Supporting the Mother - Where are the midwife advocates?

By Beverley A Lawrence Beech

AIMS Journal, 2001, Vol 13 No 1

Occasionally, at meetings and conferences, one hears midwives lay claim to being a woman's advocate and how one of their fundamental skills is the art of listening. But as Beverley Beech reports it is often difficult to reconcile these claims with the experiences that many women report to AIMS.

The current battle with the UKCC (see 'A Nail in the Coffin for Home Birth') is, perhaps, a metaphor for the midwifery profession's failure either to listen to women, or to act as their advocates.

The move into hospital has had a profound and detrimental effect on midwifery practice. Slowly, midwives were subsumed into a nursing ethic and, over the years, their midwifery skills have been downgraded or lost, as increasingly they are required to follow the hospital protocols and procedures. By disbanding the Central Midwives Board and absorbing the midwives into the UKCC, a body dominated by nurses, the midwife's voice is barely heard and often ignored.

Many hospitals, suffering difficulties recruiting and retaining midwives, try to solve their chronic midwifery shortage by disbanding the few remaining community midwifery teams and amalgamating the midwives into the hospital midwifery pool. They justify this by claiming that the midwives will rotate through the hospital so that they can "maintain their skills". The reality is that the midwives lose their midwifery skills and become more and more like obstetric nurses.

The loss of midwifery skills is accompanied by a loss of confidence. Ironically, at the same time, there is a constant call for midwives to "expand their sphere of practice". Midwives are being encouraged to take up ultrasound monitoring, ventouse deliveries and contraceptive counselling, but developing their skills in assisting women to achieve a normal breech or twin birth is now considered outside their practice. Home birth and community midwifery enable midwives to hone their midwifery skills but these services are being disbanded and withdrawn at an alarming rate.

The Midwives' Code of Practice states:

"You are responsible for maintaining and developing the competence you have acquired during your initial and subsequent midwifery education". (Midwives Code of Practice, UKCC, December 1998). Unfortunately, the competencies which the system is encouraging are not those which will produce efficient and skilled midwives who are able to maximise the chance of a woman labouring and giving birth normally."

This failure to encourage the development of midwifery skills is putting women and babies at risk. And those most at risk are women and babies choose home birth in the face of official opposition and intransigence.

When Julia Guerra decided that she was not willing to risk an obstetric delivery and management of the birth of her twins she tried to arrange for the twins to be born at home. Unfortunately for her she lived within the catchment area of Freda Kelly (criticised for trying to discipline midwives who attended a water birth at home and whose actions were described by a Royal College of Midwives representative as the most disgraceful example of poor supervision they had come across. Both midwives ended up leaving the Trust - one left the health services - while Freda Kelly remained in post).

While Mrs Guerra spent months trying to arrange for NHS midwives to attend her, Freda Kelly, and her deputy, Shirley Yeap, indulged in a series of hypocritical statements:

" 'Dawn and Angela are not prepared to go on-call if you decide on a home delivery, however there are midwives always on-call for home births' and this led you to believe that although Dawn and Angela are not prepared to attend if you decide on a home delivery but there are other experienced midwives always on-call for home births. I wish to reiterate to you that you have misinterpreted the sentence and what it does imply is there are always midwives rostered on-call for agreed booked home births. These are clients with singleton pregnancies and no risk factors identified at booking."

So, just to be clear, Freda Kelly had midwives who were prepared to attend home births, Mrs Guerra wanted a home birth, but this was not agreed, so, by implication, they were not going to attend. The argument continued for weeks while Mrs Guerra tried to unravel the "double-speak" and hypocrisy.

Eventually, in desperation and anxiety about the competence of whichever midwives would arrive (or even whether any midwives would arrive at all), and afraid that when she went into labour she would have no midwives attend her, Mrs Guerra booked two independent midwives. They did attend, and she successfully gave birth to her twins without any problem.

Freda Kelly was not prepared to allow any of her staff to attend in a learning capacity and she, and the Trust, resolutely refuse to pay the costs of the independent midwives as the Trust now claims that it was willing to supply midwives!

