York Homebirth Midwives: between a rock and a hard place (and women crushed in the middle)

Guest blog by Emma Ashworth

“If you arrive at the home of a woman and she refuses to allow you to access her home or to provide care to her, you must explain that you will need to leave and explain this decision to her. You should inform the woman that you will be happy to return to provide care should she want you to do so. The conversation should be fully documented.”

York Teaching Hospital NHS Foundation Trust: Home Birth Guideline Version No: 9, August 2017 – August 2020. Page 7

This quote from the York homebirth guidelines could lead to catastrophe.

While the senior midwives at York have said that they are reacting to a situation where they were not permitted in the house, the worrying phrase is this, “[the woman] refuses to allow you… to provide care to her”.

Women have been told that if they decline blood pressure monitoring, or intermittent monitoring, or even vaginal exams that their midwife “has been told that she must” leave their house and abandon them without care. Midwives have argued that if the mother doesn’t want to have interventions or tests, why should they even be there? What is their purpose? The knitting midwife expectantly and watchfully waiting in the corner, only intervening when necessary, does not seem to be the type of midwifery that York Trust is aiming for despite the fact that this type of midwifery leads to the best outcomes as is seen by the results of independent midwives.

Women have reported that midwives have coerced them into vaginal exams that they didn’t want with the threat of leaving them to birth alone. They have had to make the decision to allow someone to penetrate their vagina when they didn’t want them to, or to be left without clinical care for themselves or their babies.

In a discussion with one of the senior midwives at York Trust, I was assured that the threats that women were experiencing were not the intention of the policy, and that recently midwives had stayed with women despite the women declining certain interventions. I was also assured that the midwife that I spoke to would take my feedback to the community and home birth midwives to ensure that there was clarity in the guideline. She also confirmed that the guideline was in the process of review, so perhaps the very clearly written text in the current guideline saying that women in their own home are not permitted to refuse to have someone’s fingers inside them if they want a midwife to stay will be removed. However, despite my attempts to follow up this with the Trust, to date (7th August) I have not received a response to my initial or follow up requests.

In the meantime, Birthrights and AIMS have worked together on this issue, leading to an information sheet for women and midwives who might find themselves in this situation.

There are some really key points here that the Trust and its midwives need to consider about these guidelines. Midwives are under an obligation to act within the law, and coercing women into interventions is illegal. While the Trust may argue that there is no point in the midwife being there if the woman doesn’t want to have some clinical checks, we need to remember that women can decline any or all interventions at any time – and that a midwife’s role is far more than vaginal exams and listening in to a baby’s heartbeat. There is huge value in her being there, offering her support and knowledge and if necessary being able to intervene clinically. The Trust’s argument that there’s no point in the midwife being there belies the fact that skilled midwifery is in stepping in when needed, not about taking blood pressure. We need to remember that many of these interventions are not necessarily helpful, and can be harmful in some situations (and can also be very useful in others).

The AIMS information sheets on vaginal exams discusses some of the pros and cons of routine vaginal exams. Their sheet on monitoring in labour explains some of the risks and benefits of intermittent and continuous monitoring. If a woman wants to decline auscultation now, she can accept it for her next contraction, or decline it again. If a midwife forces her into a check on the threat of abandoning her, the stress of that on the woman may itself severely impact on her labour, and could cause damage to her or her baby, and the midwife is legally responsible for this. A midwife who undertakes an intrusive examination after obtaining consent through coercion needs to know that she is committing an assault on that woman, and that she could be criminally charged. Part 1.5 of the Nursing and Midwifery Code states that midwives must “Respect and uphold people’s human rights.” And 2.5 says, “respect, support and document a person’s right to accept or refuse care and treatment” 17.1 of the Code states that midwives must, “take all reasonable steps to protect people who are vulnerable or at risk from harm, neglect or abuse.” And yet, this guideline is instructing midwives that they must either neglect a woman, who while she is in labour she is by definition vulnerable (by leaving), or abuse them (by committing assault).  At the same time, if the midwife refuses to follow the guideline and stays with a woman who declines some or all interventions or checks during her labour, she is at risk of being disciplined by the Trust. And if she leaves, she and the Trust are likely to be liable for any adverse outcomes to mum or baby!

