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Risk selection is a central issue in midwifery care. It limits the tasks that we as professional midwives are authorized too and in this boundaries lies the safety of normal birth and home birth. A birth is safe only as long as the birth process is progressing within the physiological rhythms. So, midwifery care is safe only as long as the midwife moves inside the boundaries of her profession, using her specific tools to promote health (salutogenesis). Salutogenesis, in a model of continuous and one to one care can enlarge this boundaries keeping woman and babies healthy, especially in borderline situations, where inappropriate medicalization often starts.

The goal of selection is to understand until what point a woman is healthy and when she does need medical care. Medical care, when needed has to be integrated in the basic care of the midwife. Salutogenesis is always indicated, and women should never be separated from the continuous caregiver.

Let’s start with some question: 

What is the role of protocols?

Who makes the choices about intervention?

What kind of tools a midwife could use to restore health in borderline situations?

What happens by focusing on risk factors?

What happens by focusing on signs of health and resources?

How can we include informed choice in risk selection?

THE DIFFERENCE BETWEEN AN APPROACH BASED ON THE MEDICAL MODEL OF CARE AND AN APPROACH BASED ON THE MIDWIFERY MODEL OF CARE

The education of midwives is based on the medical model of care. So many midwives are in conflict between their education and practice and their inner female model of birth. Illustrated below are the main differences in the focus points of the two approaches:

MEDICAL MODEL:

Focus is on risk and pathology (diagnosis and intervention)

Caregiver and technology are at the centre of care 

Security is percieved in taking control over women

Professionals make the decisions ——-> disempowerment of women

————————–

MIDWIFERY MODEL:

Focus is on health (health promotion, salutogenesis)

The woman, the baby and her family are at the centre of care 

Security is percieved in a woman who is in control

The woman, together with her partner and the midwife, makes the decisions——->

empowerment and shared responsibility

This changes completely the approach to care for the midwife and the tools she employs.

MODEL OF MIDWIFERY CARE BASED ON HEALTH, (SALUTOGENESIS, SALUTOPHYSIOLOGY)

The roots of health are based in an active adaptation to changes including physical and psychosocial aspects. So, the approach has to be global. The person and the environment are considered as an unique organism.

Tools for physiological adaptation:

• Education to genesis of health
• Activation of the biological resources of woman and baby
• Activation of the physiological systems of adaptation, the reactive systems: steady state, fight or flight, calm and connection, tend and befriend, fetal-placenta system
• Attention to the physical perceptions and intuition
• Hormones – emotions –behaviour are linked together
• Physiological rhythms: Polarities and rhythms of the physiological systems
• Circular observation
• Communication between the physiological systems: The internal communication between hormones, autonomic nerve system, immune system and behaviour, outside environment
• Biological attachment to the baby
• Mother baby as a unit from conception to the first months
• The foetus-placenta system united with the mother and at the same time with an individual autonomy

Tools for social adaptation

• Cultural de-conditioning, positive communication
• Social, psychic and cultural resources
• Social systems of adaptation (Antonowsky) and sense of coherence
• Orientation, knowledge
• Behaviours, life style
• Modulation of behavioural rhythms
• Communication between the mental and the social system
• Social and psychic attachment to the baby
• Mother and baby as individuals

Midwifery model of care: the 5 C’s

The theoretical contour for applied salutophysiology

• Woman centred care: Focus on endogenous resources
• Choice: Unity of person and environment, body and mind
• Continuity of care: Professional, symmetric, therapeutic relationship
• Control of woman: Development of coping capacities
• Communication: relationship and empowerment

In salutophysiology the focus is on signs of health, endogenous resources, and on women’s choices.

Thus we need a different model of observation and a personalized approach to care, as every woman is different and exists in a different context. 

