Grumpy Midwife’s Swansong

Grumpy Midwife is moving on.

There may or may not be future posts – so (just in case this is a finale) here are Grumpy Midwife’s three wishes to the Good Fairy of maternity care.

Please make midwives listen to women.

Don’t just do this as part of a damage-limitation exercise; do it because women – those having babies and those whose babies have long since grown up – are the reason midwives exist. Women want what is best for themselves, their babies and their families; physically, emotionally, socially. Midwives exist to articulate, negotiate and realise these needs – especially for those women who are otherwise voiceless and powerless. That is the function of midwives, whether we are designing a new maternity unit, writing a policy or assisting with breastfeeding. End of.

Please make midwives get along better with doctors.

When GM started out many moons ago, obstetricians were seen as the enemy; it was obstetricians who oppressed midwives, stymied women’s choice, and thwarted natural childbirth. Thirty years on, midwifery is a strong, autonomous profession turning away applicants, women’s choice is embedded in national policy, and natural childbirth – well, Grumpy Midwife is not too sure what is happening to natural childbirth but she worries equally about Musketeer Midwives and defensive, policy-bound practice.

Sound professional relationships depend on mutual respect and whilst there are shining examples of confident, inspirational midwifery leadership Grumpy Midwife sadly feels that midwives do sometimes let the side down. We seem to take an almost masochistic pride in being busy; too busy to review and reflect, too busy to consider if we could be doing things better – so busy in fact that being busy is now embedded in our culture, our expectations and our management of ourselves and our services.

This attitude has to change if midwifery is to command respect as a critical, intelligent profession. Professional development is not a skive; it is necessary and integral to sound practice. Midwives should demand (and mangers should facilitate) time for audit, research and reflection. Training and development should be priorities rather than add-ons; academics and educators should be welcomed rather than marginalised – and all midwives should have the skills to understand and promote midwifery research with authority and pride.

Please make midwives be nicer to each other.

Grumpy Midwife is terminally fed-up with the perpetual, relentless bullying of junior midwives  – and part-time midwives, community midwives, independent midwives, specialist midwives, older midwives, thoughtful midwives, slow midwives (possibly any midwife whose heart doesn’t leap with joyous excitement at the sound of an emergency bell on labour ward).

This bullying is insidious and ubiquitous. It poisons relationships with women and wrecks careers and lives. It disrupts teams and impacts on service provision. It is perpetrated and condoned from the highest levels and is an embarrassment and shame to the profession. It has to stop.

UK midwifery has much to celebrate in the early 21st century – but there are no grounds for complacency and significant reasons for concern.

Good luck.

 

 

 

 

Once upon a time…

In a bookshop frequented by Grumpy Midwife there is a sign, propped up on a table piled high with the lives of sports personalities, politicians and pop stars:

Do not read history, read biography – because biography is life without theory (Benjamin Disraeli)

Or, to paraphrase very loosely: Read the lives of people because it is people and their stories that help make sense of life, the universe and everything.

In another persona, Grumpy Midwife is Grumpy Novelist and a Great War geek. She really does know a ridiculous amount about trench warfare and Tommies and Haig’s twisted thinking during the Battle of the Somme. And the source of all this knowledge? Stories. The stories of individual men and women. Diaries. Letters. Dramas. Novels. Biographies. Because without stories, quite frankly, the theory (to channel Mr Disraeli) is actually rather boring.

And so it is when we think about healthcare.

It’s all so big. So complicated. So messy. What’s an STP, for goodness sake? And what does CQUIN stand for? Or STEIS, for that matter? 697,852 live births in England and Wales. 1.82 children per woman. CS rate 27%. So what?

Four years ago Grumpy Midwife (ahead of the curve and first in the Costa queue as usual) wrote an essay for some academic course or another on the power of stories shared by midwives and obstetricians. Sprinkled with impressive references (available on request) this was the gist of what she wrote:

Stories … enable us to share events and give meaning to those events as if we were ourselves participants. Stories also help capture the complexity of practice and provide opportunities to share tacit aspects of practice. Stories … can offer serendipitous glimpses into the world of others. Stories add humanity; a story told against the teller engenders feelings of warmth and trust towards her.

