King's Fund. February 2008
Reviewed by AIMS Vice Chair Nadine Edwards
I am sure that all of us who have sat on committees, charged with producing reports with short deadlines and limited resources, do our best for women, babies and families. However, given the established trend of cutting back the scale of our health and welfare services that can offer such crucial support to families in transition, it is almost certain that from the outset, any radical ideas will be compromised and drawn towards a conservative, mainstream conclusion which cannot rock the privatisation and standardisation of health care boat unduly, or interfere too much with profit and efficiency. According to Allyson Pollock1, the Government is too implicated with multinational health care businesses for that.
The Safe Births report was awaited with anticipation. It starts off well. On page 5 it suggests that safety is usually framed negatively in terms of ‘risk and harm’, and that safety is in fact, ‘much more than simply trying to avoid harm.’ Echoes of Changing Childbirth’s2 definition of safety having positive qualitative aspects in our lives come to mind. On the next page, there is further reassurance that women's experiences of safety is part of this report, and that safety is not a simple set of procedures: safety is a process depending on ‘the interaction of components.’ Could one of the ‘components’ be continuity of carer, I wondered?
And then we read on the same page that while unsafe care cannot be of good quality, ‘Care can be of poor quality and still be safe’. Can it? Finally the gist of the Report becomes clear on page 20: The Report acknowledges that the ‘experience of care may have profound positive or negative effects on mother, baby and family’, but that ‘this inquiry has chosen not to focus on the birth experience’, and that women’s experiences merely contribute a ‘further layer of complexity to decision-making about safe care.’ Thus, while the Report attempts to understand the paths of decision-making, it fails to ground its work in the implications that decision-making has for women and babies. So while this Report achieves a great deal in terms of exploring how and why care may be technically safe or unsafe and makes many detailed recommendations, it is also profoundly and yet predictably disappointing.
It fails to grasp the nettle offered by Changing Childbirth and others, of continuing to challenge the contemporary context of how reduced resources are deployed, or adequately questioning the almost exclusive focus on more basic quantitative safety outcomes, as if they could be separated from the qualitative meanings of safety for women, babies and families. The notion of how women experience emotional and spiritual, as well as physical safety is consistently ignored or paid lip service to. This Report continues this trend. The focus is very clearly on physical outcomes. For example, the Report does an excellent job of examining the harmful impact of routine and/or unnecessay interventions when pregnancy and birth are uncomplicated. It suggests positive interventions such as continuity of care (though not carer,) continuous support in labour, midwife-led care, appropriate birth environments, intermittent monitoring and decisions about caesarean sections to be reviewed by consultant obstetricians (why is a consultant or senior midwife not carrying out such reviews jointly with the obstetrician?). However, its well documented list of harms attributable to interventions includes physical harms only.
The Report does an equally excellent job of pointing out that the ‘safety’ women may be coerced into accepting is both relative and limited. It points to recent research from the National Patient Safety Agency, and the Royal College of Obstetrics and Gynaecology, showing that the best research findings currently available are often not implemented by hospitals, senior staff are often unavailable if babies are seriously compromised during the night and junior doctors will often want to carry out potentially harmful interventions through lack of experience (pages 43 and 44). The report recommends teamwork, knowledge and skill sharing - particularly for rare, but potentially catastrophic incidents, and acknowledges the difficulty of practitioners learning from serious incidents in a risk/blame culture. The thorny issue raised by the Winterton Report3, that poverty and exclusion might increase the number of serious incidents, has been well and truly buried, other than to address this with too few resources, patchily, sporadically or not at all, despite Gwyneth Lewis' findings in the Confidential Enquiries.4
Overall this Report considers safety in the context of large obstetric institutions. It is far too influenced by neoliberal healthcare policies that focus on so-called efficiency, to maximise profit. It does not engage with the question of whether or not state services should be run on a profit-making basis as its priority rather than as a public good (see Allyson Pollock's tour de force, NHS plc:
The Privatisation of Our Health Care, 2005 Verso, and the Introduction to David Harvey's readable explanation about what neoliberalism is and does in A Brief History of Neoliberalism, 2005 OUP).
If this Report’s effor ts to encourage the efficient deployment of staff and skills in large institutions were to be followed, women, at best, could only be the centre of fragmented care, passive recipients of (hopefully) technically competent care, rather than autonomous agents of their own experiences where safety has the more holistic meaning women, babies and families define, need and deserve.
The Report even hedges the issue of lack of midwives and other staff by focusing on ‘deployment’ and ‘productivity’ rather than employment, and suggests that increasing staffing levels ‘in itself cannot guarantee increased safety’ (pages 46 to 49). While of course, it does not guarantee safe care, having too few midwives to look after women in labour at home and in hospital surely guarantees unsafe care.
The Report does not get to grips with the underlying problems of different ideologies surrounding birth, where safety might be defined differently depending on one’s beliefs, values and circumstances. There is an assumption that one of the components of safety is ‘a single set of evidence-based guidelines that are backed by professional organisations, NICE and other organisations’ (page 62). We know only too well at AIMS, and from available research that it is highly problematic to impose general rules, based on medicalised beliefs about health and bodies, on individual women and babies. For women and midwives who do not share these beliefs, the standardisation of care can feel increasingly constraining, and anything but safe.
This Report is meticulous and sets out technologically to best protect women and babies who suffer major incidents during childbearing in obstetric units and elsewhere. It should be commended for this. In terms of ‘safety’ for all women, babies and families, it fails to examine just what safety means, and does not begin to provide a more complex, nuanced articulation of the issues at stake: family well-being through pregnancy, birth and beyond, where emotional, physical and perhaps spiritual safety are woven together, however bir th unfolds.
1. Allyson Pollock (2005) NHS plc: The Privatisation of Our Health Care,Verso
2. Department of Health (1993) Changing Childbirth: Report of the Expert Maternity Group Part 1. London: HMSO.
3. House of Commons Health Committee (1992) Maternity Services Second Report Vol 1. London: HMSO.
4. Confidential Enquiries
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