- Email: [email protected]
Is childbirth in the UK really mother centred?
ARTICLE IN PRESS
International Journal of Nursing Studies 45 (2008) 809–811 www.elsevier.com/locate/ijnurstu
Guest Editorial
Is childbirth in the UK really mother centred? Keywords: Midwifery; Maternal risk; Inter-professional relations
The editorials written in the IJNS March 2007 regarding the potential divorce between nurses and midwives (Norman and Griffiths, 2007; Thompson et al., 2007; Thompson, 2007) and commentaries on these by midwives internationally (Thompson, 2007; Cameron and Taylor, 2007) reflects only the tip of a huge iceberg. The professional positioning of nurses, midwives and doctors within the British National Health Service (NHS) has been written in stone for far too long. The whole area of the ill-health of the nation, and how to deal with it, has changed markedly in the last 60 years. When the NHS first started in 1948, the major type of care being offered was of the nursing sort, with the doctors offering, to a greater or lesser extent, trial and error therapies. At this time, many of the needy came from hopelessly inappropriate home conditions, and to get them into an institutional hospital itself was a major advance. This approach to need has now been replaced, to a great extent, by multidisciplinary teams offering high tech investigations, cutting edge treatments, both medical and surgical, allied with appropriate follow up and counselling. So it is quite right that each profession should re address its role, its purpose, its associates, indeed, its very existence. The traditional lines between nursing, midwifery, and certain aspects of medicine are, quite correctly, being questioned and re drawn, or being removed altogether. As an obstetrician, when I had first heard of Direct Entry Midwifery I was horrified, but not now that I have met and worked with the final product. They are great— mostly!!. Maybe they won’t cope with every problem, but in my own discipline of maternity care, I also feel we still need a mixture of different caring professions including midwives, obstetricians, nurses, paediatricians, anaesthetists and anaesthetic nurses, all working together where and when needed. The problem in the UK, for me, is that the obstetricians and midwives seem to be involved in a
0020-7489/$ - see front matter r 2008 Published by Elsevier Ltd. doi:10.1016/S0020-7489(08)00107-7
rather unsavoury turf war, with the mother and the fetus potentially the victims. Interestingly this ‘‘war’’ is not so much in the labour wards up and down the country, but rather at the political and administrative levels. We have now completely fooled ourselves, our charges, our politicians, and anyone else who wants to listen, into believing that the skills we offer pregnant women are ‘‘mother centred’’. Nothing is further from the truth. The care of pregnant women in the UK is ‘‘profession centred’’, though it should, and could be, ‘‘mother centred’’. We have cleverly developed the badge of high and low ‘‘RISK’’ to divide the spoils up between midwives and obstetricians. Interestingly, not one other country in the developed world has followed suit!! Oh! And by the way, we have one of the highest caesarean section rates in the world by far! Until the 17th century, childbirth remained firmly in the domestic arena. The first Lying In Hospitals were established in the 18th century, following an explosion of scientific knowledge in anatomy and physiology. Learning was, at that stage, the domain of men. Concerned with the levels of maternal mortality, this led to a move in the 19th century towards supervised birth. Normalizing the role of the midwives came into play with the 1902 Midwives Act. The founding of the NHS consolidated the shift to hospital birth, and it is intriguing that in 1948 the women of Britain marched on Downing Street, to demand the right to have their first baby in a hospital! Now, 60 years later, we hear demands that mothers be encouraged to have their babies in geographically independent maternity units, or indeed at home, and this without any major design feature changes in women in the intervening years! The surge in scientific knowledge and its allied industries in the 20th century, led to the introduction of technology to childbirth. Much of the early technology in the 1960s seemed to give the impression of
ARTICLE IN PRESS 810
Guest Editorial / International Journal of Nursing Studies 45 (2008) 809–811