So imagine GM’s smug grumpiness when she read recently (courtesy of The Health Foundation) of the transformative power of story telling; how when we listen to someone telling their story we begin to “see the world as they see it, walk in their shoes”. We start to empathise; we experience “narrative transformation” – and stifle sobs as Bambi’s mother dies on screen.  Neurologists blame oxytocin for narrative transformation; oxytocin makes us more compassionate, more sensitive to social cues, more willing to help those in need.

According to The Health Foundation, we are also more likely to remember a message embedded in a story than the same message presented in facts and figures; “Statistics and data have an important place in monitoring … but the right story can have the power to motivate and change minds.”

Which all helps explain why stories are useful tools for quality improvement in healthcare; to identify problems, motivate staff, and celebrate success.

So next time you really want to know what a woman thinks about her antenatal care, set aside your F&F cards and your feedback forms and smiley face touch pads and sit down beside her and ask her to tell you her story.

Don’t interrupt. Don’t explain. Just listen.

And then go away and decide how you will use her story to change things.

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

Training – but not as we know it

As one career door closes for Grumpy Midwife and another creaks cautiously open, she would like to make clear one thing: training is not always the answer. (And here GM has to declare an interest, having recently departed a post in, er, training.)

Or (to put it another way): The answer to life, the universe and everything is not training.

Or (just in case there is still any lingering doubt): There is more to prevention and remediation of mistakes and misjudgments than training.

Medication errors, muddled decision-making, poor inter-professional communication. Up and down the country – in risk meeting minutes, in unit action plans, in incident investigation reports – the response is the same: “review training”, “add to mandatory training”, “attend training”. (Have you noticed how even “poor communication” is now considered to be amenable to training? Millenia of linguistic diversity, the infinite nuances of human body language, and several centuries of sexual and social indoctrination reduced to SBAR and RSVP – and job done.)

Time for a bit of adult educational theory*. Fear not, much of it stems from Maslow – and we all know what Maslow’s about, don’t we? (In a nutshell: even if Brian Cox is leading the seminar on particle physics, it would be all in vain if Grumpy Midwife’s bladder is full or she knows a £90 parking ticket is about to be slapped on her car.)

In order for adults to learn, there has to be an element of human agency. It’s about participation not just attendance – which is why the NMC’s revalidation plans include a requirement for 20 hours of continuing professional development in the company of others (meaning we need to watch Call the Midwife a couple of mates for this activity to count). The trouble is, engaging learners – encouraging stories, listening to fears, checking understanding – just takes so damn long and we’ve still got to fit in hand hygiene and fraud and the iv update and god where’s the day gone maybe we could just give a handout for blood transfusion…

Adult learning is all about understanding and solving real-life problems. Processing a fetal blood sample is not a real-life problem to most community midwives – but dealing with fierce dogs and speaking at child protection case conferences most certainly are. Think how much time could be saved on mandatory training days if we focused on what really matters to practitioners.

Acknowledging and building on past experience and knowledge is critical to adult learning. Which is why one-size-fits-all e-learning modules and PowerPoint lectures are doomed – and why being belittled by a know-all teacher or colleague on a training day back in 2000 means we’ve never asked a question since even though we don’t really get all this acid base stuff at all.

Adult learners’ values, attitudes, and beliefs influence their learning. A maternity care assistant won’t see the point of learning how to do supra-pubic pressure if she doesn’t, deep down, feel part of the team. Similarly, an obstetrician is not going to engage with learning how to facilitate a standing breech birth until he’s had chance to unpick his belief that all breech babies should be electively delivered by CS.

The context of adult learning is more important than any one variable. Even Brian Cox – or an internationally-renowed CTG expert or the scariest of scary risk managers – alone won’t alone change practice if clinical guidelines are confusing and badly written and midwives and obstetricians don’t respect and listen to each other.

Adult learners are capable of self-motivation and self-regulation. Missing signs of septic shock, confusing the emergency bell with the fire alarm, and loosing ones registration are intrinsically pretty motivating – so why blame the managers or the practice development team for non-attendance? Why treat grown-up professionals like primary school kids? (Yeah, yeah, Grumpy Midwife knows: vicarious liability.)

