(originally published in February 2020)
Dear midwives from all around the world,
I would like to ask for your moral support towards midwives in the Czech Republic who have been struggling for years to practise autonomously. They are now facing another challenge.
There is now a new proposed law about establishing Czech Midwifery Chamber – a self-governing professional organisation for midwives which is also a regulatory body. The idea seems very reasonable and attractive, it is being presented as a tool which will help to strengthen midwifery and make it safer for women, however the way the bill is worded could in reality undermine the autonomy of the midwifery profession and exclude independent midwives from care provision.
The explanatory memorandum of the bill states that the need for midwifery regulation arose among other things due to the “phenomenon of homebirth” which, according to the document, is dangerous. The memorandum goes on to explain that the Chamber will outline rules under which women will be deemed low risk and only then a midwife is allowed to provide care at home. But if the woman is or becomes high risk, the midwife is forbidden to provide care at home.
This is of course very dangerous. If taken to its logical consequence, if a woman starts labouring at home as low risk, becomes high risk (according to the set criteria) and declines hospital transfer, the midwife would have to stop providing care. Otherwise she could be struck off the register.
The explanatory memorandum completely ignores all recent research into the safety of homebirth, claiming that homebirth is dangerous and its occurrence has to be minimised. This is worrying as the bill itself clearly states that all midwifery care standards and regulations created under this law by the Midwifery Chamber have to be evidence based. So why is the reasoning behind introducing this law not evidence based, too?
Unfortunately, given the history of other regulations regarding midwifery in the Czech Republic, it is likely that if the bill is adopted in its current form, the rules for homebirth will be set so that they are unachievable – same as with the current regulation for opening a freestanding birth centre, which orders that a planned birth only happens in a health care institution where there is a doctor available in five minutes and urgent caesarean section can be performed within fifteen minutes.(1) And these rules will stay effective, since the bill does not bring any changes in the regulation about freestanding birth centres.
The bill also requires newly qualified midwives to practice full time for three years under direct supervision before being allowed to sit an exam with the Midwifery Chamber (which the midwives will have to pay for 2000CZK ~ £67) in order to become autonomous practitioners. This requirement seems absurd considering midwives already undertake three years of specialised university training. Why are these three years of studies, clinical placements and exams not sufficient? The bill offers no explanation.
This requirement is discriminatory towards those midwives who will not be able to work full time due to other commitments – typically looking after young children or ill family members. Furthermore, burdening the already strained Czech healthcare system by having experienced midwives supervising their recently qualified colleagues for three years on top of all their other duties will only make the current situation of staff shortages worse. It will also make midwifery unattractive for prospective applicants.
Newly qualified midwives do need to be supported by their more experienced colleagues, but they need to be autonomous at the same time. They have to take responsibility for their actions, but maybe more importantly, they need to be empowered not to carry out activities they have not been trained for and refuse if they are asked to go beyond their competencies. This is also part of autonomy.
While all midwives will have to be on the Chamber’s register in order to be allowed to practice, and they will have to pay a fee for being added on the register (2000CZK ~ £67) and a yearly fee (2000CZK ~ £67), they will not automatically become members and have a right to participate in its processes, to vote and to be elected into the Chamber’s Bodies. There is a requirement to pay a higher fee (5000CZK ~ £167 per year) in order to become a member and gain these rights. This is not only confusing but also discriminatory towards those midwives who will not be able to afford paying the higher fee and as a result, these midwives will be disqualified from participating in any decision making about their own profession. There is no explanation as to why this two-tracking is being introduced. To frame the fees, median earnings in 2019 for midwives were 40000CZK per month ~ £16300 per annum, which is the gross earning including all overtime payments.(2) Starting salary for a newly qualified midwife without overtime payments can be less than a half of the above sum.
The bill does not contain a full definition of who a midwife is and what is the scope of midwifery practice. It is designed as a frame which shall be complemented by rules and regulations later created by nine elected members of the Midwifery Chamber Board. But there is no requirement in the bill to consult midwives, midwifery educators, employers or care recipients when creating the regulations and when creating standards of midwifery care for specific clinical situations. Surely those directly affected by new rules regarding the profession should be consulted in the process.
Of course midwifery as a profession needs to be regulated for the safety of midwives and the public. And it would be great for Czech midwives to have a body who could negotiate on a government level on their behalf, however, this needs to be done in a transparent manner. Unfortunately this bill with its current wording could give unlimited power over the profession to a very small number of people and as a consequence, those midwives who do not conform to the mainstream medicalised approach to midwifery care could be completely excluded from care provision. The bill offers a wide range of disciplinary measures against those who will not comply with the professional regulations set by the Chamber.
The explanatory memorandum claims that the bill has been endorsed by the European Midwives Association. However its wording goes against EMA’s position statement on intrapartum care, which says: EMA urges Member States to fully recognise that choice of birth setting, home and/or birth centre, is a safe and beneficial option for women.(3) I have contacted EMA to verify the claim, but have not yet received any response.
EDIT March 2020 – Mervi Jokinen, the president of EMA confirmed that EMA has never endorsed this bill.
I am not sure where that statement comes from as we have never been asked for endorsement on the doc I have just returned read the translated CzUnion concerns, responded re issues that do not comply with Directive or not based on evidence. Confusion— Mervi Jokinen MSc (Distinction) BSc(Hons) RM (@EUMidwives) March 12, 2020
You can read in further detail about what this bill could mean for Czech Midwives and read an informative translation of the explanatory memorandum (the part of the bill which explains why it is being proposed).
If you can, please send a message of support to Czech midwives. Tell us what you think about the current situation of Czech midwives and Czech women. If the situation in your country is or was similar in the past, please let us know what actions you are taking or what helped to bring the change towards more choice for women and autonomy for midwives.