The Professional Autonomy of Midwives: what is it?
In a recent letter on a different matter Professor Cathy Warwick of the Royal College of Midwives said that the RCM supports the professional autonomy of midwives. In circumstances where the Albany practice has been closed and where independent midwives are being disciplined for interpreting the NICE guidelines as precisely that, guidelines, rather than protocols which must be obeyed, what is this professional autonomy? If the CMACE report on the Albany is read it is clear that their objections are precisely what made the Albany distinct: that the Albany comprised independent midwives who had contracted into the NHS and whose professional norms were not guided by NHS protocols but by their own clinical judgement in conjunction with the woman's expressed wishes.
The CMACE report criticises the Albany for developing relationships with their clients which were too close and describes such relationships as being ones where the clients might have their opinions and wishes influenced by their midwives. It particularly mentions the fact that Albany midwives accompany their clients to consultations with obstetricians as reprehensible.
Independent midwives, and by implication the midwives of the Albany, accompany their clients to consultations with obstetricians or hospital staff because they see their first contractual loyalty to their clients, rather than the institution; they see themselves as advocates for their clients; they will have discussed their clients' wishes with them before the consultation and so they will be expressing what they know are their clients' wishes. Their practice is based on a relationship with clients which is mutually trusting. Because they are guided by the concept of informed consent, they know that information must be given and that it must be given in a way which is unbiased and that their clients will sometimes make choices of which they do not approve, but which nevertheless they will support.
I doubt that the CMACE would ever be critical of pregnant women being guided by their obstetricians' wishes and opinions.
In 2004 the Freud Museum organised a conference at Guy's Hospital looking at childbirth, its importance both socially and individually, and by implication the importance of midwives. In their article publicising the conference Ivan Ward and Kalu Singh wrote "it is shocking to realise that no society or culture has ever regarded the way it treats its mothers-to-be as an index of its moral integrity or enlightened values. It may be that the time is right to bring maternity into the heart of our thinking and political debate and to argue for the unconditional, free provision of social and psychological support for the mother and child, from conception and birth through to infancy and early childhood”.
It seems to me that the people most appropriate to provide this kind of support, at least for the first weeks, are midwives: suitably trained and supported midwives. When I was practising as a community midwife it was the norm for midwives to provide postnatal care intensively for the first ten days and at their discretion up until twenty-eight days. If the suggestion made by these psychoanalysts were to be taken up then maybe midwives should continue their care for the first six weeks. However, since I stopped practising postnatal care has diminished considerably. In some parts of the country a mother at home with her new baby may only get one visit at day seven to take the Guthrie test, and that might be from a maternity care assistant and not from a midwife.
At one point a comment from the floor cited the Albany as an example of best practice and questioned why there weren't more practices like this Given the situation regarding the impending need for all health practitioners to have indemnity insurance the independent midwives' organisation, the IMUK, is working towards independent midwives contracting into the NHS. So one might have anticipated more practices like the Albany developing, if it wasn't for the fact that the Albany has been closed down for the very reasons for which it was lauded at this conference.
So it seems to me unlikely that authorities, PCTs, senior staff and managers in hospitals, let alone the NMC, will recognise any of this professional autonomy and use of clinical judgement as legitimate. If midwives are to have professional autonomy it must be recognised that the medical model of childbirth, while life-saving in certain circumstances, is only one mode of discourse. Another which in many contexts, possibly most contexts, is equally valid is that of the social midwifery model.
I gave birth to both of my sons, who are now 23 and 18, at home with the support of two independent midwives. At the time I gave birth to my first child I was working as a community midwife in the NHS. I think it would be quite interesting to look at my experiences in both of these labours, because both involved my midwives and myself making choices which would probably now be responded to with disapproval if not disciplinary action for the midwives. In writing these accounts my current thoughts and opinions will be expressed in italics.
I became a supporter of home birth on the basis of what my mother, born in 1913, told me when I was a teenager. Her mother had given birth to eleven children, including undiagnosed twins (she was the older of the twins), at home with the support of a lay midwife. Apart from the last, who was stillborn, they were all healthy. When my mother became pregnant at the age of 39 she asked her GP if she could give birth at home. He just laughed. She later told me that she laboured for 72 hours until I was born by caesarean section, a procedure which was undertaken as seldom as possible in 1952. When she told me these stories sixteen or so years later, the distress and revulsion could still be heard in her voice. I often wondered whether, had she remained at home with a midwife she trusted, I might have been born vaginally.
