Beverley Beech looks at when 'informed consent' becomes bullying
Bullying in midwifery is not new, mothers and midwives are bullied in various settings, and examination of old AIMS journals reveals numerous stories of bullying:
'There were three of them shouting and nagging trying to force an unwanted mask on my face, which I fought off with vigour I'm afraid; I hadn't even groaned and was so happy till then. One of them told me that she couldn't bear screaming; they didn't even pretend it was really for my benefit.'
(AIMS Quarterly Newsletter, Sept 1975)
'I had my last meal at 6.00pm on Sunday and at approx. 9.30am on Monday morning was taken to the theatre .... my baby was born at 12.45am Tuesday morning. I remained unconscious until about 2.00am. I asked to see my baby and phone my husband. I was refused with the words 'Shut up, you have caused enough trouble for one night. What do you think this place is?' I was shouted at for getting blood on a sheet and at no time could I find out if my baby was even alive.' (AIMS Quarterly Newsletter, June 1974, p1)
'The relationship between the Albany Group Practice midwives and medical and nursing staff on the NICU requires particular attention. Case notes review and interviews indicated that the relationship is openly antagonistic'.
(CMACE Report, 2009)
[Note: the report does not specify who was antagonistic to whom, but in view of King's decision to withdraw the service, one can draw one's own conclusions]
The publication of the Winterton Report in 1991 resulted in 'choice' becoming flavour of the month. Since then we have developed an astonishing hypocrisy. While Trusts issue statements claiming that they respect women's choices the reality for many midwives is that if they truly act and support a woman who makes a choice outside the Trust protocols they can expect trouble and, what is worse, few of their colleagues will support them. Is it any wonder that we have a serious shortage of midwives?
Currently, the most recent publicised case of bullying involves the Albany Midwifery Practice. This practice, established over twelve years ago, was noted for supporting women and really respecting their choices. As a result, they developed an international reputation for 'gold standard' midwifery care, much to the chagrin of some members of King's College Hospital staff, it seems.
Despite midwives' success and favourable outcomes, King's carefully selected a specific group of cases of hypoxic-ischaemic encephalopathy (HIE) that occurred in a selectively short time frame (31 months), and commissioned the Centre for Maternal and Child Enquiries (CMACE) to investigate. Details of AIMS' critique of this flawed and unacceptable investigation can be viewed on our web site: www.aims.org.uk/Submissions/CMACECritique.htm
The Albany Practice has brought into sharp relief the tensions between medically dominated obstetric care and a midwifery focused practice that is truly 'with women' and designed to increase women's confidence in their ability to give birth, support their choices and truly enable the women to give informed consent.
Few midwives and doctors in the National Health Service have any understanding of informed consent; it is parroted at every opportunity, but few respect or understand its meaning. The failure to accept a woman's right to make decisions about her care are revealed in the flawed CMACE Report (see AIMS' critique www.aims.org.uk). In one section the anonymous authors of the CMACE report state: 'occasions will arise when definite, unequivocal and direct advice against home birth is essential' and 'women with risk factors for a poor outcome of labour should actively be encouraged to give birth in hospital, in keeping with local and national guidelines' yet, later in the report it is noted that 'The Practice also receives referrals from King's College Hospital midwives of 'challenging' women as it was felt that the individualised care offered by this service suited this client group.' The authors do not spell out what was 'challenging' but one can surmise that they were women who were labelled as 'high risk' and were not prepared to accept the standard obstetric advice.
The failure to respect the rights of the parents in our society is reaching an all time low. While more and more monitoring is encouraged there is less and less support and respect. Maria Newcastle in her article (page 7) reveals how the hospital staff refused to send a midwife to her home birth and continuously insisted that she should travel in labour into the hospital. It was only by chance that the community midwives arrived in time. No-one considers the risks of travelling across country in strong labour and ending up delivering at the road side; nor the effect on the woman's labour of unnecessary stress at this time. Perhaps if women who have had this experience send in a Serious Clinical Incident Report the establishment will begin to understand the risks involved and take effective action to provide an adequate service?
Many women choose a home birth because they are not prepared to repeat the bullying they endured in a previous labour, and some choose not to call a midwife at all. The reaction to this is often more bullying from midwives who consider they have the right to censure the woman for that decision. Tabatha Pollock Ellam (page 22) relates the dreadful experience she had at the birth of her previous baby and their desperate struggle to arrange a home birth this time. As she says, 'I would rather give birth in a field over my local hospital.' Does anyone ever investigate why so many women adamantly refuse to go into hospital ever again? No, far better to continue the bullying by thinking up endless reasons for why they are labelled as 'high risk' and therefore 'must' be booked into a hospital.
Debbie Chippington Derrick looks at the contentious issue of vaginal examinations with specific reference to the NICE Intrapartum Care Guideline (page 8) and Mary Stewart considers the emotional effects for women of internal examinations (page 11). Vaginal examination was introduced decades ago without any research to indicate its value and continues to be used despite the disruption and discomfort caused to a woman in a normally progressing labour. No acknowledgement is made of the observations that skilled midwives use to determine what stage of labour a woman is at; and woe betide those midwives who fail to use a partogram at a home birth (another requirement designed for obstetrically managed deliveries that is as inappropriate in a home setting as it is in a hospital birth where the labour is progressing normally).
In order for women to have a straightforward birth they need to know and have confidence in their midwife; they need to be in a place where they feel safe; and they need to have the kind of care where the midwife 'follows the woman', thereby enabling care to be provided either at home or in a hospital, depending on the woman's needs and intentions; and they need to be given accurate and evidence based information in order to make an informed choice. Where this kind of care is available the majority of women find their babies' births to be an empowering and positive experience. The Albany Midwifery Practice did all of this very successfully, as their statistics show (page 19); but the medically dominated obstetric services are deeply threatened by this, hence the current witch hunt and the reluctance to establish community based case load midwifery services in every area.
In the current climate of financial constraint ensuring that there is an Albany For All midwifery services in every area would save the NHS millions of pounds and thousands of women would be saved from unnecessarily traumatic deliveries, but are the politicians man enough to seriously implement the changes that need to be made? Or are we to see yet more tinkering at the edges and a repeat of the 'pretty wallpaper syndrome' that we witnessed in the 1980s when sterile obstetric units were last criticised and every unit had to have a 'home from home' room that paid lip service to good quality midwifery care?
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