controlling childbirth. The women and strong feminist response emerged in the 1980s and 90s, and ‘‘Changing Childbirth’’, the 1993 report of the Expert Maternity Group, was the UK Department of Health’s acknowledgement of the need to change a system in the light of new evidence and a new generation of women and health professionals. We were moving away from the paternalistic phase, to what many see as the maternalistic phase. Change, yes, but not that different for the mother. Some social theorists believe that both doctors and midwives are responsible for the medicalisation of childbirth. After all, following the introduction of the UK 1902 Midwives Act, the Central Midwives Board was made up of doctors who were responsible for the education of midwives! However, concerns are still expressed about who is in control of childbirth. It would appear that the concern is not what is available, but who controls it, and to the ultimate benefit of whom? Since Changing Childbirth, there have been changes to the physical environment; more home-like rooms, birthing pools, and so on, but this has not produced a major change in the type of care offered. The introduction of more ranges of choices in terms of environment and types of midwifery care, with limited resources, is a weak response to a huge amount of effort by many very well intentioned personnel. The solutions offered were not radical enough and so Changing Childbirth has failed to make a substantial impact. New Midwifery is seen to provide an alternative position to the Obstetric model. It predominantly focuses on normality in pregnancy, labour and childbirth, and this has become its response to the increase in technology and what it sees as the medicalisation of childbirth. However, I would argue that this shift has led to professional focused care, and has been detrimental to both the autonomy and the health of women. Women who are identified in early pregnancy as high risk are filtered into a care pathway that becomes obstetric dominated, and the role of the midwife is often, sadly, lost. Such women are potentially vulnerable physically, psychologically, and socially, and could benefit to a greater extent from many of the professional strengths that midwives bring to maternity care. So, dividing women into normal, and abnormal, means that many do not receive these benefits. Dichotomizing risk produces an absolute position that the term, risk, defines. Yet women may have a number of social, psychological or medical risk factors which influence the progress of their pregnancy, and ultimately the outcome of the pregnancy. The factors may be present at the beginning or develop at any stage throughout the pregnancy and childbirth. In reality, the pregnancy experience is a dynamic one that requires a flexible response from all concerned. While classifying mothers into groups may appear easier to manage, (and therefore appeals particularly to
managers!!) such a false dichotomy leaves women vulnerable to risk in one extreme or the other. The maternal apparent low risk category also often includes high risk fetuses that are not detected. And the apparent high risk mothers, who often are carrying low risk fetuses, suffer over interference. The system only works to some degree when the low risk mother is carrying a low risk fetus, and the high risk mother is carrying a high risk fetus. Low risk status may also give women an unrealistic expectation of their outcome. Women today do not expect to have a poor pregnancy outcome. When this does happen, they, and their families are, quite correctly, devastated. Similarly, identifying a mother as being at high risk carries a high psychological burden for the mother, and can be linked to increasing anxiety and all that brings. The reality is that those who are identified in early pregnancy as low risk, can still have unexpected complications that affect both the mother and her baby. It is not until after the birth, or perhaps when the child is attending a normal school and has completed P1 successfully, that we can determine that a pregnancy was indeed normal. Sir Liam Donaldson, the present Chief Medical Officer of England & Wales, recently commented, that in the year of his birth, 1 in 1000 normal British citizens died having a general anaesthetic. He then remarked that the number now was so low, that it was unrecordable. Having been an obstetrician for over 30 years, I feel that it is time that we had the same approach to apparently low risk pregnancy. Yet, I write this article at a time when both midwives and obstetricians are comfortable with a UK perinatal mortality rate of eight per 1000, which includes five so called unexplained stillbirths (3000 annually in UK) mostly associated with anatomically and chromosomally normal babies with undetected IUFGR (intra uterine fetal growth restriction). A small number some may say, but the majority of which are still preventable. The majority of these singleton pregnancies were classified as low risk antenatally. So whose fault is it? Should those who care for pregnant women be responsible, and if so, can they up their game? Who are ‘‘they’’? Should ‘‘they’’ be doctors or should ‘‘they’’ be midwives? Or both? The problem starts at that first antenatal visit. Classifying mothers at the beginning of pregnancy, to categories of high risk or low risk is the trigger. This system is favoured by midwives, general practitioners, politicians and apparently, many obstetricians, alike. Two apparently clear cut categories allowing midwives to care for ‘‘normal low risk pregnancy’’ while their obstetrician colleagues see the ‘‘abnormal high risk’’ ones. The problem is that there is a tendency for midwives to encourage their mothers to be normal, and
