new paradigm, Antonovsky’s Salutogenesis paradigm, thus overturning the key principles on which the institutional approach to human health has been based.

The first 5 C’s of Midwifery as a universal health approach model

Centered Care: putting the person at the centre. This poses the standardisation of care at the second place, favouring the customisation of assistance. Care turns into a place where the person is recognised in its uniqueness and needs. The first point of the Sense of Coherence described by Antonovsky is the individual’s ability to orient itself in its own reality and to understand how they ended up going through a certain experience.
Choice: the choice. Free, informed. No fear-induced choice can be defined as free, no woman who is not the master of her body can be defined as free, no ignorance-induced choice can be defined as informed and consensus cannot be confused with choice: the first, passive one implies delegating to the expert whereas the second, active one implies full information and joint responsibility. Saturated information gives those control tools which belong to the second point of the Sense of Coherence theory.
Control: the sense of control and predictability of one’s own health and life improves the sense of individual and parental competence and is one of the factors of the Sense of Coherence explained by Antonovsky, the one that involves fulfilling and enhancing both one’s endogenous and exogenous resources.
Communication: relational midwifery demonstrates how communication can play a key role in making the people who are being taken care of feel competent, seen, listened to and supported. Communication, in order to be complete, must involve both the “left brain” (logic, data, statistics, rules) and the “right brain” (simbolic, unconscious, metaphorical, instinctual). This way, the assisted person can, and is helped to, come in contact with their inner root, their values, their faith and their human or spiritual motivation to live and face what is happening to them.
Continuity: assistance continuity is a key element of the empathetic-, care- but also first and foremost trust relationship. Humans, except when they fall in love (this due to the exceptional brain biochemistry of relationship) require time to form trust relationships.

The midwifery care becomes a personal growth factor

Dahlberg et al (2013) has brought the role of interpersonal relationships and of assistance continuity in the experience lived by women when becoming mothers to the attention of researchers. Where the healthcare system involves a salutogenic approach to health, care- and assistance processes turn into a chance to improve one’s self-consciousness. Body awareness, focusing on and re-evaluating one’s own endogenous and exogenous resources, the matter of consent, of one’s limit and of the cyclic nature as a factor in learning about one’s own rhythms, all of this is a part of the path that women take with midwives. Therefore, midwives are healthcare providers whose job goes beyond creating culture and doing prevention, broadly and generically speaking. By taking care of individuals in a one to one relationship, they guide them in expressing themselves, in experimenting themselves, imagining possible scenarios linked to their free choices, supporting not a prescribed “right choice” but a more individual “choice which is right for me in this moment of my life, given my needs, my competences, my limits, my available resources”.

The midwife as a “Risk-Negotiator”

Midwifery care does not deny risk, yet it accompanies and supports the assisted person along an individual path which separates personal risk from theoretical risk. In the practice, the australian study conducted by Dove et. al (2014) gives the midwife the role of the “risk negotiator” between the woman and the healthcare system. It also associates this competence to one of the key facilitating factors in following a health path reported by women. More specifically Feeley (2020) underlines that the midwife works “backstage” to facilitate human health and choices.

Applied Salutogenesis

The salutogenic approach is positively linked to the quality of a relationship, to the satisfaction with the received support, to the psychological wellbeing and the overall experience of maternity. The sense of coherence (SOC) also determines the orientation towards maternity and the choice of the birth method. The best ways to improve the mothers’ sense of coherence include ensuring the continuity of care during the postpartum period, improving parental engagement, focusing on ideas of wellbeing and having healthy relationships between parents and healthcare providers (Shorey, 2020).

MODELS IN COMPARISON
Institutional model	Salutogenic model
Focus on pathology	Focus on health
Once a symptom arises: investigation on risk factors	Once a symptom arises: investigation on health factors
If there is a risk: health falls in the background, risk and danger are the central and dominating topic throughout the whole meeting	Dialogue focused on positive physiology and health references rather than on risk (3:1 ratio)
The symptom is corrected through a therapeutic prescription	Once there is a deviation, resources must be developed
Illness corresponds to the moment in which individual competences are pushed aside	When an unexpected health event occurs, competences are called on even more
Relationship of delegation with the expert	Empowerment and shared responsibility
Standardised care	Customised care
A difficult patient is a patient who is not collaborative	A person in difficulty needs more support

The salutogenic model: how we wish healthcare was

It becomes clear how Midwifery Care is creating the reference model for the global approach to the individual in the healthcare world. An approach differing from the medical-technological one, which is focused on risk and pathology, an approach that makes it possible for people to improve their health, receive care and adapt to the unexpected in life, by focusing on their coping abilities, while being supported with compassion in a loving environment. Content edited by Anna Maria Rossetti

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