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!

 

 

ARM Study Day 2018: Conference Review by Ruth Weston

The 2018 ARM study day in Wigan was described by Dr Lesley Choucri as “Midwifery Nourishment” and I couldn’t agree with her more. This was a wonderful day of learning, sharing and refilling our cups ready to go back to our own regions “Stronger Together”.

“Stronger Together” was one of Kathryn Gutteridge’s themes, which came out of her desire to remind us all that we need to stand together during these challenging times. She pointed out that all midwives are midwives, whether they work for the NHS, private companies or as independent midwives. For the good of the profession – and every midwife – we MUST support each other. There is so much horrific bullying, and areas of practice which are lacking in compassion. Can each person make a change by reflecting on their own practice?

Of course, Better Births was an essential part of the ARM study day, and Claire Mathews , deputy Head of Midwifery for NHS England, outlined its implementation with a focus on Continuity of Carer. Because this was a midwifery audience, Claire focused on the understandable worries that some midwives have of how continuity will work for them, especially as some midwives have experience of continuity services where they were given entirely unreasonable caseloads. With a short-term target of around 20% of women to have continuity, Claire recommended that initially trusts worked on encouraging those midwives who were interested in offering continuity to jump in and have a go, lighting the way for others to follow.

I was particularly struck by Jo Dagustun’s talk on her research into women’s experiences of birth which was an uncomfortable listen for the audience of midwives. Jo explained her PhD research which included women’s experiences of  the maternity system.

The key messages I heard in this excellent, many-layered reflection were:

  • That for women the key antenatal teacher/education was their experience of the maternity system itself.  What women are told in antenatal classes and by professionals about what they can choose, the care they can ask for or receive is over written by actual experience.
  • That women’s experiences of the maternity system, including birth, is of a ‘hostile’ environment; spaces and interactions that do not feel friendly towards the health and wellbeing of mother and baby. Women therefore made decisions on what they saw as the best way of protecting the physical and mental well-being of themselves and their child. Far from this resulting in choices for midwifery led care it often resulted in women choosing a medical birth. It also resulted in women providing partial information or telling professionals what they think is expected rather than the truth.
  • Finally, the women interviewed did not see midwives as a distinct profession with in maternity. Indeed they were not clear what midwives are. Processed through a fragmentary system and seeing multiple professionals, midwives did not stand out. In this context women did not want continuity so much as kindness from the professionals they were with.

This final point provoked a lot of reflection. It is shockingly sad that kindness is not standard in the maternity system. It is also disturbing to realise that midwifery does not stand out to most women in the maternity system. Is this how far the profession has faded? Just another health care professional doing their job? It also has some real consequences for continuity, for instance, who would want continuity from a midwife who did not show kindness?

Finally, Jo, with admirable tact and honesty, presented an example of an interaction between a service user and professionals on social media. What came through to me were professionals who thought they were being kind and helpful but from the service user’s perspective were not. Also, she showed health professionals who wanted the service user to see it from their point of view but did not themselves ‘stand in the shoes of the woman’ – surely a mark of the with-woman profession of midwifery. We need to reflect on how much the maternity system has broken the midwifery tradition of being with-woman and made the midwife a just another health care professional.

In better news, a big shout out needs to happen to Airedale Hospital Trust who have been a shining light on the issue of Independent Midwives and their ability to offer intrapartum care, as Airedale is providing them with indemnity to ensure that they can continue to practice. In return the Trust has these amazing and skilled midwives sharing their experience and knowledge, leading to improved services to women and happier staff. Airedale join several other Trusts across the country who are supporting Independent Midwives in a similar way, as is outlined in the recent IMUK blog.

Aquabirths Hi-Lo Keeling Birth ChairMargaret Jowitt’s Hi-Lo system was on display alongside the Aquabirths stand (see photos to the left for two ways that the Hi-Lo can be used). Also known as the Osborne Kneeling Chair, this wonderful piece of kit is a must for every obstetric room. It is a simple, strong and easily cleaned frame with cushioned supports which women can kneel, lean or sit on. The Hi-Lo is designed to ensure that midwives can easily access women for observations, and the small footprint means that it will fit into most obstetric rooms with ease. A video explaining how the Hi-Lo works is hereSoftbirths Mini birth couch

Aquabirths also had their Softbirths mini birthing couch on display which midwives Deborah Hughes and Deborah Neiger had fun modelling as you can see!  A smaller version of the full birth couch, the mini couch fits into smaller spaces to provide comfort and support to women in different upright birthing positions.

ARM Coordinator, Katherine Hales, rounded off the day with an update on ARM’s campaign for an independent midwifery regulator. The NMC is not fit for purpose as has been discussed on this blog multiple times. ARM now believes that it is essential that midwifery is separated from nursing, and has regulation which focuses on the needs of midwives, which the NMC simply does not do. The focus now is on the midwifery code and midwifery panel being managed by midwives under the umbrella regulation of the Health and Care Professionals Council which oversee many other similar sized groups, such as physiotherapists. This regulator seems to work better to support the professionals it oversees than the NMC does.

All in all, an exceptional day – many thanks to ARM for all their hard work!

#WiganARM18