ARTICLE IN PRESS Guest Editorial / International Journal of Nursing Studies 45 (2008) 809–811
there is a tendency for obstetricians to over-interfere when they become involved. In general terms, I believe obstetricians medicalise too much in what is, in retrospect, normal, and midwives probably under-interfere in what is found later to have been an abnormal situation. Thus, many potentially salvageable diagnoses, such as IUFGR, are left undetected till too late. In the western, developed, resourced world, good health is increasingly becoming the major desire, and indeed demand, of every nation. As each family in the UK has a fewer numbers of babies, the desire to have a consistently successful outcome has, rightly so, increased. Dealing with uncertainty is difficult for health professionals and women alike. However, we have to deal with what we know, and in terms of the fetus, that is still relatively little. Intervening in the face of uncertainty may help us to feel in control, but it is not necessarily best for mother and baby. For example, the large number of inductions of labour that are carried out throughout the UK for a pregnancy that has reached 10 days past a date calculated from when a women last menstruated is using a sledgehammer to crack a nut, albeit an important one. It is a spectacular waste of resources, when we could and should be focusing on trying to determine the few pregnancies that do indeed require our timely and appropriate intervention for impending fetal compromise, and leave the extremely large number of perfectly healthy pregnancies to a carefully observed mother nature. Likewise there is a need for expert midwifery care in pregnancies with complications, and more explanation provided for these mothers on the role of midwives. There is also a need for expert medical care in apparently normal pregnancies, in order that normality can indeed be confirmed, and ‘‘abnormality’’ detected. To address the dichotomization which currently exists, in the first instance, we need a complete reorganization and rationalization of education of those involved, both midwives and obstetricians, whose responsibility is the care of child bearing women. With the present trend towards the modularization of educational material and curricula, there should be combined modules of learning for medical students, student midwives, midwives, and obstetricians in Specialist Training. Inter-disciplinary working should not be something that just happens at the end process with qualified personnel doing drills together, but indeed should be occurring throughout the learning process of anatomy, physiology and the approach to normality and disease. In the UK we should move away from risk assessment at the beginning of pregnancy as it perpetuates the profession focused model. Rather, we should treat all women equally with a team approach, which will improve the skills of the midwife, with regards to abnormality, and the obstetrician with regards to normality. Both midwives and obstetricians need, to a
811
great extent, to abandon professional positioning. We need to focus on the goal of a successful outcome for the mother, her offspring, and her family, while we train and work together caring for all women, at all time, in all situations. Finally, all the above applies to the developed world. We need to remember that only one third of our world is developed, and when writing in an international journal we must remember that over 60% of women in the world delivery without a trained birth attendant at their side. If we are going to address this problem we have to stop using our developed world models in a developing world scenario. We need to encourage the development of a completely new health professional to help mothers and babies in their time of need. This person should be chosen primarily because of their apparent vocational strengths, and should not require the same high stringent academic entry criteria that are needed by midwives and obstetricians in this country. This health professional would be a multi-skilled person rather than be part of a multi-skilled team. They would have the appropriate skills of the obstetrician, midwife, anaesthetist, paediatrician, pharmacist and haematologist, which would allow them to cope with the vast majority of the problems of childbirth and neonatal care. But then that would be another editorial altogether!
Conflict of interest At the time of writing, the author was Senior Vice President/International Officer of the UK Royal College of Obstetricians and Gynaecologists. The views expressed are personal and not necessarily those of the College.
