Domiciliary Care in Midwifery

1. Brief History of Domiciliary Midwifery Services

• Throughout the ages, women have depended upon a skilled person, usually another woman, to be with them during childbirth.
• In the United Kingdom, midwives' skills are increasingly valued, and they are urged to expand their roles in public health.
• In Uganda (1960s): Midwives routinely looked after mothers in the home environment. They conducted antenatal care, delivered mothers in their own homes, and continued with postnatal care. This gave them the opportunity to provide health education to the entire family.
• In Uganda (1970s): Political instability and insecurity forced midwives to stop delivering mothers at home. Instead, mothers were delivered safely in hospitals and maternity units. However, midwives continued to nurse mothers and babies at home during the postnatal period.
• Today: The service continues and is heavily practiced by Private Midwives and student midwives undertaking their Diploma in Midwifery.

2. Types and Forms of Domiciliary Care

Domiciliary care can be organized in several ways depending on the midwife's decisions, the family's choice, the community's nature, and the availability of basic requirements.

Types of Domiciliary Care

• Type One (Continuity of Care): The woman is completely cared for in her home throughout the antenatal, intrapartum (delivery), and postnatal periods. She only visits a hospital if a complication requires specialized gadgets. One midwife provides all the care.
• Type Two (Community Integrated / Centralized Care): This is a mixed service. Antenatal care or delivery may occur in the hospital, while the puerperium (postnatal) period is managed at home. This is compulsory for student midwives during their training.
• Independent Practitioner: The midwife works privately in the community. She may own a maternity center for part of the care and combine it with home visits. This is the most common type in Uganda.
• Midwifery Autonomy / Medicalized Approaches: The midwife acts as part of a team in a health setting but maintains a high level of autonomy over her practice in the community, under professional control.

3. Objectives and Advantages

Objectives of Domiciliary Care

• To take midwifery services near to the community, drastically increasing accessibility.
• To encourage full participation and involvement of male partners and family members for maximum support.
• To reduce maternal and infant morbidity/mortality, as the midwife has a lesser workload and concentrates on one woman.
• To reduce severe overcrowding in hospitals and health facilities.
• To promote a strong midwife-mother relationship and mutual understanding.

Advantages of Domiciliary Services

• Minimizes fears and phobias of childbirth by keeping the mother in a familiar environment.
• Promotes strict continuity of care and close supervision.
• Highly cost-effective because only relevant, tailored care is given.
• Allows the mother to continue her household responsibilities and supervision without disruption.
• Provides complete peace of mind to the mother, husband, and children because they remain together.
• Ensures privacy, security, and respect with much less interference and physical exposure.
• Promotes autonomy, creativity, and job satisfaction for the independent midwife.

4. Advantages and Disadvantages of Early Discharge

In modern settings, mothers often deliver in the hospital and are discharged early to be cared for at home by a domiciliary midwife.

5. Selection of Mothers (Risk Groups)

A midwife cannot safely deliver every mother at home. Mothers must be assessed and placed into one of three risk categories:

• Group 1: Low Risk: Para 2 to 4. Women who have delivered at least one baby but not more than five. If they have no history of major complications, they can be cared for in the community throughout pregnancy, labour, and puerperium.
• Group 2: Suspected Risk: Primigravida (1st pregnancy), Grand multipara (more than 4 deliveries), short stature (less than 152cm), or a history of previous complications (e.g., cord prolapse). These mothers are only managed at home for antenatal or puerperium, but must deliver in a hospital.
• Group 3: High Risk: Mothers with obvious complications (e.g., multiple pregnancy) or underlying medical conditions like cardiac disease, diabetes mellitus, or sickle cell disease. Must be referred immediately to a well-equipped Health Centre IV or Hospital.

6. How Domiciliary is Carried Out

Booking Criteria & Home Delivery Requirements

A mother booked for a home delivery must have no risk factors (no CPD, no multiple pregnancy). The midwife must inspect the home to ensure it meets strict safety standards:

• Housing: Well-ventilated, no overcrowding, highly hygienic. Must have more than 4 rooms (bedrooms, toilet, kitchen) and a cemented floor.
• Utilities: Must have tap water and an easy means of boiling water for sterilization.
• Distance: The home must be less than 2 miles away from a referral hospital in case of an emergency.
• Consent: Both husband and wife must willingly agree to the care.