In an earlier letter a supervisor of midwives stated

"Whilst midwives are experts in normal delivery the risk factors mitigate against twin delivery being considered as normal. As long as labour and delivery progress normally midwives remain the lead professional but if they detect any deviation from normal it is their professional responsibility to seek medical assistance promptly."

"In the case of obstetric emergencies speed is of the essence in summoning medical assistance that is why we recommend hospital delivery for multiple birth. However we respect your rights to make an informed choice".

The catch, however, is that when Mrs Guerra made an informed choice the hospital refused to supply any midwives.

None of the midwives was prepared to act as Mrs Guerra's advocate. Freda Kelly was not prepared to provide the service, but appeared perfectly content to leave Mrs Guerra to her own devices.

The Midwives Code of Practice states:

"The needs of the mother and baby must be the primary focus of your practice. The mother should be enabled to make decisions about her care based on her own needs, having discussed matters fully with you and with any other professionals involved with her care". (Midwives Code of Practice, UKCC, December 1998).

But when a woman makes a decision about her care that is contrary to local policies, she is subjected to months of pressure, threats and intimidation to force her to comply.

In a recent case a woman expecting a baby by the breech who intended to birth at home was also told that:

"Midwives are practitioners of normal midwifery and as such are not skilled in breech deliveries. I therefore regret that I cannot assist you as requested ... I believe that a water birth with a breech is a dangerous procedure and one in which we have no expertise to offer".

No evidence was produced to support this statement but while denying the mother midwifery attention the Director of Midwifery suggested she contact the Independent Midwives Association.

The Trust persisted in their insistence that the woman had to be delivered in hospital, with no evidence that the midwives would do anything other than arrive and insist she go into hospital, the woman lost all confidence and when she went into labour called the independent midwives.

As they felt they could not, ethically, leave a woman to get on with it unattended, as the Trust clearly did, they rushed to her assistance. When they arrived, the baby's foot was emerging. They assisted the mother to give birth to a 5kg baby without even a tear. Instead of congratulating the midwives on their skills and inviting them to teach the Trust's midwives the Supervisors of Midwives harassed the midwives concerned seeking evidence by which they could carry out their threat to report them to the UKCC.

In a further case, where Yasmin Sumpter wanted a water birth at home, she too was told that there were no midwives in the area who were skilled at assisting a woman to birth in water. As the months went by, Yasmin became increasingly disheartened and did not believe that she could trust the midwives to support her if they did arrive.

She gave birth unattended at 3.00am and rather than ring the midwife immediately she decided to ring her at 9.00am later that morning. When the midwife arrived she was surprised to find a very fit and healthy mother and baby, however, a few days later a social worker from the Child Protection Unit and a policeman arrived on the doorstep to investigate a report of "possible child abuse"!

Both the social worker and the policeman were very nice and noted that there was nothing to concern them and left. This mother now has post traumatic stress disorder. She has flashbacks and nightmares dreaming that her baby is removed from her breast and her older child taken away into care.

In none of these cases did any NHS midwife support the women, they chanted the party line that they were "high risk" cases and had to give birth in hospital. Hypocritically, the midwives who were meant to be supporting the woman expecting the baby in a breech position subsequently asked her why she had not called them, because they would have come and were "very disappointed" not to have been called.

This, of course, was said after the woman had been attended by two skilled midwives who had helped her birth the baby without even a tear. The woman in this case is convinced that had she been stupid enough to call the local midwives they would have gone into an absolute panic and insisted that she go into hospital immediately - a drive of some 20 miles!

These cases illustrate the inability of midwives to act as advocates for women and the UKCC's failure to give midwives direction and support. Time and again, independent midwives, all over the country are, at the eleventh hour, bailing out cases which the NHS midwives consider difficult and will not support.

The hypocrisy of telling a woman that what she wants is outside the professional competence of midwives (only because doctors in their eagerness to extend their influence deemed it so) but not outside the professional competence of independent midwives is, frankly, shocking.