Earlier this week, Grumpy Midwife had lunch with a very nice Kenyan midwife. (GM was actually in Kenya at the time, sitting around drinking Tusker beer and missing iPlayer.) Over a plate of plantain (locally reputed to keep one young) beans and salad, GM asked Liz about traditional birth attendants. As you do.
Liz told GM that in her area over 38% of women choose to pay for care with a TBA rather than access free MoH maternity services.
Why? asked GM, assuming (smugly, because she’d just read an article about it) that the answer would be women’s familiarity with the local TBA and appreciation of her respect for traditional practises (1).
No, said Liz. It’s because women are treated so badly by nurses and midwives in the government facilities. Verbal abuse if they make too much noise. Slaps if they don’t keep still. Intimate procedures without consent or explanation.
This is not a local problem (2,3) – or even an African problem. A policy document from the Washington-based White Ribbon Alliance describes a range of abusive behaviours in maternity services in developing and developed countries (1) made all the more appalling by the vulnerability of childbearing women.
Research exploring why practitioners behave in this way is thin on the ground. Liz’s opinion that it is related to over-work and low pay seems to be widely shared, whilst The White Ribbon Alliance suggests a link with lack of respect and compassion afforded to staff themselves from within healthcare services (echoes here of Don Berwick’s work on staff engagement in the UK and clinical outcomes: search on http://www.kingsfund.org to find out more).
Liz has made tackling this issue a personal campaign. Apart from identifying and rewarding exemplary practitioners, she uses the Charter of Universal Rights of Childbearing Women (4) to raise awareness. The Charter places maternal rights firmly within the context of human rights, mapping each right to international and national standards. Right 1 is freedom from harm, Right 2 concerns consent and information, 4 is the right to dignity and respect – and so on.
Her interest piqued, Grumpy Midwife cruised the internet (never mind anything else, decent wifi is surely a human right!) to find out more. En route, she visited the websites of the European Court of Human Rights (which offers some nice fact sheets of legal decisions pertaining to women’s health) and UK Birthrights (more excellent fact sheets) arriving by a series of random clicks at a Judgement of the United Kingdom Supreme Court concerning care of a woman at risk of shoulder dystocia (5).
Grumpy Midwife will quickly summarise the relevant bits of this 38 page document – just in case you’ve fallen behind with your legal reading over the summer.
Mrs M was expecting her first baby. She is five foot tall and has diabetes. She was anxious because she had been told her baby was large. Dr M, her obstetrician, reassured her that she could deliver safely vaginally and did not mention elective caesarean section as an option for delivery. Why? Because (in Dr M’s words) if she had Mrs M “would no doubt have requested a caesarean section” and “it’s not in the maternal interests for women to have a caesarean section”.
Mrs M’s labour was induced and augmented and (during a forceps delivery) shoulder dystocia occurred. The obstetrician attempted a symphysiotomy and Mrs M was given a GA in preparation for Zavanelli manoeuvre and CS. In the event, Baby M was delivered vaginally 12 minutes later and, tragically, was later diagnosed with cerebral palsy affecting all four limbs.
In upholding Mrs M’s appeal against Lanarkshire Health Authority, the Lords cited a woman’s right to autonomy and self-determination. In their words: a woman “is entitled to take into account her own values, her own assessment of the comparative merits of giving birth in the ‘natural’ and traditional way and giving birth by caesarean section”.
In her day job, GM dabbles in fitness to practice investigations and is becoming aware of a bit of a theme: midwives being just too nice; being kind (or economical) with the truth when things are going wrong because they don’t want to upset the woman or their relationship with her or the progress of labour – yet (as with Dr M) all this actually boils down to is midwives believing that we know what is best for the women in our care.
Isn’t it interesting that his mis-placed kindness – or arrogance – is now a human rights issue?
(PS Do read the full Judgement for fascinating stuff about medical opinions, use of “therapeutic exception” – and why Bolam is not applicable in this case.)
(1) Armbruster, D and many others (2011) Respectful Maternity Care: The Universal Rights of Childbearing Women. The White Ribbon Alliance, Washington DC Available at: http://www.whiteribbonalliance.org
(2) Okwako, JM, Symon, A (2014) Women’s expectations and experiences of childbirth in a Kenyan public hospital. African Journal of Midwifery and Women’s Health, vol 8, no 3, pp115-121
(3) Ebu, NI, Owusu M, Gross, J (2015) Exploring women’s satisfaction with intrapartum care at a teaching hospital in Ghana. African Journal of Midwifery and Women’s Health, vol 9, no 2, pp77-81
(4) Hastings, MB (2015) Pulling back the curtain on disrespect and abuse: the movement to ensure respectful maternity care. The White Ribbon Alliance, Washington DC Available at: http://www.whiteribbonalliance.org
(5) Montgomery v Lanarkshire Health Authority (2015) Available here: http://www.bailii.org/uk/cases/UKSC/2015/11.html