Finally, the ability to reflect is critical to effective adult learning – BUT reflection is neither natural nor intuitive. Teach a midwife that iv antibiotics should be given every four hours and you tick a corporate box. Teach her or him to reflect with insight and intelligence on why she forgot during a busy night shift and you save a career (and possibly a life).

It’s training, but not as we know it, Jim.**

*Kaufmann, DM and Mann, KV (2010) Teaching and learning in medical education: how theory can inform practice. In Swanwick, T (editor) (2010) Understanding Medical Education, Wiley-Blackwell, Oxford.

**Apparently, Spock never actually said this (with reference to life) in Star Trek. What he actually said was: “It is not life as we know it or understand it, Yet it is obviously alive, it exists.” So now you know.

Grumpy Midwife has given birth

Grumpy Midwife is ridiculously proud to announce the birth, after a 12 month gestation, of a brand new smartphone app for midwives, obstetricians, maternity support staff, midwifery and medical students. Funded by a grant from NHS Thames Valley Health Education Midwifery Fund and imaginatively entitled Childbirth Emergencies, the app gives step-by-step management of the Big Five of obstetric emergencies – plus sepsis. There is also a nice little section on support of women and their families and staff caught up in traumatic events. It’s available totally FREE to download from the Apple App Store (and, no, sorry, there are no immediate plans for an Android version; the money has run out). Follow @MidwifeApp on Twitter to find out more or just search “childbirth emergencies’ in the App Store.

Grumpy Midwife hopes that her baby will now make it’s own way in the world, spreading enlightenment, giving encouragement, empowering maternity care staff everywhere (although written for the UK, the content is pretty ecumenical). In the meantime, she would like to use this blog to do what all good midwives do: reflect on the experience and draw out some pertinent learning points. (In doing so, GM has, of course, blown her cover since her real name is all over the app – although it was only ever two clicks on this site away for observant readers.)

First: Working on this app has made Grumpy Midwife appreciate the maternity services: the infrastructure; availability of basic drugs and equipment; opportunities to train; expectations of cure; the knowledge that help will come running when we press that emergency call bell. Others who care for mothers and babies across the world are not so lucky.

Second: Grumpy Midwife didn’t think she would ever say this but communication in the NHS is easy. We speak a common language, based on culture and shared history, sprinkled with jargon, abbreviations, and innuendo. We laugh at things that gross other people, know our place in the hierarchy, act according to expectations. Talking to normal people is hard work, littered with potential for misunderstanding and confusion.

Third:  The NHS does not have a monopoly on working hard or long hours. Grumpy Midwife’s early morning texts and nocturnal emails to her app developers were frequently responded to by return. Nor are we the only ones stressed by exacting bosses and moving goalposts.  We in the NHS may feel daily dealings with life and death set us apart on some sort of moral high ground but the work of others is equally valid and life-affirming. We are fortunate to do work we love but not special or entitled in any way.

Fourth: Engaging other professionals to check content is necessary and reassuring and Grumpy Midwife is eternally grateful for all the suggestions, corrections, and requests for clarification. But there comes a point when one starts going round in circles trying to please everyone, endlessly referring and deferring. Teamwork is all very well but someone eventually has to take control, accept responsibility, and move things forward.

Fifth: In the last few days of this project, after a week of immersion in haemorrhage, sepsis, and ruptured organs, one of the techies told Grumpy Midwife of his impending marriage. Screens of coding quite suddenly took on a human dimension and GM was reminded how childbirth touches all of us.

Six: There is never an easy way to start talking about vaginas and buttocks and perineums to young men half your age.

Seven: Apple Macs really are things of great beauty and extraordinary function.

And finally, on the wall of the meeting room at at the app developers is a framed poster, in the style of vintage ‘keep calm’ notices. This one instructs employees to “Work hard and be kind to each other”. Nuff said.

The Invisibility of Midwives

Throughout last year, Grumpy Midwife facilitated a (frankly, brilliant) interactive training session on obstetric haemorrhage based on the tragic story of Princess Charlotte.

Princess Charlotte of Wales was the only child of the future King George IV. Had she lived, she would have displaced Victoria as Queen of England etc and so changed the course of European history. Tragically, Charlotte died in childbirth in 1817, at the age of 21.

