Rheumatoid Arthritis (RA) is a chronic, systemic and generally progressive disorder of unknown origin which affects connective tissues. RA is commonly manifested by inflammation of the synovial membrane of joints, immobility and general fatigue (1). Concurrent and symmetric polyarticular inflammation, which is its first clinical symptom, initially involves the small joints in the hands and feet (2).

RA knows no geographical or racial boundaries and may occur at any stage of life. Its prevalence and incidence increases with age (3). According to other studies, its global prevalence rate is reported as 1% and such rate is the same worldwide (21, 4). According to the World Health Organization’s 2002 annual report, RA accounts for 0.8% of total years lived with disability. Besides, the mortality rate of people affected is twice than that of general population at the same age. Also, the rate of its prevalence is significantly increasing in the recent years (21, 5).

Furthermore, women are more likely to develop such disease than men as 70% of the patients suffering from RA are women. The disease, which mostly occurs in the fourth and fifth decades of life, can disrupt normal daily activities (21, 6). RA may cause numerous physical complications among which chronic pain, fatigue, impaired mobility and limb deformities are the major ones (7).

RA-induced complications are not limited to apparent limitations in mobility and activities of daily living; but obscure systemic effects of such disease can also lead to organ failure, death or serious health problems such as pain, fatigue, sleep disturbance and changes in self-image. Such complications can cause disabilities and permanent changes in the patients (8).

The chronic nature of rheumatic diseases necessitates obtaining the required knowledge about the disease to make sound decisions for managing the health condition and developing a treatment plan tailored to the patient’s lifestyle. Fundamental objectives and strategies to deal with such diseases includesuppressing inflammation and autoimmune response, controlling pain, maintaining or improving joint mobility and functional status as well as increasing the patients’ awareness of the disease process (8).

Encouraging patients to adopt correct and proper self-care behaviors is an important factor which contributes to successful management of the disease (9). Self-efficacy also seems extremely important in managing RA.Unpredictable courses of the disease and its varying activity can make the patients find their disease uncontrollable which, in its own turn, can decrease their self-efficacy in managing it (10).

Self-efficacy is a form of self-confidence defined as one’s belief in one’s own ability to successfully organize and accomplish a particular task, behavior or any changes in cognitive status regardless of the underlying terms and conditions (11, 12). It is also a prerequisite for behavior change which affects the amount of efforts and level of performance (13).

People with higher levels of self-efficacy hold a belief that they are able to control their life events effectively. Such perception and belief, which can affect their behaviors directly, create a standpoint for them different from that of people with poor self-efficacy (11). Hence, self-efficacy is a critical factorcontributing to the success and failure of people throughout their lives. Individuals’ perceptions of such sense, is the most powerful predictor of their ability to change risky behaviors. It also determines how they face obstacles and difficulties.

The people with low self-efficacy are easily convinced that their attempts are useless so they quickly stop striving. However, those with high self-efficacy not only can remove the barriers by improving self-management skills and persistence, but they also can stand against problems and have more control over their affairs. Besides, reinforcing self-efficacy can result in maintaining and preserving health-promoting behaviors (14). Its significant role in the initiation and maintenance of healthy behaviors,in case of occurrence of any disease such as arthritis, asthma and diabetes mellitus occurs, has been frequently reported by researchers (15). Previous studies have shown that using structured education can improve it in patients suffering from chronic obstructive pulmonary disease as well (16). It is also reported that increased self-efficacy could improve self-care skills and behaviors in the patients with diabetes mellitus (17).

The evidence show that it is essential to enable the patients to take care of themselves using scheduled training programs, which are based on patient-centered approaches, including patients’ active participation in improving their quality of life.It is of extreme importance due to several reasons such as priority of prevention to treatment, the chronicity of the disease, shorter hospital stay and spending recovery period at home as well as the problems of access to health care (18-20).