A number of years practising midwifery in the NHS gave me the opportunity to see many cases of unthinking disregard of mothers and babies if not active rudeness and bullying. Institutions often produce staff who are institutionalised, who take routine for granted, and hierarchical institutions can produce staff who are envious and competitive.
When my partner and I began considering having children I knew I wanted to give birth at home and which independent midwife I wanted to attend me. She had trained in the same place as me, the year after me, and I had been impressed by her politics and philosophy and the way that they were enacted in reality. As it happens, when I became pregnant at 34 I had recently been diagnosed with relapsing remitting MS which, at that time, was only affecting me mildly. When I was given the diagnosis I asked the neurologist about having children and he said that I had the reproductive system of a normal, healthy woman of my age. I interpreted this as meaning that a home birth would be entirely in order.
I asked my preferred midwife before I was pregnant whether she and her partner would be willing to take me on and her reply was an instant: of course. When my midwife immediately took me on despite my recent diagnosis she did so after having known me for some years, so she knew my general health was good. However she also took me on the basis of a philosophical assumption that pregnancy is normal unless factors show it to be otherwise. This is in contrast with the common dictum at that time that labour could only be described as normal in retrospect. At no time in my pregnancies did I see a doctor, either a GP or an obstetrician. Had I gone to my GP I imagine that he would have said that a home birth was not a good idea because he disapproved of them in principle, as many people do, or because I was comparatively old, or because of my recent diagnosis of MS (with regard to the last point he might have wished to have consulted a neurologist). If I had then persisted a response which I consider legitimate would have been something like 'I don't agree with your decision, but I will support you in any way I can.' What would not have been legitimate would have been to have been told that I was not allowed a home birth, or that I was putting my life and my baby's life at risk. This last remark I heard many times when I was a midwife.
Throughout my time working as a midwife I had known of cases where women had wanted a home birth (the judgemental term 'insisted' was often used). She would be initially granted one and subsequently somebody would suggest that the woman be told untruthfully that something was amiss in order to coerce her into a hospital birth. One of the reasons I had wanted an independent midwife was because I knew that she would be committed to home births for philosophical reasons and therefore would not lie to me. I knew that if she was to recommend a transfer into hospital it would be for legitimate and serious reasons. I did not know that I could trust NHS midwives in this regard. And this mistrust was not based on unknowing prejudice but on past experience.
The due date for my first child's birth was 25th March 1987. His father's birthday was 6th March and on that day in 1987 I had four hours of regular and painless contractions. I was used to Braxton-Hicks contractions. I had been noticing them since sixteen weeks, especially after passing urine. These were different because of their regularity, both of occurrence and length. On 7th March while watching the news (the cross-channel ferry the Herald of Free Enterprise had just capsized off Zeebrugge harbour) my waters broke. I had been palpitating myself ever since there was something to palpate, and I knew my baby's position was ROP, so I was not surprised by the initial rupture of membranes, but I was surprised by the date. Immediately after my waters had broken I started regular painful contractions every four minutes. We rang the midwives to warn them.
At no time was it suggested that going into labour at thirty seven and a half weeks was abnormal and that I should transfer into hospital. The assumption was that a normal pregnancy lasts between thirty-seven and forty-two weeks. The NICE guidelines on intrapartum care reiterate that this is the normal duration of human pregnancy. (I know of one case recently where a young mother whose baby was less than 38 weeks, but healthy and weighing more than 3 kg, was threatened with social services intervention when she wanted to go home rather than wait for the results of unspecified tests on the baby.)
After about three hours my partner was feeling very nervous and wanted the midwives to be present. I was anticipating many more hours yet. When I knew that my baby had settled into an occipito-posterior position I had prepared myself psychologically for a long and backachy labour. I had done this by reading an account Billie Hunter had written of the birth of her baby which had been in a posterior position; that labour had lasted thirty-six hours and had culminated safely in a home birth. Kieron O Driscoll in his book Active Management of Labour describes how steps are taken to intervene when it becomes evident that cervical dilatation is occurring slower than 1 centimetre per hour. This has come to be taken unthinkingly as a norm; partograms attest to this. O’Driscoll does not describe on what grounds he based this judgement. This is an example of how certain practices become routine without being soundly based on any stated evidence. Another example of this, given that a human pregnancy lasts between 37 and 42 weeks, would be to question why labour is routinely induced at 40 weeks +10 days.