Contemporaneous record keeping leaves a bit to be desired but we know that this was Charlotte’s first baby and the pregnancy was probably post-term. Her labour was long and inefficient and she birthed a large still-born baby boy after several hours of second stage. Shortly after, she started to bleed so her attendant performed a manual removal of placenta; the bleeding stopped but Charlotte collapsed and died three hours later. Cue, 200 years later, an excellent opportunity for inter-professional professional discussion on the possible causes of her death – and small group work on we would do today to manage the situation. (It is not known exactly why Princess Charlotte died, although Grumpy Midwife’s money is on a ruptured uterus. Or sepsis.)

Poor Charlotte was cared for in labour by Sir Richard Crofts. He not an obstetrician but a “man-midwife”; a male specialist in childbirth and the choice of wealthy women of the day (the alternative being a village midwife). By all accounts, Sir Richard was a skilled and compassionate practitioner but, at in a time before oxytocics and antibiotics, he could only watch and wait as tragedy unfolded. (Ironically, village midwives had probably been using raw ergo(metrine) for a couple of centuries but doctors did not approve.)

The country reacted to Charlotte’s death with (according to accounts) emotional bordering on hysteria, prolonged mass mourning, and profound anger – directed principally at Sir Richard. Three months after Charlotte’s death, whilst attending another woman in labour, Sir Richard apparently lost his nerve, left the room, and shot himself. (Grumpy Midwife recently visited Croft Castle in Herefordshire, the family home of Sir Richard. It was a poignant experience.)

Given the pressures of caring for royalty in labour, Grumpy Midwife can understand why four eminent doctors of various specialities felt it necessary to hover anxiously during the labour of the Duchess of Cambridge yesterday. She has a fond image of the men huddled together in a pocky staff room – drinking espresso, checking their phones, adjusting their ties – jumping every time the door opened. Meanwhile, two experienced midwives got on with the job, just as other midwives were doing at that moment  in hospitals and health posts and homes all over the world.

Waking up to gushing headlines this morning, Grumpy Midwife was initially irritated by the absence of midwives from this modern-day nativity. Surely a missed opportunity to spread the word about midwives as lead professionals in low-risk childbirth? A vehicle to celebrate natural childbirth and skilled midwifery care? A chance to redress the negativity of Morecambe Bay and Guernsey?

Then, after a while, GM calmed down and realised that – no – this is how it should be: midwives with women, quietly, reflective, nudging, guiding, supporting, protecting – but ultimately just there as the woman herself, princess or pauper, births her baby. Because it’s her show, not ours.

Chocolates mean nothing

Grumpy Midwife has been extraordinarily busy for the last three months; hence her silence. But she would like to take a few moments to share a recent Damascene conversion experience.

GM is of the generation that attended Sunday School and confirmation classes so she knows all about Saul travelling to Damascus in Syria (in more peaceful times, around 2000 years ago, give or take) and experiencing en route an event that so upset his life that he changed his name and stopped prosecuting Christians and starting preaching. According to an article in New Scientist (April 25, 2015), the bright light and thunderous noise (and temporary blindness) experienced by Saul/Paul may have been caused by a meteorite – which is really interesting but the means need not distract from the outcome.

No meteorites involved in Grumpy Midwife’s conversion – just a couple of conversations with a wise woman and a lightbulb moment so mundane (in retrospect) that it is almost embarrassing to devote calories or kilobytes to the sharing. But here goes.

Midwives must listen to women. And not just listen: midwives must embrace what women are saying. Which actually sounds terribly dated, doesn’t it? As dated as Changing Childbirth (1993) in fact.

As she types this, Grumpy Midwife can sense the protestations: “But we have Family and Friends! We have birth afterthoughts and birth reflections! And MSLCs and PAT and CQC and LWFs! And complaints and debriefs and cards and chocolates! Lots of chocolates!”

Okay, so we are asking (closed questions, tidy tick boxes) but we are only asking because we are told to do so, by Cameron, by the CQC, by our commissioners. And, yes, we do listen, but only to a select group of women – and (again) because we have to, because they have complained or we think they may complain. So we listen – but with arms folded and minds closed, composing our replies, defending our practice, limiting the damage.