References Cameron, J., Taylor, J., 2007. Nursing and midwifery: reevaluating the relationship. International Journal of Nursing Studies 44 (5), 855–856. Norman, I., Griffiths, P., 2007. ‘y And midwifery’: time for a parting of the ways or a closer union with nursing?. International Journal of Nursing Studies 44 (4), 521–522. Thompson, J.E. (Ed.), 2007. Response to Thompson D, Watson R, Stewart S (2007) Guest Editorial: Nursing and midwifery: time for an amicable divorce?, International Journal of Nursing Studies 44 (4), 651–652. Thompson, R.T., Watson, R., Stewart, S., 2007. Nursing and midwifery: time for an amicable divorce?. International Journal of Nursing Studies 44 (4), 523–524.
Jim C. Dornan Queens University, Belfast, UK E-mail address: [email protected]
International Journal of Nursing Studies 45 (2008) 809–811 www.elsevier.com/locate/ijnurstu
Guest Editorial
Is childbirth in the UK really mother centred? Keywords: Midwifery; Maternal risk; Inter-professional relations
The editorials written in the IJNS March 2007 regarding the potential divorce between nurses and midwives (Norman and Griffiths, 2007; Thompson et al., 2007; Thompson, 2007) and commentaries on these by midwives internationally (Thompson, 2007; Cameron and Taylor, 2007) reflects only the tip of a huge iceberg. The professional positioning of nurses, midwives and doctors within the British National Health Service (NHS) has been written in stone for far too long. The whole area of the ill-health of the nation, and how to deal with it, has changed markedly in the last 60 years. When the NHS first started in 1948, the major type of care being offered was of the nursing sort, with the doctors offering, to a greater or lesser extent, trial and error therapies. At this time, many of the needy came from hopelessly inappropriate home conditions, and to get them into an institutional hospital itself was a major advance. This approach to need has now been replaced, to a great extent, by multidisciplinary teams offering high tech investigations, cutting edge treatments, both medical and surgical, allied with appropriate follow up and counselling. So it is quite right that each profession should re address its role, its purpose, its associates, indeed, its very existence. The traditional lines between nursing, midwifery, and certain aspects of medicine are, quite correctly, being questioned and re drawn, or being removed altogether. As an obstetrician, when I had first heard of Direct Entry Midwifery I was horrified, but not now that I have met and worked with the final product. They are great— mostly!!. Maybe they won’t cope with every problem, but in my own discipline of maternity care, I also feel we still need a mixture of different caring professions including midwives, obstetricians, nurses, paediatricians, anaesthetists and anaesthetic nurses, all working together where and when needed. The problem in the UK, for me, is that the obstetricians and midwives seem to be involved in a
0020-7489/$ - see front matter r 2008 Published by Elsevier Ltd. doi:10.1016/S0020-7489(08)00107-7
rather unsavoury turf war, with the mother and the fetus potentially the victims. Interestingly this ‘‘war’’ is not so much in the labour wards up and down the country, but rather at the political and administrative levels. We have now completely fooled ourselves, our charges, our politicians, and anyone else who wants to listen, into believing that the skills we offer pregnant women are ‘‘mother centred’’. Nothing is further from the truth. The care of pregnant women in the UK is ‘‘profession centred’’, though it should, and could be, ‘‘mother centred’’. We have cleverly developed the badge of high and low ‘‘RISK’’ to divide the spoils up between midwives and obstetricians. Interestingly, not one other country in the developed world has followed suit!! Oh! And by the way, we have one of the highest caesarean section rates in the world by far! Until the 17th century, childbirth remained firmly in the domestic arena. The first Lying In Hospitals were established in the 18th century, following an explosion of scientific knowledge in anatomy and physiology. Learning was, at that stage, the domain of men. Concerned with the levels of maternal mortality, this led to a move in the 19th century towards supervised birth. Normalizing the role of the midwives came into play with the 1902 Midwives Act. The founding of the NHS consolidated the shift to hospital birth, and it is intriguing that in 1948 the women of Britain marched on Downing Street, to demand the right to have their first baby in a hospital! Now, 60 years later, we hear demands that mothers be encouraged to have their babies in geographically independent maternity units, or indeed at home, and this without any major design feature changes in women in the intervening years! The surge in scientific knowledge and its allied industries in the 20th century, led to the introduction of technology to childbirth. Much of the early technology in the 1960s seemed to give the impression of
