October 12, 2004

Defensive midwifery

The workshop over the weekend in Leamington Spa (south of Birmingham) offered some interesting insights into the ways that midwives are often forced to work. The group was a mix of older, experienced midwives and younger graduates, and it was clear that the hospitals they represented were quite medicalised in their approach.

In such an environment, one strategy that is often used to stop midwives from deviating from accepted norms is to quote “policy” as the reason for certain tasks or interventions being done. A case in point was the discussion that arose around the management of the second stage of labour. One midwife stated that at the home births she facilitated, she didn’t feel constrained by any time limits on the pace of second stage, but in the hospital she felt obliged to adhere to the policy of “if, after 20 minutes for a multip or 40 minutes for a primip there is no progress, some form of hurry-up intervention (which I gathered usually meant urging the woman to “push, and push hard”) must be started.. As soon as she had finished this description, a colleague jumped in and said that she was wrong with this policy, as it was 30 minutes without progress for multips, not 20 as she had stated. At this point, a more senior midwife joined the discussion and stated clearly that there was no policy of time limits for second stage. This was news to many in the group, and it seemed to me that this was a good example of how non-existent “policy” is often quoted to coerce midwives into conforming to someone else’s timetable or practise preferences.

It is another example of horizontal violence that so bedevils midwifery. It is also a good reason why midwives need to learn how to ask the appropriate question, “could you please show me this policy?” before blindly accepting such statements at face value. Newly qualified midwives are easily cowed by dictatorial behaviour from colleagues and this leads to fear setting in and the potential for defensive midwifery to develop. I worry when midwives say they cannot question a policy because they fear for their jobs if they create waves - if they can’t stand up to bullying colleagues how can they ever act as advocates for women who are even more disadvantaged in the often hierarchical, officious and bureaucratic system called health care?

Of course, when I put these challenges to some midwives, they find it easier to blame me as the messenger (after all, as I am not a midwife, I could hardly know what goes on, could I?), rather than accept that their system (or themselves) need to address these problems. I can take these criticisms, and agree that sometimes I am provocative and maybe seem harsh in my comments about their practise. However I won’t accept that these conditions can’t be changed. Those who are part of these systems are in the best position to stir the pot and demand better things for themselves and the women they care for. Where there is a will, there is a way.....

Posted by andrea at October 12, 2004 05:27 AM

Comments

Hi Andrea,
My name is also andrea, and I am a student Midwife. I am increasingly becomming disillusioned into why I chose this career. As a young child I was always curious about birth, and hoped that one day I could help women through their birth experience.
However currently in the process of finishing my qualification as a Midwife is a hospital, I am alarmed at how cheated I feel at becomming a Midwife. I feel more like the enemy to women rather than a compassionate helper. I feel powerless to stop the ARM's, active management of 2nd and 3rd stage.
I am exhausted at fighting the system, at asking "why can't we just leave her membranes intact", "why can't we let her push at will", "why do we have to continuously monitor the fetal heart rate". But as a student I am to do as told if I want to complete my year of study, and finish my book for midwifery registration.
Next year I will be working with a home birth Midwife, and there I hope to learn what it is to be a true midwife, not an obstetric nurse.
I find it pleasurable reading the articles on your website as they inspire me to continue to fight for the right to natural birth.
Thank you for your inspiration.
From Andrea

Posted by: andrea albertini on October 19, 2004 04:13 PM

Comments

Hi Andrea,
I work at this hospital, and was unable to attnd the study days because of my work load that weekend, and the Waterbirth session I hold twice a month. I and many of my colleagues encourage active birth, and even though I have encountered some raised eyebrows, on the whole the atmosphere is one of support, both for hospital and home confinements of which I attend approximately 2 each month, from Midwives and medical staff alike. The policies are not rigid, as long as a midwife can justify her desicions. I personally have attended 31 births this year, 29 were spontaneous vaginal deliveries with no intervention at all, in some cases not even vaginal assessments. Policies come into play when Midwives are inexperienced or unsure, they are not tablets of stone and should not be approached in this way.
No I am not management, I work as an intergrated midwife 1/2 in hospital and 1/2 in the community.

Posted by: Jan phipps on October 24, 2004 01:54 AM