If women find themselves in the situation where they are being coerced in their own home, I would advise that they remind the midwife of her obligations under the NMC code and the law. Showing the midwife the Birthrights document could be enough to encourage the midwife to break out of the intolerable situation that she’s been forced into by this unfair and unreasonable Trust document. Know that what is being asked of you in your labour is not reasonable, it is not normal practice and it is not something you need to say yes to.

Midwives – rise up! You are autonomous practitioners and you cannot accept the risks to your own safety and practice that this guideline traps you in. You need to escape because no matter which way you choose you are exposing yourself to risk. Be part of the fight to change this guideline! Stay with women and request support from senior midwives (who have assured me that they will give it).  Don’t let this happen to you and to the women you’re caring for!

 

 

Post PSA report – is the NMC Fit to Practice?

 

Guest blog by Emma Ashworth

The Professional Standards Agency (PSA) is the organisation whose role it is to oversee the regulators, such as the NMC. In May 2018 the PSA released a report into the NMC’s handling of the deaths of women and babies at Morecambe Bay’s Furness General Hospital.

Background
Between 2004 and 2016, in Morecambe Bay, Lancashire, UK, there were deaths of a woman and 11 babies during birth and the early postnatal period, where families were left with concerns over whether the level of care given by staff at the Trust was acceptable. Some of these families worked very hard over the subsequent years to try to establish what truly happened to their loved ones, and eventually an investigation was instigated by the Secretary of State for Health, and was run by Bill Kirkup, CBE. The full Kirkup report can be read here: Click for Kirkup Report Link

Media mis-representing of “normal birth at any cost”
There is no doubt that the Kirkup report is hard reading. Much of the media picked up on various terms and phrases were repeated ad nauseam (and continue to be portrayed, erroneously, as actual findings from the report) such as “normal birth at any cost”. This refers to a quote from the report by Lindsey Biggs, a midwife later struck off by the NMC over cases which were looked at in the Kirkup report, where she is reported to have said, “there were a group of midwives who thought that normal childbirth was the… be all and end all… at any cost… yeah, it does sound awful, but I think it’s true – you have a normal delivery at any cost”. 

Systemic problems at the Trust
The majority of the media and other discussions following the Kirkup report were focused on blaming the midwives for their actions. There is no doubt that there were midwives whose practice was severely impaired and in some cases was found to be contributory to the deaths of babies and women (1), but the problems at the Trust were systemic, all the way through from midwives to doctors to management. Kirkup states, “we were dismayed to hear the extent to which obstetricians, midwives and paediatricians had allowed the breakdown of personal and interdisciplinary relationships to jeopardise care.” (2) and he reports on, “suboptimal care in which different management would reasonably have been expected to make a difference to the outcome.” (3). Furthermore, Kirkup’s report states, “[the 2010 report] contained significant criticisms of the Trust’s maternity care, including dysfunctional relationships, poor environment and a poor approach to clinical governance and effectiveness. The report was given very limited circulation within the Trust, and was not shared with the NW SHA until October 2010, or with the CQC and Monitor until April 2011. Although we heard different accounts, and it was clear that there was limited managerial capacity to deal with a demanding agenda, including the FT application, we found on the balance of probability that there was an element of conscious suppression of the report both internally and externally.” (4) There is no doubt that some midwives in Morecambe Bay were found to have failings serious enough to mean that they were no longer permitted to practice midwifery, however the media almost entirely missed the fact that vast swathes of the Trust were also responsible for what happened, including what appears to be a deliberate cover-up according to Kirkup.

Due to the fact that the problems found by Kirkup were caused by both clinical staff of various disciplines and management staff, there was no single body which was able to do a level of investigation into the problems as a whole, nor a single organisation that the parents could complaint to and obtain an investigation into their cases. The midwives were referred to the NMC, but the NMC’s processes were so flawed that by the time it got to the end of the fitness to practice investigations, at least one of the midwives had retired, and was no longer on the register (5). Other failing parts of the Trust were not covered by the NMC’s investigation as their remit only covers midwives, leaving the parents in limbo between multiple organisations.

Professional Standards Agency Report
In May 2018, the PSA published its investigation into the NMC’s handling of the cases of the midwives of Morecambe Bay. The report was nothing short of catastrophic, showing that the NMC failed to protect the public – its stated aim – and also to appropriately support midwives, putting them through hellish and absolutely unnecessary delays during fitness to practice proceedings.