Atak et al (2010) reported the significant effect of education and subgroups of regular exercise, choosing healthy diet and controlling complications of the disease on the mean of total self-efficacy scores in the patients with diabetes mellitus (21). Furthermore, the results of another study revealed that education could significantly affect perceived self-efficacy in the patients with arthritis with respect to their ability to exert control over pain; however, it was not significant in terms of shin-related exercises. The researchers justified the lack of educational effects on exercise-related self-efficacy by explaining that training in a limited period of time cannot enhance the patients’ confidence in taking such action due to severe complications such as joint stiffness, pain and inflammation they experienced (22).تکراری

Vikery et al conducted a similar study to examine the effect of self-care trainings on disease outcomes. The obtained results showed that self-care training could decrease morbidity, the number of medical visits required and consequently healthcare costs (23). Even a small percentage increase in the self-care of chronic conditions can have major effects on reducing the demand for specialized services in health care (24).

Patrich (2008) believe that without training the patients and their participation in their self-care process, health care will be more costly and quality of life will be more impaired (25).Patient training is a vital aspect of nursing care for those with arthritis to enable them to live as independently as possible, take their medications correctly and safely and use assistive devices properly. Such training is focused on the type of disorder, possible changes resulting from the disorder, prescribed treatment regimen, side effects of the medications and strategies to maintain individuals’ independence and performance as well as patient’s safety at home (8).

Several studies showed that training the patients can raise their knowledge and result in the improvement of self-management activities and health status so that they can prepare themselves for decision-making and compliance with the treatment regimen (26). It is worth mentioning that the aim of training the patients with chronic diseases is to sustain their behavior change for a longer period of time and even until the end of life.Due to the nature of the disease, immediate changesare not expected to be seen; for example prompt resolution of disabilities and difficulties is not expected to occur in case of chronic diseases such as arthritis. However, self-management training seems essential and profitable; so, the patients should obtain required knowledge and skills needed for decision-making and solving their own problems and those related to communicating with others (27).

The term “midwife” derives from the Latin meaning “with woman” or in France “wise woman”. “Throughout the ages women have depended on a skilled person, usually another woman to be with them during their childbirth” (Cooper & Fraser 2003:4).

Midwives provide care to women and their babies antenatally, postnatally and of course during child birth. A major role of the midwife is to help the woman adjust to this life changing event. Helping her do this can be very effective on a one to one basis or in a group of women with their partners. Continuity of midwifery care is very important and beneficial to a pregnant woman and this type of care is rarely seen on medical wards. In the context of community midwifery a woman is usually with the same midwife or is familiar with other midwives in the community birthing teams throughout her pregnancy. This means the midwife will gain a greater understanding of the woman’s history and birthing plan. This essay will discuss the different comparisons in hospital based births and home based births, different experiences with mothers and midwives and the services available in Ireland that enable home based births.

In Ireland routine intervention in labour is common; however, since the early 1990s some changes in the Irish maternity services have taken place. Trial projects on community midwifery have been introduced in selected areas. The Challenges associated with the provision of maternity care in the Health Service Executive, North Eastern area (formerly the North-Eastern Health Board) led to the creation of the Kinder report, which included a recommendation to introduce pilot midwifery-led units (MLUs). (Devane D. Murphy-Lawless J. Begley CM, 2007). Since the late 70’s there have been moves toward hospital birth with medical intervention as people may think this environment is a safer place to give birth. Many people accept the premise that because of modern technology, hospitals are the safest place to give birth (Tew 1990). The maternity care in action report (Department of Health, 1984) said: “as unforeseen complications can occur in any birth, every mother should be encouraged to have her baby in a maternity unit where emergency facilities are available”. In some cases this statement may apply to some women but in more recent times we are aware that it is not vital for every baby to be born in a hospital, as the majority of pregnancies will not have complications. For example in a study of the personal registers of 300 midwives working during the years 1948-1972, Julia Allison analysed data on 35000 homebirths (Allison, 1996). ” she identified that the rates of stillbirth and neonatal death were consistently less at home than in hospital, despite the fact that 50% of women who gave birth at home would be considered ‘unsuitable’ for homebirth by current criteria.” (Allison, 1996, cited Henderson and Mac Donald 2004:401:402).

The aims of midwives and mothers are united.

