Rance S, McCourt C, Rayment J, et al (2013) Women’s safety alerts in maternity care: is speaking up enough?
Quality and Safety in Health Care 2013;22:348–355.
The context for this study by Suzanne Rance and colleagues includes a Care Quality Commission investigation of a maternity service where serious incidents occurred. The Commission found evidence that women had routinely been ignored and left alone in labour. In a similar vein, Rance et al's study found that women often found it difficult to raise concerns and found they were not always listened to by health practitioners.
The opening sentence of Rance et al's paper states that ‘Patients’ contributions to safety include speaking up about their perceptions of being at risk.’ (p348) The authors do not suggest that this idea is new or novel, but were struck by how often the women they interviewed spontaneously mentioned that they had had difficulty speaking out about their concerns and/or being heard by health practitioners. There have been some notable feminist texts suggesting that often women do ‘know’ best and often ‘know’ best in the context of safe environments and supportive relationships. The literature examined by the authors of this paper also found ‘some evidence that patients can detect suspected adverse events earlier than professionals’, but that women ‘hesitated to raise concerns that they felt staff might consider irrelevant’. (p348) They too suggested that ‘Patients readiness to speak up was substantially affected by the quality of their relationships with staff.’ (p348)
This research was part of the Birthplace study and took place across four Trusts in England that were considered to be functioning well and were particularly concerned about improving safety and care. They were located in both urban and rural environments, provided a variety of settings for birth and cared for both advantaged and disadvantaged families. This paper focuses on the in-depth interviews with 58 postnatal women and partners. Women were asked questions such as ‘How was the birth experience for you?’
‘Speaking up, defined as insistent and vehement communication when faced with failure by staff to listen and respond was an unexpected finding’. (p348) It was mentioned by 30 of the 58 women interviewed and 14 of them said that the situation was urgent. Of the 28 who didn’t mention this, 15 women thought professionals had more knowledge then they did, thought they should comply, or feared they would be seen as ‘over-demanding’ (p349). Subsequently, some blamed themselves for not speaking out.
Nine of the women felt they didn’t need to speak up as they were able to talk with staff who listened and were responsive. Their comments demonstrated the positive value of being listened to and supported, especially when they had had difficult experiences. Conversely, the comments by women who felt ignored were distressing: ‘I just felt like I was being ignored … I felt like I was screaming and no one was listening. I felt like my wishes were being completely disregarded …’
A number of factors were found by the researchers to help women to speak up, such as feeling strongly at risk, having enough information to feel more confident about their own knowledge, and/or the presence of a partner or relative. But speaking up did not guarantee being heard. The women described staff: ‘ignoring requests or dismissing safety concerns; delaying or withholding information, care or support; disbelieving the woman’s account of stage in labour or symptoms in self or baby; responding brusquely or rudely to requests for help; refusing labouring women admission or sending them home feeling unsafe; refusing presence of midwife to attend planned home birth.’
The authors acknowledge that pressure on staff impacts on their ability to listen and respond to women, but also suggest that: ‘The failure to listen so frequently reported in our study may be associated with institutional cultures that normalise reduced attention to women’s calls for help.’ (p353) They also noted that while it is assumed that advantaged women speak up more than those who are disadvantaged, care from caseloading midwives could ameliorate this for the disadvantaged women in their care.
They concluded that support from a partner or relative was the most helpful factor for women, but asked whether or not women should have to depend on this and whether women on their own are ‘more exposed to risk’. (p353) The authors suggest that awareness among staff about the importance of listening and responding, as a safety measure, needs to be increased and that while this is difficult to do, they cite successful examples from the UK, North America and Australia.
None of these findings come as a surprise to AIMS. We hear similar comments from women who have not been listened to on our helpline and elsewhere. While it is concerning to hear about the extent of this problem, even in maternity services committed to good care, it is useful to have published findings from respected qualitative researchers, telling us that women are often ignored and disrespected during their childbearing experiences.
One of the most important aspects of the study is the authors’ view that not listening to women could be due to ‘institutional cultures’ that ‘normalise’ this. We now have a wealth of research showing that trusting relationships between women and midwives develop when midwives and women get to know each other and that one of the best ways of achieving this and contributing to safe (in its broadest meaning) care is by introducing case loading midwifery.1 But the NHS is renowned for not listening to women (or midwives). And as services face increased cuts and privatisation, the likelihood of cultural and individual change decreases. Hard pressed staff who lack sufficient resources cannot easily listen and respond, far less design and introduce systematic initiatives for change.
Meanwhile, it is still not widely enough known among parents that a Supervisor of Midwives is on call at alltimes, in all areas, to support women and midwives. Any woman can contact a supervisor, even in labour, if she has concerns about or wishes to discuss her care. See: www.nmc-uk.org/patients-public/Women-andfamilies/ How-supervisors-of-midwives-can-help-you/ and www.nmc-uk.org/Documents/NMCPublications/NMC%20Supervisor%20of%20midwives.pdf
The AIMS helpline can also be contacted any time at firstname.lastname@example.org. A group of volunteers answer queries and can suggest other sources of support and information.
1. Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2013, Issue 8.
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