The normal model of risk selection in the medical model of care is linear: 

From the symptom———–> to diagnosis based on pathology ————–> to medical care

In midwifery care (salutophysiology) the approach is circular, a process of reasoning and problem solving:

From the symptom to  – 

———->  searching for signs of health in the woman’s physiological and mental systems and in her environent,

 ———> evaluating the balance between signs of health and signs of disease

———-> activating the woman’s inner resources, if there is enough time

———-> promoting women’s choice 

———-> doing an assessment 

———-> either health is regained or, if the woman’s inner resources are not sufficient, 

———-> integration with medical care. 

TOOLS FOR A CIRCULAR EVALUATION, OBSERVATION AND INTERVENTION

All observation of symptoms and signs of health are done on three levels:

1) CLINICAL LEVEL: Body, physiology, baby, womb

2) ENVIRONMENTAL AND BEHAVIOURAL LEVEL: Human and social environment, public health services, behavioural rhythms,  kind of support

3) EMOTIONAL AND RELATIONAL LEVEL: Personal and social experiences and conditioning, relationships with others and the baby, emotions.

Usually one of these levels emerges more than others: for example, the mother arrives with a physical complain (first level), or she appears stressed and anxious (second level) or she bursts out in tears after the first exchange of words (third level). Although they are all linked together, we can start with intervention at the more acute level. 

The following observation chart gives you an example of how to organize your observations and illustrates how to become conscious about the level of every sign that you capture, often in an instinctive way.

OBSERVATION CHART

OBSERVATIONS	SYMPTOMS OF HEALTH	SYMPTOMS OF ATTENTION	RESOURCES AND NEEDS
CLINICAL ASPECTS Hormonal system   Autonomic nervous system   Placenta-foetal system (baby)   Stress tolerance level   General health condition Nutrition Other
ENVIRONMENTAL AND BEHAVIOURAL ASPECTS Kind of support and supportive people available   Rhythm of life   Behavioural rhythm   Capacity of coping, adaptation, flexibility reactivity   Other
EMOTIONAL AND RELATIONAL ASPECTS Bonding with the baby   Bonding with the partner   Bonding with the family   Reactions to changes   Emotional openness/closure

Now that you have an idea about the circular or holistic approach toward salutogenesis (origin of health), we can move a step forward and look to the traditional medical model of risk selection and to the salutophysiological model of risk selection in the midwifery model of care.

The linear, medical model of selections follows an outline like the following:

Flow diagram for determining responsibility for care during pregnancy, birth and puerperium, as used in drawing up the revised indication list

relevant condition?	no	A
Yes
Specific policy?	no	A
Yes
Increased risk?	no	A	transport     risk?  no       A
	possible	↑ consultation B
Yes				Yes
		C	D

A. Primary obstetric care. The responsibility for obstetric care in the situation described is with the primary level obstetric care provider, midwife or GP 

B. Consultation situation. This involves evaluation involving both primary and secondary level care. The individual situation of the pregnant woman is evaluated and agreements are made about the responsibility for obstetric care based upon the above mentioned five questions. Consultation will take place unless structural agreements have already been made at a local level. The section on obstetric co-operation provides information about such agreements.

C. Secondary obstetric care. This is a situation requiring obstetric care by an obstetrician at secondary level for as long as the disorder continues to exist.

D. Transferred primary obstetric care. Obstetric responsibility remains with the primary care provider (midwife/GP), but in this situation it is necessary that birth takes place in a hospital in order to avoid possible transport risk during birth.

This way of selection is very rigid and creates a high transfer rate to medical care without any use and true benefit.

CLINICAL REASONING

CIRCULAR RISK SELECTION OR PERSONALIZED CARE PLAN

In woman centred, personalized midwifery care, the rigid concept of selection can be substitute by the flexible concept of a personalized care plan, who searches in every moment to find the best solutions for the current situation with the woman’s active participation. This flexible way requires however to reason about every case and find different solutions every time. 

Together with the circular evaluation and the option of salutophysology or non medical interventions women have much more possibilities to stay healthy and to activate their own resources and forces.

The following outline can support the clinical reasoning and help in taking appropriate decisions together with the woman, respecting her choices and her needs. It offers criterias to find the best individual solution.