I consider twenty four hours a reasonable length for a first labour and a longer labour when the fetus is posterior to be physiologically normal. And I consider the length of labour to be irrelevant as long as the physical condition of both mother and baby is good, as well as the psychological condition of both mother and midwife. I maintain that what I have written above about basing decisions for intervention on the well-being of the mother and the baby, rather than arbitrary time limits, as the better option to be justified. All interventions have side-effects. A ventouse extraction for example must inevitably bruise the baby, and the healing of this bruise is more likely to predispose to jaundice. A baby with a headache is going to be more fractious, probably leading to greater maternal anxiety, and possibly making the initiation of breastfeeding more problematic. It may well be better to allow the second stage to be longer than intervene operatively.
The midwives did not perform a vaginal examination to diagnose labour; a spontaneous rupture of membranes and a number of hours of regular, painful contractions which were increasing in strength and frequency was considered sufficient evidence to make the diagnosis. At least one independent midwife has been disciplined by the NMC for not performing a vaginal examination to diagnose labour. The fact that this is so is interesting, because the NICE guidelines do not state that vaginal examinations should be carried out routinely, only if they are certain to provide useful information and if the woman does not object.
If independent midwives do not perform a vaginal examination it is not because they are lazy or unskilled. Vaginal examination is literally invasive. When women are in labour they need to be producing oxytocin to cause the contractions, and the secretion of oxytocin can be inhibited by stress hormones. Some women may have had past experiences which cause them to find vaginal examinations traumatic. At best, it means that women need to switch off a part of their psyche to render this procedure clinical rather than sexually intimate. Women in labour without pharmacological pain 'relief' are in a psychological state where they need to be focusing on the moment, on something intensely physical; needing to make intellectual decisions can impede the progress of labour. This psychological state is more akin to being sexually active than anything else. It is because independent midwives recognise the uniqueness of this state and wish to encourage it that they try not to interfere as much as possible. The NICE guidelines seem to support this.
After a number of hours I was feeling end of tetherish, and I requested a VE because I wanted to know how far I had got. The midwife said 'you're fully...' and I thought incredulously 'I can't be, it hasn't been long enough' but she then went on to say 'effaced and one centimetre dilated.' She could see from my face that I was disappointed and went on to say that this was useful information, that it was good progress, and that we could now pace ourselves. It was my first baby, and he was posterior. It would not have been unusual for an NHS midwife to it said something like 'it's going to be a long labour and you are already at the end of your tether. Why don't we transfer in so that you can have an epidural?' If I had then done so I would probably have needed either a forceps delivery, a ventouse extraction or even a caesarean section. To reiterate, all of this involve greater levels of morbidity than normal birth, especially one over an intact perineum.
I did pace myself. I found, to my surprise, that I liked VEs; it seemed as though if there was adequate room for the midwife's fingers there would be enough room for the baby's head. I requested another one some hours later and was told this time that I was fully dilated. His heartbeat was checked approximately every five minutes after a contraction and I could hear that it was fine. It was two hours from that vaginal examination until the baby was finally born. Again, this judgement was based on well-being rather than time limits.
When I went into labour with my second son it was as though I imagined it would be identical to the first. I thought my waters had broken late on the evening of his due date. Throughout that night I did not sleep. After my first son had been taken to my mother's to be looked after, the contractions started coming with more force, and after they had been coming forcefully for five hours my waters most definitely broke. What had happened previously must have been a hindwater rupture. The midwife did not do a vaginal examination to confirm second stage; we both thought that five hours of forceful contractions in a second labour followed by SRM was sufficient to make an assumption. I started pushing and when, after two hours, there was no sign of a baby she did examine me and found an oedematous anterior lip which she pushed over the baby's head. He was born two hours later in good condition; again throughout the heartbeat had been fine.
This assumption on the basis of a spontaneous rupture of membranes was erroneous, but since throughout my condition and the baby's were good it was not a serious error. I do not remember being particularly tired; the whole process was tiring. In hospital an operative procedure would have been the norm, given these timings.
I gave birth to two healthy children. I experienced no physical or psychological trauma; my perineum had been uninjured. Some years later I mentioned this to my social worker who had just become a new father and he said 'you were lucky'. I replied that I had not been lucky, that I had made choices deliberately to obtain good midwifery care.