Buying anything online nowadays – a book, a pair of knickers, a holiday – invites an onslaught of pop-up surveys, requests for feedback, suggestions to share the experience. Because sellers know that if we don’t like what we buy, or the experience of buying it, we will look elsewhere. Yet when it comes to having a baby (arguably an experience marginally more life-changing than a couple of cinema tickets), consumer engagement is an add-on, begrudgingly and half-heartedly requested, if we have time. Satisfaction and due gratitude are, arrogantly, assumed.

It’s as if the maternity services operate in a 50s time-warp, harking back to a generation of users grateful for the largess of a public health service. Amongst midwives there seems to linger the notion that we all work jolly hard and modern mums are jolly lucky, let me tell you, epidurals blah blah, nappies blah blah, in my day blah blah. Grumpy Midwife is aware that midwives are an ageing workforce but this is ridiculous. Get with it, ladies!

The context for GM’s personal conversion was a gentle debate over the involvement of lay reviewers in the auditing of statutory supervision of midwives. Many midwives (including GM pre-Damascus) are aggrieved by the concept of a lay reviewer listening to a handful of new mothers and then having the audacity to contribute to an official report on that service. Grumpy Midwife would like to charitably assume that this antipathy is reflective of a lack of understanding of the validity of qualitative research sampling techniques but, sadly, having witnessed the response of midwives (often very senior midwives) to proposals to engage with women, she knows this is not the case.

Chatting to new mums in Children’s Centres; setting up a Facebook page to gather opinions; shadowing women and partners through clinics; sitting on beds to listen to birth stories; asking mothers for feedback on their midwives for annual reviews. So simple, so cheap, so normal – but such suggestions are met in too many maternity units with apathy and arguments and (sometimes) downright antagonism.

Of what are we afraid? Releasing an unstoppable genie of ingratitude and discontent? Learning stuff about ourselves and our service we would rather not know? Opening the gate to complexity and change and real-life messiness?

Chocolates, incidentally, don’t mean a thing. Women give midwives chocolates for the same reason we tip mediocre service in restaurants; because we are nice, polite people, who want to be liked. And may make a return visit. Especially if there is nowhere else to go.

Out of Africa

Many years ago, Grumpy Midwife wrote a rather silly article (which somebody actually published) berating UK midwives for worrying about waterbirths whilst women in Africa walked miles for a single bucket of water. (In her defence, GM was probably still in that rather irritating post-third-world-volunteer phase of wearing ethnic jewellery and ostentatiously reading West African in WH Smiths.)

GM now realises that her thinking was rather muddled. Why? Because what UK midwives think and do actually matters to midwives in Africa. (At least it does in English-speaking countries; GM has no experience of Francophone Africa beyond a rather nice lunch in Lomé with a charming Catholic priest in the mid 1980s.)

A quarter of a century ago, Young Grumpy Midwife, recently qualified and a paid-up member of the Association of Radical Midwives, arrived in a remote clinic in Ghana looking forward to supporting lots of lovely active births in clean mud huts with bougainvillea growing around the door. In reality, the women all laboured unsupervised out under the mango trees in the clinic grounds before staggering into the dusty, dimly-lit delivery room in advanced second stage and hauling themselves up onto one of the two narrow beds. Feeble entreaties by YGM for them to maybe squat or stand were met with expressions of disgust and horror from staff and women alike and words probably roughly translatable as “p*** off stupid white woman”.

Earlier this year, Grumpy Midwife returned to Ghana, not to the same clinic but to a small hospital in the north of the country. There she found a row of scrubbed theatre wellies that would shame her own unit, a beautiful old Singer sewing machine for hemming homemade swabs, laminated emergency algorithms on the wall – and a communal labour ward furnished with three tatty but very clean delivery beds complete with poles and stirrups.

Research published this year (1) in the African Journal of Midwifery revealed that 70% of low risk women booked at a Kenyan hospital gave birth to their last baby in the lithotomy position. (Note that the instrumental delivery rate in most of Africa is in single figures.) Half of the midwives interviewed for the study said that lithotomy was their preferred delivery position – because it afforded a good view of the perineum, was safest for the newborn, and more comfortable for themselves. A third felt that it was not appropriate to offer women a choice in the matter.

Oddly, 70% of the women agreed that lithotomy was also their preferred position; a finding less surprising when the study also revealed that women’s main sources of information on birth positions were attendants, previous births, and the experiences of family and friends. In other words, in the absence of Mumsnet, the NCT, and enlightened midwives: a self-perpetuating cycle.

