Remote Midwife NT.

Today’s story comes from Lyn, a midwife in remote Australia. In this story, Lyn gives an account of her conversation with Louise (pseudonym), following Louise’s request to cease her contraception. Louise had a complicated obstetric history that could have compromised her pregnancy outcome if her request had been granted without serious consideration. Lyn describes the dilemma she faced in dealing with this case—mainly owing to her limited professional skills in this area. The story also gives insight into the engagement strategies she employed to get her client to understand the situation and to enable her (the client) to make informed decisions on the way forward. Lyn concludes her story by highlighting the need for an appropriately-skilled and highly-knowledgeable midwifery workforce in rural and remote Australia that is also sensitive to the contexts of the lives of the women they assist.

Lyn’s story: 

Residents of very remote communities in Australia are predominately Aboriginal, highly mobile, and young (Australian Institute of Health & Welfare 2011). Given the burden of need in very remote communities, remote midwives often extend their practice, with knowledge and procedural skills in women’s health, sexual health and contraception. However, there is a need for remote midwives to have a broad understanding of wider health issues and apply procedural skills appropriately.

A few weeks ago, I saw Louise (pseudonym) a 24-year-old Aboriginal woman with one daughter—3 years old. She wanted her contraceptive implant removed as her partner was coming out of jail. She was diagnosed with diabetes during her last pregnancy—probably pre-existing but undiagnosed until pregnancy. Her daughter was born premature. Following the birth of her daughter, it was recommended she stay on oral hypoglycaemics and insulin. She attends the local clinic irregularly. Her last HbA1c, taken a month before she requested ceasing her contraception, was 13.1mmol/mol. She smokes cigarettes and has limited access to a healthy diet.

Louise’s request raised a dilemma for me. Removing her contraceptive implant is a procedure undertaken by the appropriately-trained remote midwife. Louise enjoyed being a mother and wanted to expand her family. However, given her previous obstetric history and current medical problems, what was the best thing for her and any future pregnancy? Louise’s request provided an opportunity for us to work together to ensure she had the best possible information to base her health decisions on.

This consultation was a long session. The desire to achieve a future healthy pregnancy provided an incentive for Louise to spend some time investing in her own health needs. Together, Louise and I discussed these needs; diabetes management, medication management including supplements, appropriate referrals, immunisations, screening for domestic and family violence, sexually transmitted infections, and cervical cancer. Preconception counselling encompasses a wide range of topics. We collated a comprehensive obstetric, medical, and social history. I was able to provide resources and education about how to maintain optimal health for pregnancy. Having spent much of the consultation in discussion, I then conducted a head-to-toe examination of Louise, collected appropriate pathology samples—some related to preconception screening, some required for her pre-existing medical condition—and provided her regular medication, as well as preconception supplements.

The lengthy discussion, and some pictorial resources, helped Louise with her decision to continue with her contraceptive implant for a few weeks longer. She would try hard to make some lifestyle changes and reduce her blood glucometer levels. Having been reassured that fertility usually returns quickly once contraceptive implants are removed, she was happy to work on her general health and wellbeing. We planned to touch base the following week to see how she was going and to discuss her pathology results. As with all consultations, our discussion, actions, and follow up plan was then documented in Louise’s clinical record.

This case illustrates the need for remote midwives to not only be highly knowledgeable and skilled within their own scope of practice, but to also understand the burden of disease and context of women’s lives. Remote women live in a context that predisposes them to a high burden of ill health. Remote midwives need to be alert to cues that might indicate the need to explore further, or consult other health care professionals. In recognition of the complexity of health needs of remote Aboriginal woman, the Minymaku Kutju Tjukurpa Women’s Business Manual has been developed as a standard treatment manual for women’s business in remote and Indigenous health services in central and northern Australia. It provides an easy-to-read, comprehensive clinical guide to common clinical challenges seen in remote Aboriginal women.

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