Right to know best

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

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

Why do midwives do this?

This won’t be a very long post because for once Grumpy Midwife doesn’t have any clever answers.

A few years back, when Grumpy Midwife was involved in a birth reflections service, a woman told her she was unable to go to the gym since her baby was born nine months ago. Why? Because she couldn’t bear to see the exercise balls, lined up all pink and purple ready for girly sit-ups, because they brought back such terrible memories of her labour. But it wasn’t the pain she recalled – or fear or indignity – but, specifically and horrifically, the two midwives who cared for her during those hours.

Some time later, another woman told Grumpy Midwife, not entirely in jest, that she felt about midwives as other people feel about bankers or traffic wardens or tax collectors because of how she was treated in labour.

Then, early this January, another story: this time a fellow student on a course; a consultant surgeon whose wife had just had their first baby. Labour was induced on the antenatal ward and contractions started almost immediately. Tentatively, politely, aware of how intimidating it can be to care for doctors and their families, this gentle man asked the midwives to attend his wife; once, twice, three times, for six long hours of patronising platitudes, until her waters broke and she started to push and suddenly it was all her fault for not using her call bell.

Why do we behave like this? How do we manage to inspire at once gratitude and adoration – and fear and loathing?

Proud to be a Midwife

Grumpy Midwife is proud to be a midwife. She’s proud of the whole second-oldest-profession-in-the-world thing. She loves the idea of being the latest in a long line stretching back to Biblical times; presiding over the primordial mess and raw emotion of an event that levels princesses and paupers, prisoners and pop stars.

Grumpy Midwife is even secretly rather proud of Call the Midwife; lynchpin of the community, respected by men, revered by women, keeper of secrets, defender of the weak, wise woman, witch. She likes the fact that when people ask what she does, she can simply say “midwife” with no need for explanation or elaboration. What other profession is thus so nicely defined?

If she had more time, there is a risk that Grumpy Midwife would find herself quite overcome by the sheer pathos of birth: her hands the first to touch this brand-new, blood-streaked little body; her words at this time remembered forever by the mother; her protection of this infant during the most dangerous moments of his life the first of step of his journey to nobility, Nobel prize, or notoriety. She still sheds a few discrete tears at every birth she witnesses, secure in the knowledge that these will be unnoticed in her general bustle and bossiness.

There have been times when this pride has been dented; by Grumpy Midwife’s own cynicism and discontent or by events or the opinions of others. But not for long – and never so much so that she has managed to walk away. And certainly not since she was recently reminded – by healthcare workers listening intently to her every word in a dusty, dilapidated classroom in a remote corner of Kenya – of the importance of midwifery skills, stripped of all romance and pretension, to millions of women across the world.