Before we start feeling too smug, Grumpy Midwife needs to point out that, according to a 2013 CQC survey, 56% of women birthing vaginally in her own unit did so lying down, half of these with legs up in stirrups. GM is prepared to bet (in the absence of access to Google at the time of writing) that reasons given by UK midwives will be not dissimilar to those offered by the Kenyan midwives.

And the link between the two? How about 50 years of shared text books (Maggie Myles still rocks in Malawi), eager volunteers, student electives, professional consultancies, well-meant donations of redundant books and equipment (including those delivery beds), UK training for overseas doctors, international obs & gynae conferences, training videos (one particularly awful one in widespread use is voiced by an English doctor and features six masked people clustered around a draped figure with legs in the air pushing out her baby) – all wrapped up nicely in Western aid packages and charity funding? And if evidence is needed of the irritation such largess incites, look no further than a pithy editorial (2) in the AJM warning of “nursing and midwifery colonialism”.

Ever nosey, in the last twelve months, Grumpy Midwife has raised the birth position issue with midwives across the continent (ok, in three countries: Malawi, Kenya, and Ghana) generally over milky coffee and dough balls in breaks in training. She has gathered consensus on three points: First, the 70% lithotomy use quoted above is a gross underestimation. Second, almost all engaged in maternity care remember being told in training to promote maternal choice and upright birthing positions. Third, nobody does because to do so is dirty, impractical, and potentially dangerous for all concerned. In summary – and reported without a hint of irony – use of lithotomy is now “traditional”; to the degree that some TBAs in Malawi are reported to be replicating the position at home births.

The point is that Grumpy Midwife got it wrong when she insinuated that UK midwives should drain the birth pool and donate the water to Oxfam. On the contrary:

It matters that midwives in the UK care about core midwifery skills.
It matters that midwives strive to empower women through genuinely informed choice.
It matters that midwives are committed and enthusiastic and eternally curious about supporting women in active birth – and that our research agenda and publications reflect this passion.
And it matters that midwives make sure obstetricians and finance people and others with influence understand the profession of midwifery and advocate for midwives – and the unique expertise of midwives – at every level.

Because if things don’t change in the next quarter century, Grumpy Midwife will be rather cross.

(1) Mwanza, L (2014) An investigation into the perceptions and preferences of birth positions in a Kenyan referral hospital. African Journal of Midwifery and Women’s Health, 8(2), pp 82-89.

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

Midwives and fear

A few weeks ago, Grumpy Midwife left her cosy office convenient to Costa yet within screaming distance of labour ward and ventured out once more to meet a real-life pregnant woman in her actual home. Her visit this time was at the request of an experienced community midwife who felt she needed the support of a supervisor of midwives to ensure her client understood the risks of the various care requests she was making for her forthcoming home birth,

Although perfectly happy to venture outdoors, Grumpy Midwife cannot help but be aware of a disturbing trend in the communication of risk to women. Not only must women be lectured on each and every risk however tenuous its link with whatever it is they are requesting outside of official guidance, but everybody else needs to know that this information has been imparted, a process requiring evidence and emails and special folders on labour ward.

Grumpy Midwife would not mind if this process (a) removed the necessity for all subsequent carers to reiterate all risks previously cited, and/or (b) led to more intelligent and respectful care, but it doesn’t – because at the heart of this is midwives’ fear of blame rather than women’s wellbeing.

Symptomatic of this fear is the roping in of others – consultant midwives, supervisors of midwives, anybody better paid – to explain or re-explain what any sensible midwife is already perfectly capable of explaining but lacks the confidence to do so, convinced that she will Say The Wrong Thing and be duly splattered when the s*** hits the fan and the unfortunate woman has a tricky second stage CS.

We are not alone in this feeling this fear. A brilliant essay in The BMJ (BMJ 2014; 349:g6123) describes how healthcare professionals are “required to consider an ever greater array of potential risks to the patient’s health, however well that patient might be feeling” and the “joy sapping consequences” of screening processes.

