October 30, 2003

Guernsey, part two

This posting about Guernsey is rather late - I had prepared it at the end of the workshop with the intention of putting it on the site as soon as I arrived in Italy the next morning. However, I didn’t count on the telephone system in Italy. I have been unable to get access to the Internet for the past week!

Therefore, here is my final reflections on Guernsey and tomorrow I will post my observations on the Conference that I was attending in Italy.

I decided to alter my approach with the second group of midwives in Guernsey. I began by asking those who had seen a natural birth (not a normal birth, as definitions of this vary widely) to raise their hands. I then asked them to lower their hand if the birth had included: artificial rupture of the membranes; any kind of medication for pain; oxytocics for any part of labour; episiotomy; TENS, or horizontal or recumbent position for the birth. Gradually the hands fell, but still some remained in place. It transpired that these midwives had witnessed or assisted at these births elsewhere, not in Guernsey.

This was a revealing exercise, because ostensibly, the midwives on this island are trying to offer an alternative to the doctor dominated service that now exists. They have established a midwives clinic and are working towards offering home births as part of an integrated approach to care. The reality, however, is that there are 600 births per year on the island and four obstetricians, and the caesarean section rate is unacceptably high. Due dates are based solely on the scan date and births are rigidly induced at term plus 10 days, leading to “failed inductions” and caesarean births. Epidural use is high and midwives see no problems in using diamorphine (heroin) liberally in labour, especially if the woman requests it (even in transition). One midwife stated that she considered a birth to be quite normal if it included diamorphine (but then she had earlier said she used it herself, and claimed it was excellent for her).

There are 5 midwives employed by the hospital who were born in Guernsey - the other 30 or so midwives have come from elsewhere. Although I was told that this could be a strength if people contributed ideas found useful and effective in other places, it was made very clear to me that midwives were expected to conform to the rigid protocols and policies that operated on the island, and without delay. I was given the distinct impression that any “outsider” who rocked the boat would be made to feel as uncomfortable as possible in the hope that they would either buckle under or would leave.

I heard lots of “blame the woman” statements as well - excuses for the labour management style and questionable outcomes being sheeted home to the woman. “If a woman requests drugs she should not be denied them in case she complains later” was a tired old excuse that I heard once again. I was told that the Island Health Board had enough money and could support requests for completely unnecessary elective caesareans, if that was a woman’s choice.

Whenever I hear these claims being made and the women being blamed for the high rates of interventions, I know that midwives are covering up poor practice, limited skills and a lack of experience of natural birth. In some ways they can’t be blamed for their predicament - if they have never seen a woman give birth completely under her own steam then it must be hard to accept that it is possible. To not even want to find out how it could be done and to be wary of anyone who can verify that this is indeed possible (to the point of trying to discredit them) is however, unprofessional.

Yet this is what is happening on Guernsey. A midwife, with many years of successful home birth and water birth experience in Britain, was employed to institute change and move midwifery services forward on the island. Her approach was discovered to be “radical” in the eyes of the other midwives and her practice style has challenged many of the traditional views of her colleagues. Rather than learning from her experience they have set about crucifying her, with the apparent aim of getting her off the island as fast as possible. They have become so unsupportive of her that it has made it difficult for her to practice safely, an outcome that has, in turn, been held against her.

It is the old story - change is uncomfortable, and people like working within narrowly defined rules that ensure everyone toes the lines and no questions are asked. Never mind that labouring women are individuals and deserve appropriate care, or that this system makes it easy to hide mistakes (or even perinatal deaths), from scrutiny. The doctors set the pace and dictate how the midwives will work, and the hospital threatens that anyone stepping outside the guidelines, or practising in a different way, will be viewed as a dangerous radical to the status quo.

I don’t think I will be asked back to Guernsey - I think the midwifery managers found my presentation very uncomfortable and challenging. Some in the group did welcome the timely reminder of what midwifery was all about, as they indicated on their evaluations, but I suspect that anyone who really wants to practice midwifery should not consider Guernsey as a potential workplace. The “small island mentality” that is so common in these kinds of geographic locations is well illustrated by their maternity services!

Posted by andrea at October 30, 2003 07:42 AM

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