Midwives, Medics, and Professional Identity

Grumpy Midwife is still obsessing with issues of professional identity. She has concluded that, like patriotism, a strong professional identify and pride in that identity is a good thing – but only in moderation and only when the end justifies the means.

Recent research conducted by the General Medical Council amongst doctors in training revealed that over 13% had experienced bullying and nearly 1 in 5 had witnessed somebody else being bullied in the workplace (which suggests that being bullied is under-reported). The same survey concluded that 26.5% of the 50,000 respondents had been subjected to “undermining behaviour” from a senior colleague, undermining behaviour being defined as “persistent and deliberate belittling or humiliation” that eroded “professional confidence or self-esteem”. So far, so worrying – but now it gets personal.

Trainees in obstetrics and gynaecology are more likely than any other speciality to report bullying or undermining. And the perpetrators of such behaviour? First consultants, and second “nurses and midwives” – by which we mean midwives since there are virtually no nurses in obstetrics and nurses in gynaecology now seem to be lumped in with surgery and, in any case, seem far too harassed and busy and nice to waste time and energy belittling anybody. Yes, midwives are officially the Bitches of Birthing.

Incidentally, the nearest rivals for the toxic distinction of Nastiest Speciality is pathology. Isn’t that interesting? Obs and gynae is probably the most visible of specialities, with women and families witnessing almost everything we say and do (contrary to popular belief amongst staff, labour ward doors are not soundproof) – whilst pathology is arguably the most invisible (GM knows virtually nothing about working in pathology but imagines a tense and silent lab full of microscopes and anxious people in white coats being constantly interrupted by phone calls from clinicians too impatient to wait for results on the intranet).

So what is it about midwives? GM was recently invited to attend a talk on unacceptable behaviour on the labour ward, delivered by an obstetrician tasked with addressing this issue in maternity units. (The occasion was a Deanery educational event attended by around 100 obstetricians. And three midwives. GM is nothing if not brave.) The speaker (a charming woman of around GM’s vintage) ran down a list of factors that may contribute to unpleasantness in maternity care: stress, shifts, demanding training, risk of litigation, traditional attitudes, lots of female and overseas doctors – and midwives; “midwives are [palpable pause and carefully choice of words] not like nurses“. Cue nervous laughter around the auditorium.

Not like nurses? Meaning… Autonomous practitioners fully accountable for the care of mother and baby throughout normal pregnancy, labour and the postnatal period (Midwives’ Rules, 2012)? With continuing responsibility even when obstetricians are involved to provide “holistic support, maximising continuity of carer and promoting … normal physiological processes” (Safer Childbirth, 2007)? Confident professionals with a long and honourable history? That’s good, surely? Well, not if “autonomous” = insular, “holistic support” = colluding and obstructive, “promoting normality” = blinkered and short-sighted, and “confident” = bullying and belittling.

This isn’t a new or isolated issue. Our Code of Conduct (NMC, 2012) stipulates that midwives “work cooperatively within teams and respect the skills, expertise and contributions of … colleagues”; very similar words to those used in the GMC’s Good Medical Practice guide (2013). Meanwhile, the International Confederation of Midwives in a position statement makes clear that autonomy does not mean working “alone or in isolation from the woman or colleagues” – and this warning brings us back to what really matters in this whole sorry mess.

A strong professional identity – yes – so long as we remember what that identity is and for whose benefit. Midwife = “with woman”; “with woman” not to feed our professional ego but sensitively, skilfully, humbly with each woman. If we place women genuinely at the centre of care there would be no room for bossing or bullying or belittling, just calm professional conversations to plan the best possible care for each and every mother and baby.

Well, that’s Grumpy Midwife’s theory anyway.


Midwives do not have the monopoly on maternity care

Across the world, 40 million women each year give birth without a trained attendant. Two million of these women are totally alone.

In the UK, it’s all about one-to-one midwifery care in labour, 40 hours of consultant cover on wards, and epidurals within 30 minutes. For 50% of women in sub-Saharan Africa, it’s about a modicum of privacy, a clean blade to cut the umbilical cord, and skilled hands to stop bleeding.

As a Supervisor of Midwives, Grumpy Midwife spends more than her fair share of time dealing with issues of professional accountability and autonomy, blogs about how proud she is to be a midwife, and is embarking on Masters research looking (in part) at the impact of midwives’ professional identity on collaborative care. Across the globe, the title of ‘midwife’ is reserved for those appropriately qualified and legally licensed and, in the UK at least, it is a criminal offence for anyone other than a midwife or doctor to plan to deliver a baby (Dimond, 2013).

Meanwhile, in parts of the developing world, there are fewer than two registered healthcare practitioners per 10,000 people; in some places because of absolute shortage, in others a reflection of unequal provision as specialist healthcare workers (not unreasonably) vote with their feet for a living wage and personal security.

Midwives do not feature much in remote villages in Africa and Asia. Women are attended in childbirth by nurses – public health nurses, nurse midwives, nursing assistants – or traditional birth attendants. Or nobody. Most of these nurses also give antenatal care and immunisations, treat malaria and snakebite and diarrhoea, resuscitate the newborn and tend the dying.

A recent editorial in the African Journal of Midwifery and Women’s Health (Iliffe, 2014) warns against “colonial” attitudes on the part of Western donors and advisors who link funds to “one particular way of doing things” in terms of health practitioner roles and regulation. When you’re five hours from the nearest midwife or medic, it’s not the status of the birth attendant that matters but her skills and her access to lifesaving medicines and transport.

Yes, midwives are the experts in normal childbirth and – yes – of course we should be leading on this; educating, innovating, inspiring, driving up standards. But ours cannot be a mindless monopoly on the care of mothers and babies.

Save the Children Fund (2014) Ending Newborn Deaths: Ensuring Every Baby Survives

International Confederation of Midwives

Dimond, B. (2013) Legal Aspects of Midwifery. London: Quay Books

Iliffe, J (2014) Beware nursing and midwifery colonialism. African Journal of Midwifery and Women’s Health, 8(1), p.6