Lucia Montesinos asks midwives to come together and support each other to change culture
I am a caseloading home birth midwife within an NHS trust in London who has faced bullying in the form of Investigations during my first year after qualifying. I know I am not alone, and I hope my story can offer support, hope and inspiration to other midwives who might be experiencing similar circumstances when working 'with-woman'. When midwives are bullied it affects the care they are able to offer to women and may make them practise defensively instead of in the women-centred way they wish to work.
There is a wealth of evidence1 that midwives who go against policy in order to practise autonomously and promote normality, the core values of our profession, suffer from unreasonable investigations made by managers or their professional body. This is causing stress and fear amongst midwives, and as a result stops them from being autonomous. I believe the way forward is to work together and support each other for the benefit of women and babies. The process of any investigation is always stressful and it can make one question one's own practice. Sometimes these investigations are appropriate and necessary to explore and reflect on a case that had a poor outcome or to answer to a complaint in order to get more information from all the parties involved, ultimately to learn and improve practice. However, the growing dominance of managerial and obstetric control and the enforcement of standard and fragmented care can lead to unreasonable professional investigations.1
Sometimes midwives who work autonomously in the system with a philosophy of working 'with woman' may feel that the rationale behind these investigations is far away from a practice issue and has more to do with wanting to control midwives and to impose the obstetric protocols and hospital policies. The process of inquiry about midwives' actions and decisions is formally done by an investigation. This is formalised by the midwives' professional body. The NMC has this written into the Code of Conduct: 'As a professional, you are personally accountable for actions and omissions in your practice and must always be able to justify your decisions'2
In accordance with the NMC Rules and Standards: 'A practising midwife who is responsible for providing care or advice to woman or care to a baby during childbirth must do so in accordance with standards established and reviewed by the Council in accordance with article 21(1)(a) of the Order.3
Mavis Kirkham explains that newly qualified midwives, return to practice midwives and those who don't fit in are vulnerable groups for bullying within the NHS culture.4
Let me give you a personal example: My first encounter with an investigation during my first year as a midwife was after being reported by a colleague for sleeping during the night at a home birth, while taking on the role of the second midwife, during the first stage of labour. That night I was called out in the middle of the night to bring some entonox to a home birth. On arrival the woman, who was having her third baby, was well looked after by the first midwife and her cervix was about 4cm dilated. I decided to stay as she could potentially progress very quickly and give birth very soon and the midwife could call me promptly. The family was happy with this decision.
The woman kindly offered me a spare room to rest, I decided to take up the offer as I thought she must feel safe to have two midwives at her home and I knew that if I went into another room I wouldn't disturb her privacy to labour freely. She knew I was there and that nobody else needed to come in. Unfortunately my managers were not thinking the same and thought that my behaviour was very unprofessional; they told me that they would have preferred that I went back to my house and potentially miss that birth.
This was taken further into an investigation with the allegations that my behaviour breached the NMC Code of Conduct and the hospital policies. My whole world collapsed during the first investigatory meeting, as then I could clearly see how the system takes care of itself and not so much of the woman, putting the needs of the hospital above the woman's. This conflict of interests is explored further by Mavis Kirkham where she examines the culture of the NHS and raises this long standing conflict of interest between the institution, the profession and the client. She goes on to explain that since the Midwives Act of 1902, midwives have been controlled and inspected by the inspectors of midwives.5
Today the inspector's role is taken by the majority of supervisors of midwives (SOM) who help to ensure that the midwife's primary loyalty is to the institution and her profession rather than to her clients, even though the NMC says that she is in place to protect the public. In my case the managers were more concerned about the reputation of the hospital than about the safety of that mother and child.
Midwives have the right to choose their own supervisor, and this is something very important and I highly recommend midwives exercise this right more often. As a midwife you should find someone supportive and that you can trust - even if this means finding someone outside your hospital. This was also my first encounter with the union representative for midwives and I must admit it wasn't a positive experience either, as it made me realise how little support midwives have. Midwives under investigation can face inadequate support and representation from trade unions and other professional bodies. I didn't feel the union was supporting midwives and it was not interested in empowering us either. It seemed to me that it was working for the system instead of for us. I was pressurised to comply with the system and told that I should agree that what I had done was very wrong and therefore I should apologise.