The tragedy for midwives – and for the women for whom we care – is the manner in which this fear is contributing to an erosion of professional confidence just when we need it most to meet the expectations of society. State of the World’s Midwifery 2014 describes midwives as “connective tissue for communities” whilst the Framework for Personalised Care and Population Health emphasises the lasting impact of midwifery care on the life of every mother and child.

A good midwife models and nurtures responsibility and resilience, self-confidence and self-belief. A good midwife helps women do the seemingly impossible in labour and afterwards. Succumbing to the fear of blame, and communicating this fear to women, diminishes us.

So what did the woman visited by Grumpy Midwife want from her carers? Nothing too scary; just assurance of peace and quiet in labour and lack of distraction at crucial moments, which may means that she declines the occasional auscultation of her baby’s heart if the moment is wrong. That’s all. How sad.

Supervision of Midwives: if we didn’t have it, would we invent it?

Grumpy Midwife has been meaning to write about supervision of midwives for a while now; in fact, ever since the Ombudsman’s report rattled teacups and got knickers in a collective knot back in December 2013.

It all dates back to the Midwives Act of 1902, designed to bring all the dirty, illiterate – but oddly effective – village midwives into the fold by making it illegal to practice midwifery without a certificate. And so the Central Midwives Board was born (later to morph into the ENB, the UKCC, and finally the NMC, all four of which – to her horror – GM remembers), and moves were made to standardise training, punish misdemeanours, and generally whip the profession into shape.

A system of supervision was established, administered by county councils and other civic bodies. The first supervisors were called inspectors and most were doctors – which is about as logical as asking vets to supervise dentists and probably contributed to the next 100 years of rivalry and ill-feeling (continued to this day, albeit generally masked by good manners on both sides and the liberal gifting of doughnuts by obstetricians).

The inspectors’ early duties included checking midwives washed their syringes, wore suitable dresses, and kept satisfactory case records. A century later, Grumpy Midwife and her fellow supervisors still rummage through community midwives’ bags looking for dog hairs and out-of-date ergometrine, obsess over uniforms, and are neurotic about record keeping.

Today’s supervisors are experienced midwives, chosen by a ballot of peers, prepared for the role by six months of post-graduate training, appointed not by NHS managers but by a parallel structure of Local Supervising Authorities. The stated purpose of statutory supervision remains much the same as in 1902: to protect women and babies by actively promoting safe standards of midwifery practice. The subtext is regulation of the profession on behalf of the NMC: annual, individual review of practice; checking evidence of professional updating; monitoring of medicines safety; intervention in difficult situations; investigation of errors and incidents; implementation of remedial action.

At best, Grumpy Midwife and her colleagues are respected and inspirational leaders of the profession: chosen for their wisdom, approachability, professionalism, and fair-mindedness; supporting midwives in ever-more complex practice situations, engaging with women in developing a responsive service, enabling exemplary standards of midwifery care.

At worse, supervisors are worn out by their own practice and the extra demands of supervision, mistrusted by midwives, misunderstood by risk managers, out of their depths with the forensic skills demanded by investigations, terrified by the prospect that decisions made and reports written now may be torn to pieces in the future by inquests and professional hearings.

So why do midwives need statutory supervision? And note that we are not talking here about clinical or educational supervision; mentoring,  coaching or buddying; empowering management – but a relationship mandated by law, determined by statute; an extra layer (comfort blanket or barbed wire, depending on your perspective) between modern professionals and their regulating body. What’s so different about midwives?

Yeah, midwives are autonomous practitioners – but so are doctors. Midwives have the potential to harm people in their care – but so do police officers. Midwives deal with difficult clients – but so do social workers. Midwives face increasingly complex clinical situations – but so do ITU nurses. Midwives are burdened with increasing expectations from the public – but so are teachers, heaven help them. Midwives can supply and administer drugs on their own authority – but so can chiropodists. And a handful of midwives work outside the NHS – but so do almost all dentists.

Grumpy Midwife is running out of arguments.

Perhaps it really is time for midwives to interface directly with the regulating body; to take personal responsibility for the nuts and bolts of practice; to be fully exposed to the wrath of managers and the distress of complainants; to develop skills of self-awareness and self-criticism; to find dynamic and demanding mentors; to inspire, nurture, and care for each other.

Perhaps it is time for the profession to grow up.

[Towler, J, Bramall, J (1986) Midwives in History and Society, London: Croom Helem]