Not only were the NMC’s processes catastrophically flawed, the way that they responded to the grieving parents was horrific. Again, not only did the NMC fail to protect the public from midwives who were eventually found to be “not fit to practice” but they failed to protect them from the abuse that they received from the NMC itself.

One family’s experiences outlined within the PSA report (Mr and Mrs A) explain how initially the NMC decided that there was no case to answer against the midwives, including one or more who were eventually struck of the register. This happened because the family’s statement appears to have been disregarded in the face of contrasting evidence from the midwives themselves, the local investigations and the Trust’s own statements. Any discrepancies between these accounts were not addressed (6). The father continued to press for answers and over a year later, the NMC discussed the issues, referred the case to the CQC and decided to await the police report which was now underway (7). The father continued to send evidence of what he considered to be collusion between the midwives involved, some of which was dismissed by the NMC, and the rest appears to have been forgotten until yet another three years had passed, when the cases were finally looked at again – by which time one of the midwives had retired from practice anyway (8).

Two years MORE passed, and eventually two of the midwives came in front of a fitness to practice (FtP) panel. Over seven years had now passed since the death of Mr and Mrs A’s baby boy. Seven years for the parents to continue to fight and for the midwives to have the case hanging over their heads. Yet at this hearing, much of the parents’ evidence was not even put before the panel. During the hearing, Mr A specifically gave the NMC the missing evidence but they still refused to admit it, stating that it would not be likely to affect the outcome (9). If this wasn’t enough for the parents to endure, Mr A was informed that he must refer to his dead son as “baby A” during the hearing – which he quite rightly refused to do.

Following the hearings, Mr A continued to raise concerns with the NMC about its actions, or lack of them. He decided to make a Subject Access Request (SAR) under the Data Protection Act, and received, in the documents package, copies of papers which included discussions within the NMC about him which were offensive in nature (10), and pages of redactions which included one page with the entirety of the text covered up other than Mr A’s own name (11).

Mr A is quoted as saying that he, “…felt hopeless and that they were just following a process for the sake of following it. It felt like nobody really cared about what they were doing. Nobody understood that there might be mothers and babies at risk and it was like an administrative process that nobody really cared about.” (11)

This is not the NMC protecting the public.

The report goes on to discuss the cases of six further catastrophic incidents at Morecambe Bay, and how the NMC failed to protect the public.

We hoped that we were on the cusp of change, with a new CEO being put into place after the last one, Jackie Smith, resigned the day before the PSA report was published!  Yet the new Chair of the NMC, Philip Graf, apparently dismissed the findings of the PSA report out of hand by saying, upon its publication, that “public safety was not put at risk” (12) by delays by the NMC in dealing with complaints against the Trust. Graf U-turned on this position a few days later when he admitted:

“Multiple opportunities to take action were missed, we didn’t investigate concerns and when we did, we took too long. We are very sorry for this.
Due to our failures to act and the resulting delays in our investigations and hearings, some midwives continued to practise who may not have been safe to do so and mothers and babies may have been at risk of harm during this period.”

Does this mean that the NMC are starting to reflect on their failings?

The recent resignation of Midwife Helen Shallow as Midwifery Education and Policy Advisor to the NMC (her 11 page resignation letter was discussed in the Nursing Times (13)) following her appalling experiences within the organisation, midwives and birthing women alike are not holding their breath that they will be able to expect proper regulation and protection anytime soon. When Dr Shallow states that she felt registrants were seen virtually as “the enemy” by the NMC, and that midwives are “somehow inherently not to be trusted or a potential adversary who must be kept in check at all times” we should be very concerned indeed that the NMC really is Not Fit to Practice.

References:

  1. Kirkup report, page 12
  2. Kirkup report, page 13
  3. Kirkup report, page 9
  4. https://www.professionalstandards.org.uk/docs/default-source/publications/nmc-lessons-learned-review-may-2018.pdf?sfvrsn=ff177220_0 Para 3.27
  5. PSA report, page 15
  6. PSA report, page 16
  7. PSA report, page 16
  8. PSA report, page 18
  9. PSA report, page 57
  10. PSA report, page 61
  11. PSA report, page 25
  12. https://www.channel4.com/news/parents-says-regulator-has-not-learned-lessons-after-baby-deaths
  13. https://www.nursingtimes.net/news/professional-regulation/exclusive-expert-midwife-attacks-nmc-in-explosive-resignation-letter/7024875.article

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