When you have to write your statement, as part of the process of the investigation, you are advised to get it checked by the union representative before you submit it. The representative is supposed to read it, and offer you advice and information about the process, so you feel supported and well informed to make your own decisions. To my surprise that wasn't the case; the representative read my statement and told me what I must and what I must not write. I wasn't allowed to disagree with the representative's opinion and direction. I was pressured to write what I was told and be compliant with the system or otherwise the agreement with the union would finish and I could see myself with no support at all. You can imagine that this situation adds more stress to the mix. I decided that in this case I was still an autonomous practitioner and therefore also accountable for what I wrote and it needed to feel right to me; thus I took the advice that I felt was appropriate. We discussed the need for informed choice, what it meant for me and for her, and that, at the end of the day, it was my responsibility if what I wrote didn't work. That took courage and trust in myself. In the end it turned out that I had to go to a second investigatory meeting by myself because the representative wasn't available and the hospital gave me only three days' notice, as per protocol. A few weeks later our home birth team supported a woman who was discovered to have a breech baby at term and didn't want to have a caesarean section. I had recently finished a course on moxibustion. Moxibustion is a safe procedure to turn breech babies.6
One of my colleagues put this woman in touch with me to see if I could help her. I taught the woman the self-application of moxibustion as per my training. She went into labour, and the baby was still breech. It was agreed that two midwives would be present, along with a Supervisor of Midwives (SoM), for her home birth. So, when the woman went into labour, she rang the first midwife who then rang me and the supervisor. Once I got there, the baby was born very quickly. As Mary Cronk advocates, 7 we kept our hands off the breech and had the honour of witnessing a footling breech birth with no problems at all. It was an amazing and breath taking birth. The woman was very happy and the SoM arrived after the baby and the placenta were born to have a cup of tea with us.
The SoM discovered that night that I practised moxibustion without asking for explicit permission from the managers, and decided to commence a formal investigation about it. The reason for that investigation wasn't a practice issue, nor a poor outcome, because the moxibustion didn't cause any problem and the woman was very happy with using it. This made me realise that the system doesn't want autonomous practitioners, what the system wants is handmaidens. As part of the process of that investigation, I had to stop my clinical practice and do auditing in the office while the investigatory process was taking place.
When I rang the union again asking for support, the officer that helped me with the previous case told me that this time I had to write everything verbatim, otherwise the agreement to help me would terminate. I realised I had to make a decision then, as I wasn't happy to have the same experience as before. I found this person more stressful than helpful. I emailed the manager and told her that I needed to change the representative as I was having difficulties with this person. The manager and I exchanged a few emails and she insisted that the representatives have caseloads of midwives and these can't be changed. She suggested that if I wasn't happy an investigation would need to take place to find out why I was unhappy with my representative. I insisted that I didn't have time for another investigation at that time and that I needed someone to support me now. I couldn't believe what this woman was offering me - another investigation when I was in the middle of one already. It was all nonsense and very ridiculous.
That night I went to an Association of Radical Midwives (ARM) meeting and met a new midwife who had been through the process of investigation and had a similar experience with her hospital and the union. Finding someone who had gone through this was very special, helpful and made me feel better. She also felt that her case was very unfair and she had a similar experience with the union where she didn't feel supported. It inspired me to find again more courage and trust within myself. At that point, I decided to let the union representative go: it was very clear that she was not helpful. I knew I needed help to fight this fight, so I started to find help and support amongst my colleagues and friends. I knew I would still need help with the statement so a very wise and very well-informed colleague helped me with it and another colleague came with me to the investigatory meeting.
Unfortunately, as Margaret Jowitt explains: 'midwives must be managed by protocols and guidelines and the most effective way to enforce these is by peer pressure and, if this fails, by making an example of midwives who step out of line.'8
Management can work on the principle of 'divide and rule', reinforcing the behaviour of midwives who comply with the system and making an example of those whose practice deviates from it. If management make an example of a particular midwife, they know it will have an impact on the rest.
I believe the investigations into my practice were also meant to provide an example to frighten other home birth midwives. Will the other midwives stand up and support the midwife? In my case, at the time of these investigations, we were seven midwives working in the home birth team, and most of us worked for the women. These investigations unfortunately had a negative impact on the team: four exceptional midwives left the team, horrified by what was going on. Ultimately, the women are the ones who lose out from these political issues: local women lost four experienced, woman-centred home birth midwives.
I realised then how important it is to have a good support network and that every midwife should take responsibility to build up her own. Perhaps one of the first priorities as a newly qualified midwife is to build up your support network. Choose a supportive SoM, someone who is there for you and for the women and colleagues that you can trust. It is important to build up meaningful and trusting professional relationships with like-minded people so we can help each other and work together for the highest good. I found informal support networks such as the ARM meetings very supportive as you always find people who think like you and share similar ideas and vision about midwifery. This also made me realise that we cannot carry on working as isolated individuals because it won't change the status quo - we must work together if we want to make a change for women and their babies.
Both investigations ended up well. In the first one, the woman who offered the bed was also interviewed. She was very happy with her home birth, with the care she received and to have two midwives in her house. In the second investigation, after the first investigatory meeting the managers decided to drop the case. After these events, I must admit that for the few weeks after the investigation, work was very stressful. When I returned to practice I didn't feel safe - I was double-checking everything and making sure I was documenting perfectly. I felt that I could be investigated again for any stupid reason any minute. It took a few weeks to regain my confidence and to let go of that fear. A good three weeks travelling around the USA and a visit to The Farm, in Summertown,Tennessee, helped that process of coming back to myself and my own peace - I did what needed to be done. I decided to carry on in my job because I love what I do, I love having the opportunity to offer continuity of care to women and be part of those amazing births that only happen at home.
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