"It's hospital policy..."

AIMS Journal 2004, Vol 16, No 1

The language of birth can be very disempowering for women, perhaps no more so, argues Alice Charlwood, than when a practitioner utters this devastating phrase

After 15 years as an Active Birth teacher, I have heard countless times that a mother was told "It's hospital policy" to explain some birth intervention or postnatal treatment. Yet, I can't think of any other branch of medicine where this remark might be made to a patient.

I know the general public still takes the doctor's word as mostly gospel, but I doubt that patients who ask questions and want more information are brushed off with a curt "it's hospital policy". So where do midwives and obstetricians get off effectively shutting up women who have perfectly legitimate questions or concerns, or want to discuss their options?

So what's going on when those three little words come out? The women get the message: "You have no choice". No wonder that's what so many of them believe. That's where the insecurity and anxiety comes from when they ask: "Do I have to come into hospital if my waters break? Am I allowed to eat in labour? Do I have to be induced? Must my breech baby be born by caesarean? Am I allowed to have my baby at home?"

When questions like these meet with nothing more than an abrupt "It's hospital policy", the woman learns nothing except that she has apparently lost all control over her body and her baby. I know it's difficult to press a point or take issue with an expert, especially one in a white coat, but it still amazes me how meekly most women receive this response. They wouldn't dream of coming back with a "Why?". They hate the idea of 'making a fuss' or being thought 'difficult'. Going against hospital policy is breaking the rules, and with wrong-doing comes the spectre of 'getting into trouble' and other dire consequences.

On giving birth to her second daughter at our local hospital, a woman was given antibiotics in labour but, afterwards, she was told her baby also had to take them for three days because she had been born too quickly. The registrar said that the antibiotics must be given because it was hospital policy. So they were. No one consulted the mother or asked her permission to treat her baby. It was hospital policy, so there!

So I wish to make a plea, especially to midwives. Please stop telling pregnant women and new mothers what they can and cannot do because "it's hospital policy". Hospital policy has been the direct cause of some of the worst developments in medicalised childbirth over the past 100 years, and is still a critical factor in the appallingly low numbers of natural births in hospital.¹ As Wendy Savage once said to me, "What on earth are we doing to women in hospital that so few of them manage to have their babies without complications and intervention?"

Hospital policy sounds synonymous with greater safety but, despite decades of risk-scoring and more hospital-sponsored ultrasound, inductions, augmentations, drugs and birth by extraction of one sort or another, the rates of mortality and of conditions like cerebral palsy remain virtually static.²

I know midwives are constantly struggling with staff shortages, but please resist the temptation to fob women off with this "hospital policy" stuff because failure to listen or to take the time to communicate more openly and honestly makes a mockery of woman-centred care, reducing your midwifery to 'Groupthink'. This term, coined in 1972 by Yale psychologist Irving Janis,³ describes "a mode of thinking that people engage in when they are deeply involved in a cohesive in-group, when the members' strivings for unanimity override their motivation to realistically appraise alternative courses of action." Catastrophes like the Vietnam war and the bombing of Hiroshima are examples of Groupthink, but it can also be seen in the family, workplace or committee - wherever loyalty to a team, organisation or system leads to tunnel vision and a lot of pressure to conform, making concurrence seem more important than the merit of what is being proposed.

Although not all bad decisions are down to Groupthink, and not all cases of it end badly, for women who give birth in hospitals, there needs to be more communication, more questioning, more freedom to dissent from 'hospital policy'. We need midwives who can facilitate more, and impose solutions less.

Trust the women - they'll ask all the right questions if you let them. Empower them with information, encouragement and self-confidence, and these qualities will probably start to feed back to you - so there will be fewer demoralised, frustrated and unhappy midwives leaving the profession because they feel so badly compromised in the way they work.

References

1. Down S, McCormick C, Beech BAL. Labour interventions associated with normal birth. Br J Midwif, 2001, 9: 602-6
2. Wagner M. Bad habits: a poor basis for medical policy. AIMS Journal, 2000, 11 (4): 9-12
3. Irving J. Victims of Groupthink: A Psychological Study of Foreign- Policy Decisions and Fiascos. Houghton Mifflin, 1972

Editor's note: Women are often told they must do something because it is hospital policy when, in fact, it isn't. Any woman who is told this should insist on seeing a written copy of the policy immediately - and if you get one, please send a copy to AIMS.