7. Equipment for Domiciliary Care (The Kit)

The midwife must carry a light metal kit or a suitable bag containing specific, sterile items for the mother, the baby, and herself.

For the Mother

• Sterile bowl and gallipot.
• Sterile cotton wool for swabbing the vulva and perineum.
• An antiseptic lotion (such as Savlon or Dettol).
• A sterile urinary catheter.
• An antiseptic drying agent (such as mercurochrome) for sutured perineums.
• A clinical thermometer, pulsometer (or a watch with a second hand), and a tape measure.
• Syringes, needles, and ampoules of Oxytocin.
• Plastic bags for the disposal of used swabs.
• Basic treatments for minor complaints (e.g., Antibiotics, Paracetamol, Antimalarials, Ferrous sulphate, Folic acid).

For the Baby

• Sterile cotton swabs specifically for the baby's eyes.
• Mucus extractor (for clearing the airway).
• Baby's weighing scales and a clean towel.
• A separate baby thermometer.
• An ampoule of Vitamin K.

For the Midwife & Delivery

• Plastic apron, sterile gloves.
• Bowl for water, soap, towel, and a nail brush for scrubbing.
• Fetal scope (Pinard horn).
• Sterile scissors and two artery forceps.

What the Mother Must Provide: A basin and towel for bathing the baby, clean soap and warm water, and clean baby clothes.

8. Roles of the Midwife & The Daily Visit

The midwife is responsible for comprehensive care across the reproductive cycle. Her roles involve highly detailed assessments of both the mother and the newborn.

General Roles During Domiciliary Care

• Care Before Conception: Health education on nutrition/hygiene, life skills, giving tetanus toxoid, and counseling adolescents.
• Care During Pregnancy: Immunizations, antenatal check-ups, treating minor problems, and educating on danger signs.
• Care During Labour: Monitoring via partograph, delivering the baby, and maintaining strict infection prevention.
• General Postnatal Roles: Checks vitals (BP, pulse, temp, respiration). Notes uterine involution, inspects lochia and perineum. Examines breasts and legs. Instructs on diet, personal hygiene, and vulval swabbing. Gives iron/folic acid. Re-emphasizes the importance of the 6-week postnatal clinic and Young Child Clinic (YCC) attendance.

The Postnatal Daily Visit Routine

During the puerperium, the midwife visits daily. If complications arise, she makes additional visits. The daily routine includes:

Assessment of the Mother

• History & Coping: Ask how she is feeling, sleeping, and eating. Ask if she is passing urine and stool normally. Ask how she is coping with the baby, if breast milk is adequate, and if breastfeeding is satisfactory. Sit, listen, and respond to her anxieties.
• Vital Signs: Check temperature, pulse, BP, respiration, and look for any signs of pallor (anemia).
• Breast Examination: Examine for signs of severe engorgement, cracked nipples, or sore nipples. Give immediate advice on breast care and feeding techniques.
• Abdominal & Pelvic Check: Have the mother completely empty her bladder. Palpate the lower abdomen for tenderness and measure the fundal height to accurately assess uterine involution.
• Perineal Check: Check the lochia and perineum for proper healing, signs of infection, oedema, or breaking down of stitches. Encourage strict hygiene and correct self-vulval swabbing.
• Leg Examination: Examine the legs (calves) for any tenderness or swelling to rule out deep vein thrombosis (DVT). Encourage early ambulation and postnatal exercises.

Assessment of the Baby

• General Observation: Observe the baby's overall color, respirations, cry, and movements.
• Infection Check: Look very closely for any signs of infection in the eyes, skin, mouth, and specifically the umbilical cord.
• Physical Care: Help the mother with bathing the baby and supervise her for the first few days. Check the baby's temperature and weight.
• Feeding & Elimination: Inquire if the baby is feeding well, sleeping properly, and passing normal stool and urine. Encourage exclusive breastfeeding.
• Immunization: Inspect the BCG site and give advice accordingly.

9. Qualities of a Domiciliary Midwife

Because the midwife is operating outside a hospital, her professional behavior must be impeccable.

• She must remember that she does not belong to the family; she is only a guest. She must adapt her behavior to respect the family's routine.
• No commands or orders should be given—only professional, persuasive advice. She must be highly flexible.
• She must create a friendly, trusting relationship but maintain strict professional boundaries.
• Avoid embarrassing the mother in front of the family.
• She must have the ability to make quick, correct judgments independently in the event of an emergency.