One cannot argue that there is always an intensive care baby unit readily available if needed in an emergency situation and perhaps this would make an expecting mother less anxious. Some may link hospitals as a place where sick people attend and this in turn may make a patient anxious. The goal of a midwife includes helping a woman recognize that child birth is a natural life process and is not associated with an illness. The midwife and the woman will work together on the home birthing plan which can make the woman feel more in control and homebirths can have positive results for not only mother and baby but other people involved, e.g. family, partners and children. “Midwives are in a unique position to contribute to women’s healthcare and wellbeing by Recognizing, Responding and Referring childbirth complication efficiently and swiftly” (NICE, 2001: 92). This is a time of transition for midwives. A transition from primarily medical-based, obstetrician led deliveries to natural and midwifery – led deliveries. To assist midwives in this transition, it is vital that confidence and clinical skills are re-established after being eroded by the hospital model of maternity care. This has to be done in order to re-establish the professional role of the midwife as central to successful home births. (SNMAC, 1998).

The role of the midwife will not change even if the location of the birth is changed. This role is to assist the woman during her labour and in the postnatal period. A midwife should detect and undertake correct action if there is any sign of fetal distress or any sign of complications. The midwives role does not end after the delivery. She has further support to give postnatally also. Midwives will give further education to parents including baby bathing, feeding method, and nappy changing for example. ” midwives are in a privileged position to support the work with parents during their transition to parenthood, particularly those with little or no experience of parenting, but also for more experienced parents who may still need support and guidance with a new and/or needy baby” (Henderson & MacDonald 2004:371)

Advantages of community – based services

There is no evidence that women should deliver their babies in consultant – run, obstetric hospitals (Campbell, 1987). Home births can appeal to women for the same or different reasons. There can be many reasons why a woman may prefer a homebirth. Like anyone else women feel comfortable in their own home where the surroundings are familiar and here they will feel more in control as hospital can seem intimidating to some people. Also a major reason many women opt for a home delivery is to avoid medical intervention like caesarean sections. It also includes less hospital interventions like antenatal and postnatal checks as these are all done at home which offers the benefit of more time given to the woman who would in turn prepare her better for her labour and a sense of being in control of the labour. The fact that the birth of the child is in the home also brings happy memories of the birth and a more relaxed environment for the mother.

Disadvantages, complications and risks

There is no doubt when dealing with home births there can be severe risks involved if all does not go well and if it is not dealt with immediately. The midwife herself will need to be very aware of the woman’s condition and monitoring her very closely and documentation is vital. If there is need to be hospitalized a midwife must be efficient in reporting any symptoms and it is critical to get to the nearest hospital for medical assistance which is very stressful and worrying for both mother and midwife but this is necessary if the worst case scenario occurs and results in the death of a baby or the mother. Although there are rarely any cases of infant or maternal mortality there have been a few incidences of mortalities in regard to home births. A more recent example of this was in July 2004 when a lady gave birth to her son and lost him as a result of negligence by the midwife that managed the home birth, Midwife Elizabeth Ann O’Toole admitted liability in the proceedings brought against her by Julie Stuart over the death in hospital of her son Dagan five days after suffering brain injuries during his birth at home in July 2004(The Irish Times). The main negative aspects of a home birth would be the lack of medical interventions like forceps, ventouse delivery and the specialist clinicians and staff. This includes analgesics. However, midwives who regularly attend home births have noted that women are less likely to require pharmacological analgesia when they labour and give birth in their own homes (Cronk and Flint, 1989; RCM, 1993). This can be bad if a woman is not coping very well with her pains. In the postnatal period there is also less support for the woman in regard pain relief, care assistants, meals and also care for the baby. This care in the hospital can give mothers a chance to rest and to allow them to adapt to motherhood.