I consider the decisions made by my midwife and myself were valid, as were the philosophical foundations on which they were based. If midwives are to have professional autonomy then this discourse needs to be represented as legitimate in the creation of protocols and the NICE guidelines, for example. The CMACE report on the Albany needs to be examined critically and its political and ideological nature recognised. The Albany group practice needs to be reinstated, and other similar practices founded, and the IMUK's recommendations about the way in which independent midwives can contract in to the NHS be taken on board. And senior midwives: heads of midwifery and consultant midwives and the Royal College of Midwives need to start demonstrating leadership, rather than allowing their interests to be eclipsed by those of the medical profession.
Risk assessment is not an easily quantifiable exercise. Certain risks can be quantified. It is known that smoking increases the risk of lung cancer, but it is not easy to predict who might develop this. This correlation has been known for many years, but still some people choose to smoke. When it comes to the factors influencing the nature of labour they are too many and various to be easily quantified. My choice to have my babies at home would be seen by many people as a riskier than to give birth in hospital, even though it is nowadays considered suitable for women thought to be at low risk. I did not consider either my age or diagnosis to have increased my risk factors. I knew I was well nourished and habitually walked and cycled more than most people. And had the neurologist not said that my reproductive system was healthy? I knew myself, my dislike of institutions, and that I would feel much safer at home. I had taken the history of my grandmother and the contrasting experience of my mother deeply to heart.
If measures are taken which are intended to reduce risk then it is impossible to know what would have happened had the measures not been taken. In obstetrics many things are done ostensibly to reduce risk which actually create a different set of risks. Artificial rupture of membranes in an attempt to reduce the length of labour (something which also cannot be demonstrated scientifically) frequently makes the experience more painful and the mother is more likely to take refuge in pharmacological pain relief, all of which have negative consequences for the baby's well-being.
There are therefore subjective aspects to risk. I felt happier at home; other women may feel happier in hospital. This sense of security may well influence the nature of labour in the efficiency of the secretion of oxytocin. There are also political and ideological aspects of risk. When 100% hospitalisation of birth was recommended in the 70s it was accompanied by the changes in the NHS which brought district midwives from being independent practitioners employed by the local authority into the NHS sphere of influence. This represented a considerable reduction in the status of community midwives accompanied by a concomitant emphasis on obstetrics. Homebirth was represented as dangerous and primitive. This opinion was not accompanied by statistical evidence, but it was very powerful ideologically.
Even if risks are known and quantified, that does not mean they should not be taken. It is recognised in health and safety circles that there are some risks which, if taken, are socially beneficial. It is debatable whether homebirth is more risky than hospital birth, but even if it were (and it is generally and wrongly assumed to be by the wider general and obstetric culture) it could be argued to be one of those risks worth taking. It could be argued that in my case having a home birth was by far the less risky option.
The NMC gives advice to midwives whose clients might choose free birthing, in other words to give birth without the attention of a health professional. This is not against the law, but it is against the law to practise midwifery or medicine without being registered, so the legal situation could become complicated if the woman chooses to give birth in the presence of other people who may then be deemed to have behaved beyond their competence. The NMC's advice covers the legal situation. It also goes on to remind midwives that they must respect women's choices. I think that this advice is sound and ethnically based.
But I think this advice contrasts very interestingly with the way in which the NMC has disciplined independent midwives who have respected the choices their clients make and in doing so do not meet NICE guidelines or hospitals' protocols. It is almost as if the NMC would rather women gave birth unsupported so that they, the NMC, are absolved of all responsibility than use the services of an independent midwife who, in supporting her client's choices and working as her client’s advocate, is using professional autonomy and moreover doing precisely what the NMC rules and code of conduct say that she should.
The status quo which I have described above favours the unethical over the ethical. To put it in the simplest terms nobody can be treated against their will accept under the various sections of the Mental Health Act and even then only for the mental illness for which they have been sectioned. Theoretically to touch a patient without their consent is assault. To do a vaginal examination without the woman's consent is sexual assault. It could be argued that to try to persuade a woman to have a vaginal examination when she does not want one is unethical. It certainly is not acting as the woman's advocate or respecting her wishes. The NICE guidelines, which are based on the Cochrane Commission, would seem to be considerably more enlightened than the NMC. This is possibly because the interests of midwives are not sufficiently well represented on this body which is dominated by nurses numerically and possibly philosophically.
This was submitted to The Practising Midwife early in 2010. It was initially accepted but then a number of months went by without it being published. In October-November somebody contacted me apologising for the delay. Then Jenny Hall e-mailed me to say that she was relinquishing the editorship and that the new editor thought that it was not suitable for publication because it was too angry.