OUTLINES FOR DECISIONS

THE QUESTIONS	THE CARE GIVER	DECISION   INFORMATION	INTERVENTION THE TOOLS   WOMAN’S CHOICE
What are the risk factors for this woman? üOn a personal level üFrom a medical point of view	Who is the caregiver with the most effective tools?   (doctor, midwife, psychologist, homeopath, osteopath etc.)	What does the care giver know about the problem?   What does the woman know: intuitions, perceptions, resources   What do we know from EBM?   What is hospital practice?	Which tools are needed? What is the level of professional experience? What is the best approach? What is the woman’s preference?
Is it possible to prevent these risks?     Yes   ————>>             No          !                !               V	Who has the most effective tools?     The midwife?——->           ————– The doctor? ——–>   Others?	What is known from Physiology? What is known from EBM?   What are the resources?   What is the woman’s/midwife’s perception/intuition? ———— ————————-à	What kind of tools? –      Clinical, hands-on, treatments –      Social: setting, context, rhythms, lifestyle –      Emotional: professional and affective relationship, support———— –  Diagnosis and therapy ——————————- What is the woman’s choice?
It is possible to diagnose these risks early on?     Yes   ————>>         No          !                !                !               V	Who has the most effective tools?     The midwife?——->           ————– The doctor? ——–>   Others?	What is known from Physiology? What is known from EBM?   What are the resources?   What is the woman’s/midwife’s perception/intuition? ———— ————————-à	What kind of tools? –      Clinical, hands-on, treatments –      Social: setting, context, rhythms, lifestyle –      Emotional: professional and affective relationship, support ——————————- –  Diagnosis and therapy ——————————- What is the woman’s choice?
It is possible to afford these risk, should the pathology manifest itself?   Yes   ————>>     No          !                !                !               V   The woman remains with midwifery care	Who has the most effective tools?     The midwife?——->           ————– The doctor? ——–>   Others?	What is known from Physiology? What is known from EBM?   What are the resources?   What is the woman’s/midwife’s perception/intuition? ———— ————————-à	What kind of tools? –      Clinical, hands-on, treatments –      Social: setting, context, rhythms, lifestyle –      Emotional: professional and affective relationship, support ——————————- –  Diagnosis and therapy ——————————- What is the woman’s choice?

DESCRIPTION

Point 1) Definition of the risk:

You need to understand the symptoms and analyze the true risks for this woman. To make the right diagnosis, you need to know physiology very well. Using the observation chart and circular evaluation can help.

Point 2) Who is the caregiver with the most effective tools:

Here you have to look at both medical and non-medical tools. Usually doctors have medical tools, midwives have non medical tools like manual and relational tools such as counselling, active listening, problem solving, manual treatments like massage, anti-stress treatments, body work, relaxation and others.

Also, evaluate your education and experience, the tools you own. A more experienced midwife will have more tools then a less experienced, and will have less need to refer to medical care. But, if you don’t have the tools, medical care may be safer for the woman.

Point 3) Decisions and information:

Here you need the tools of Informed Choice. You bring together objective and subjective elements.

The scientific knowledge is integrated with the woman’s resources and other subjective elements like intuition and perception. A woman in control, who is listening to her body and is not distressed, is able to feel very well how is her baby and herself. A midwife who is in a good relationship with the woman, is similarly capable to feel on an intuitive level what is going on.

Bringing all these elements together, you have a good ground for taking informed decisions that you and the woman are confident about.

Point 4) Tools and the woman’s choice:

Here you can use the observation chart again, looking to the needs and resources. The first intervention will be done on the most evident level between the three, where the symptom appears. Then you integrate the other levels.

Very often there are two possible approaches to the problem: the medical approach and the salutogenic, midwife specific approach. You can propose both to the woman and enable her to make her choice.

Sometimes medical care has priority; in that case you will integrate medical care into the other levels.

(The schedules  and concepts are pubblished in my last book Schmid V. (2007) “Salute e nascita, la salutogenesi in gravidanza, Apogeo ed., Milano – Health and childbirth – Salutogenesisi in pregnancy and motherhood)