I’ve been hearing a lot over the last few weeks about the Kirkup report into maternity care at Morecambe Bay, where there were several tragedies. The subsequent media attention focused on the blame laid at the feet of a group of midwives. There have been accusations made that the promotion of physiological birth directly caused deaths and doctors have written letters to newspapers saying that midwives don’t call them in.
I don’t know all the ins-and-outs. I haven’t read the full Kirkup report and don’t plan to. I am not a commissioner, a manager, a midwife or an obstetrician. In many ways, I am an outsider in the maternity care system. A layperson who reports to no one (though I do of course have the Doula UK Code of Conduct to abide by!), is held to no targets and works with clients alongside midwives, obstetricians, health visitors – anyone who helps care for my clients and their baby. When working with clients, and personally, I have experienced excellent care from midwives, registrars and consultants, and also suboptimal care from all three.
I wonder if this means I have a different view of this situation? I am not on the defensive. I do not feel that I am being attacked. But I see maternity care in practice.
Two things have been emphasised in the coverage and discussion around the Kirkup report (despite the report stating that all levels of staff failed in their duty of care): the promotion of “normal” physiological birth over safety and the refusal or reluctance of midwives to call doctors into help care for women as a team.
Two things that don’t seem to have been a big part of the discussion, but that seem to me to be critical, are: NHS targets and financial constraints; and the training of doctors.
As I understand it, the need to meet targets because of the Trust applying for Foundation status, was a factor in what happened at mid-Staffs and also Morecambe. If targets are being put ahead of safe, compassionate care, then this is wrong. Is it the fault of the midwives caring for women? I don’t think so. They are just the ones who have the most time with the women and babies in maternity care. You could argue that they have a responsibility to the women and babies in their care, so perhaps they should stand up to pressure from management to prioritise targets. But when the reality is that midwives are concerned that they could lose their jobs or have their career restricted AND are often just surviving in a system of 12 hour shifts perhaps without supportive management, I understand why so many midwives might just go along with what management tells them.
This idea that midwives are reluctant to refer women to doctors when there are clinical concerns is not something I have ever seen and the same was said by other, more experienced, doulas I have discussed this point with. I have however worked with clients in hospitals where the midwives and doctors are NOT working well together as a team. This has never been the fault of the midwives, but of the doctors’ training. Unbelievable as it may seem, doctors working in maternity care are not likely to have had training in women’s legal rights in birth, compassionate care, the effect of language or environment on the hormones of birth or physiological birth. In my experience, the effect of this is seen most in junior doctors, such as registrars. Some are utterly marvellous, but that is down to them, their personality, any additional reading or learning they might have done and the characteristics of their mentors, NOT what they all get taught as part of their training.
In my experience, doctors, especially the more junior ones, are more likely to come out with phrases such as “you are not allowed” (of course she is! A doctor does NOT get to make decisions for his patients in maternity), “you must”, “you are not progressing fast enough” (to women who are doing beautifully, but are not dilating in a linear way, as many women don’t!) or “we don’t do that” (when a woman has made a perfectly informed choice, as is her right, to do something or ask for something that may not be usual or within guideline recommendations). They are more likely to come into a birthing space and turn on bright lights, not use compassionate language and not be prepared to make their own jobs harder to make a woman’s birth experience more positive.
All of which can have a direct, negative impact on the progress of labour and the birthing experience of a woman and her partner. Language and support, or lack of, are common factors in birth trauma for new mothers and fathers. The research around birth trauma is that it is not really the mode of birth that predicts whether someone will develop birth trauma (or postnatal PTSD) but how supported they felt. I have read quotes from 19th century doctors textbooks on the importance of being quiet and respectful when entering the birthing space and keeping the birthing woman in a positive state of mind, to avoid stalling the labour. Unfortunately such advice seems to have gone out of fashion in medical training.
Some midwives do do all of this too, but less often.
If a were a midwife caring for a woman, who perhaps really wanted to avoid a surgical birth, was doing all she could to stay mobile in labour and wanted to avoid vaginal examinations, would my happiness to ask a registrar for an opinion be affected by whether I knew that doctor would come into the room, turn on the lights, tell the woman she had to get on the bed on her back for a vaginal examination and use negative language in discussing options (“you’re only Xcm. If you don’t progress, we will have to intervene” – who hasn’t heard this?!)?
Perhaps. I hope it would never affect safety. But. Perhaps.
Until doctors all get training in physiological birth, compassionate care and birthrights before working in maternity, there will be barriers to midwives and doctors working in harmonious teamwork, no matter how good the management is. And this has nothing to do with midwives “being territorial” and all about wanting the best outcomes in terms of physical and mental health for mothers and babies.
I don’t know what happened at Morecambe and how all of the factors played together. I do know that in many areas of NHS maternity care, a culture change is needed. Teamwork. Compassionate care. Respect for birthrights. Working to have as many families as possible have positive birth experiences, whatever the outcomes.
And what would that mean? Safer care.
I would love to hear your thoughts.