Articles by Month: January 2007

Horizontal violence in midwifery

The issue of horizontal violence in midwifery units has again surfaced, as it does from time to time. In the UK there have been several enquiries and some useful research done to investigate ways of attracting newcomers into midwifery and maintaining midwives in the workforce, as falling numbers and the rising average age of midwifery staff start to ring alarm bells.

The telling outcome of these studies is the main reason that midwives leave their chosen profession is a lack of job satisfaction and recognition for the work they do. Many midwives cite a lack of support from management and poor relationships amongst their peers as underlying their decision to move on. Much of the behaviour they have suffered would be classified as “horizontal violence” and it seems that nursing and midwifery are particularly prone to this terrible phenomenon.

Many midwives struggle in unhealthy, unrewarding workplaces, and many cave in and leave, in the hope of finding more success elsewhere. As they depart, the work falls on fewer shoulders, adding further strains to the stretched services, and the cycle continues.

Many of those who remain are older and have developed ways of surviving in this socially toxic environment. They become hardened and withdrawn, going through the motions of “getting the job done” with little regard to the needs of women or their colleagues. Others become bullies, taking out their own frustrations and insecurities on others, who then have to find ways of dealing with the abuse or (more likely) dodge the issue by leaving.

It is a real problem and one that takes strong management and sensitive handling to eradicate. Good team work and the building of a strong shared goals and vision are important. There are midwifery units where these conditions have been developed with great success and unsurprisingly, these are usually the units where birth outcomes are also good, reflecting the way that happy staff have more time and energy to create happy birth places for the women they are serving.

For those who are interested in reading more about these issue, I can recommend these articles from our website:

Dying for the Cause by Carolyn Hastie

Horizontal Violence in the Workplace by Carolyn Hastie

Both explore the issue in depth and offer suggestions for ways of overcoming this insidious problem that in many ways is hampering the birth reform movement for women and their midwives.

Posted by andrea at 08:56 AM

The quality of prenatal classes

I have been spending the last few days marking the final Observations assignments for the final group of students completing the Graduate Diploma in Childbirth Education (which was phased out on December 31st).

A number of these assignments have been reports from observing prenatal classes. The student is required, in part, to sit in on classes being provided in her community, report on the details of their structure and presentation and offer some reflection on their effectiveness and style. Marking this work gives me the opportunity to review what is happening in the hospital system, the prenatal classes and in community health facilities in a number of areas around the country, and it has always been an interesting way to keep up with developments.

The classes that these students have been observing leave me feeling very concerned. Many programs are clearly still based on lectures designed to force feed pregnant parents with as many facts and details as can be crammed in to the short time allotted (usually a series of 2 hour sessions). Many educators are using overheads, even Powerpoint (!!) to present their material and very few offer any opportunity for parents to practice practical skills, especially for labour. The facilitators of these program are no doubt doing their very best to engage the parents and offer useful information. It seems though that the guiding principle is one of “let’s tell them everything we know they will need” rather than enabling parents to take some responsibility for their own learning and offering opportunities for them to develop vital self-help skills. A class that is taught as a series of lectures, especially with overheads or Powerpoint slides is not based on adult education principles and is impossible to evaluate effectively. This is very poor practice, is not evidence based and is probably a waste of time. Many class groups report falling numbers as the weeks roll on, very likely a sign of dissatisfaction.

Some topics within these programs are being taught by educators with little direct experience. For example, in many programs, the sessions on positions and comfort aids for labour are taken by physiotherapists. From my observation, very few physiotherapists have ever spent time in labour wards (apart from having their own babies) and have scant experience of using these techniques as support people for labouring women. These are topics that should be covered by midwives, who have a vast knowledge base of labour from which they can offer suggestions.

There seems to be a perception that using group activities that involve parents “will take too much time”. In reality, a well designed group activity that includes practical work, problem solving and discussion can save a lot of time, because many issues can be addressed in a short time. Those educators who shy away from this approach probably do so because they fear they either won’t cover the allotted material or are inexperienced at facilitating groups. It is easier to lecture when you have few skills at working with groups, and very few educators working in the hospital system have any qualifications or training in working with adults.

I have always been appalled at the overall quality of the classes offered to parents in the hospital system. The standards are low, not from want of trying (many educators are enthusiastic and dedicated to this work) but because of the lack of training and support for programs that are better structured and more appropriate to expectant parent’s needs. The lack of practise time for self-help skills for labour (positioning, massage, use of heat etc) is especially worrying, because without a clear idea of how to help themselves, parents will feel helpless and be more likely to opt for drugs (especially epidurals with their promises of complete freedom from pain). A brief discussion, viewing a poster or two and watching a demonstration of various positions (either by the educator or on video) is completely inadequate for preparing women and their partners to manage labour by themselves. The practical session involving self help should be a central theme of the entire program and used as an opportunity to build confidence and positive attitudes to managing labour. The concept of “informed choice” is also lacking – without practice in making decisions, and a chance to work out solutions for themselves, parents will not have the necessary skills to navigate their way through the rigid construction of protocols and policies that operate in most hospital labour wards.

These kinds of deficiencies, which I have been observing over the last 30 years, are the underlying reason why I developed The Essential Educator. I know that educators try their best to pack as much in as possible into the limited time they are given for their classes. I know that they want to do their best. I know that they are given few resources, let along training, in how to facilitate groups and incorporate fun, practical sessions into their programs. The teaching package that I have developed enables educators to do all of these things, using professionally prepared materials and proven activities. Each activity has guidance notes for effective presentation, an in-built evaluation strategy and automatically incorporates the principles of adult learning. Anyone can use this pack from scratch, if necessary, to present an effective program that will not only give parents the information they need, but most importantly build their confidence and trust in the natural process of labour.

Powerpoint presentations and set of slides or overheads are no substitute for practical sessions that focus on the parent’s needs rather than the system’s. The quality of much prenatal education is so poor (from my observations) that most parents would be better off without it. Much of it, as it now stands, will unwittingly set parents up for accepting inductions, drugs, epidurals and caesareans.

Prenatal education programs are a gift – a rare opportunity to work with a group of motivated adults (they have made the effort to attend) at a time in their lives when they can hone the life skills that will be vital for taking care of themselves and their babies. That so many educators (and parents) miss out on this golden opportunity seems almost criminal to me. It could be so much better …..

Posted by andrea at 02:14 PM