Different Countries Experiences

A control trial was conducted in Australia. A control panel was randomly conducted among 1089 women to compare their experiences. Some women received the new model of continuity of midwifery care and some received the standard hospital care throughout their pregnancy. The women that participated in the trial were all of mixed obstetric risk and would fill out a questionnaire from 8 to 10 weeks postnatally. It was found that 69% of women had completed and returned questionnaires. It was shown that the women from St. George Outreach Maternity Project (STOMP) talked more openly to their midwife about their birth plans and their knowledge of labour, caesarean sections, complications and so on. It was also shown that 63% of STOMP women indicated they knew the midwife with them and because of this reason; they felt a ‘more sense of control’ in the labour and postnatal period. The sense of control over care and the childbirth process (Green et al, 1990, Hundley et al 1997) and the existence of a trusting relationship with the midwife (Tinkler and Quinney 1998). Brown and Lumley (1994, 1998:8) identified ‘having an active say in decisions made during labour and birth’ as an important factor in satisfaction and ‘feeling in control’ to fulfilment and postnatal emotional well-being. The outcome of this survey showed that STOMP was shown to be successful and advantageous to women. They felt more knowledgeable to all their birthing options and felt they could talk openly and freely to their midwife about their birthing plans, opinions and emotions and also felt they were in control considerably during their third stage of labour. In comparison standard care given to women by multiple caregivers across the three trimesters of her pregnancy were shown to have a higher level of negative experiences. The STOMP group was shown to have a 50% reduction in the caesarean section rate.

With regard to home birthing, most women who choose home birth want a natural birth, with little or no intervention: They see birth as a normal part of the normal life process, not as an illness requiring a hospital stay. When at home they feel in control of their environment and who is present. (Cohen & Dorsey, 1998).

On the 6th of February 2007 Sheila Shribman the National Clinical Director for Children, Young People and Maternity Services conducted a policy called “Making it Better: For Mother And Baby for the National Health Service in England. She stated that in the beginning of the 1950’s there was a 1 in 1500 chance of mothers dying while giving birth or postnatally, while 30 out of 1000 babies born died due to stillbirth or other causes. Today, the trend in her study shows 1 in 20,000 mothers have a chance of dying and in regard to infant mortality it is fewer than 5 in 1000 babies. This shows a six-fold decline. There is no doubt that this is because giving birth is so much safer than any time previously. But as we know this also means there has been an increase in medical intervention. There is evidence to suggest that a return to community based midwifery may be under way. This movement is supported by the Maternity Services Review Group (Kinder, 2001) which recommended that maternity services should be in essence community – based wherever possible.

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Today in Ireland community based and hospital based midwifery is much more common. In The National Maternity Hospital (NMH) there are 3 types of midwifery:

1.      The Domino Scheme

2.      Home Births.

3.      Early Transfer Home (ETH)

The ‘Domino’ scheme is offered to women with no health implications or complications. This scheme involves the woman and a small group of midwives that will all work with the woman at some stage throughout her pregnancy. The scheme provides constant care to the woman throughout her pregnancy which includes visits to her home and in the community which is usually in Ballinteer health centre or Greystones health centre or the midwives clinic in NMH Midwives Clinic in the NMH.  It is through services like the Domino scheme in Holles Street that we students can experience how child birth should be without the necessity of medical intervention. These services are available to people living in South and East Dublin and North Wicklow region.

Home Births are open to woman with no obstetrical risks or complications available. The women can only benefit from this service is they are living in the South and East Dublin and North Wicklow region. The reason for this is in case there is any emergency situation that would require the woman to come into NMH. Otherwise all checks are carried out in the woman’s own home including 10 days postnatally.

The ‘Early Transfer Home’ or (ETH) service is commonly for low-risk woman. The first antenatal visit is usually between 18- 22 weeks and will take place in the NMH. All other checks are given at home (antenatal and postnatal checks). However compared to the home births the birth of the baby will take place in the NMH and will be transferred home usually within 36 hours if there are no underlying complications.

Conclusion

The future of community midwifery is clearly the way forward. Negative attitudes toward home birth are becoming less and less. Health service executives are facing challenging times especially in the current economic downturn and in the way …….. recruitment morotoriam, and budgeting constraints to mention but a few. This will undoubtedly slow the pace of provision of community led services including the emerging priorities in the midwifery profession. In the meantime midwives can undertake the role of further informing women and gathering groups in individual hospitals and health centres of skilled midwives and community nurses and further inform women of the advantages they can gain from this service with the help of hospital – linked supports and independent midwives themselves.