ARTICLE IN PRESS 810
Guest Editorial / International Journal of Nursing Studies 45 (2008) 809–811
controlling childbirth. The women and strong feminist response emerged in the 1980s and 90s, and ‘‘Changing Childbirth’’, the 1993 report of the Expert Maternity Group, was the UK Department of Health’s acknowledgement of the need to change a system in the light of new evidence and a new generation of women and health professionals. We were moving away from the paternalistic phase, to what many see as the maternalistic phase. Change, yes, but not that different for the mother. Some social theorists believe that both doctors and midwives are responsible for the medicalisation of childbirth. After all, following the introduction of the UK 1902 Midwives Act, the Central Midwives Board was made up of doctors who were responsible for the education of midwives! However, concerns are still expressed about who is in control of childbirth. It would appear that the concern is not what is available, but who controls it, and to the ultimate benefit of whom? Since Changing Childbirth, there have been changes to the physical environment; more home-like rooms, birthing pools, and so on, but this has not produced a major change in the type of care offered. The introduction of more ranges of choices in terms of environment and types of midwifery care, with limited resources, is a weak response to a huge amount of effort by many very well intentioned personnel. The solutions offered were not radical enough and so Changing Childbirth has failed to make a substantial impact. New Midwifery is seen to provide an alternative position to the Obstetric model. It predominantly focuses on normality in pregnancy, labour and childbirth, and this has become its response to the increase in technology and what it sees as the medicalisation of childbirth. However, I would argue that this shift has led to professional focused care, and has been detrimental to both the autonomy and the health of women. Women who are identified in early pregnancy as high risk are filtered into a care pathway that becomes obstetric dominated, and the role of the midwife is often, sadly, lost. Such women are potentially vulnerable physically, psychologically, and socially, and could benefit to a greater extent from many of the professional strengths that midwives bring to maternity care. So, dividing women into normal, and abnormal, means that many do not receive these benefits. Dichotomizing risk produces an absolute position that the term, risk, defines. Yet women may have a number of social, psychological or medical risk factors which influence the progress of their pregnancy, and ultimately the outcome of the pregnancy. The factors may be present at the beginning or develop at any stage throughout the pregnancy and childbirth. In reality, the pregnancy experience is a dynamic one that requires a flexible response from all concerned. While classifying mothers into groups may appear easier to manage, (and therefore appeals particularly to
managers!!) such a false dichotomy leaves women vulnerable to risk in one extreme or the other. The maternal apparent low risk category also often includes high risk fetuses that are not detected. And the apparent high risk mothers, who often are carrying low risk fetuses, suffer over interference. The system only works to some degree when the low risk mother is carrying a low risk fetus, and the high risk mother is carrying a high risk fetus. Low risk status may also give women an unrealistic expectation of their outcome. Women today do not expect to have a poor pregnancy outcome. When this does happen, they, and their families are, quite correctly, devastated. Similarly, identifying a mother as being at high risk carries a high psychological burden for the mother, and can be linked to increasing anxiety and all that brings. The reality is that those who are identified in early pregnancy as low risk, can still have unexpected complications that affect both the mother and her baby. It is not until after the birth, or perhaps when the child is attending a normal school and has completed P1 successfully, that we can determine that a pregnancy was indeed normal. Sir Liam Donaldson, the present Chief Medical Officer of England & Wales, recently commented, that in the year of his birth, 1 in 1000 normal British citizens died having a general anaesthetic. He then remarked that the number now was so low, that it was unrecordable. Having been an obstetrician for over 30 years, I feel that it is time that we had the same approach to apparently low risk pregnancy. Yet, I write this article at a time when both midwives and obstetricians are comfortable with a UK perinatal mortality rate of eight per 1000, which includes five so called unexplained stillbirths (3000 annually in UK) mostly associated with anatomically and chromosomally normal babies with undetected IUFGR (intra uterine fetal growth restriction). A small number some may say, but the majority of which are still preventable. The majority of these singleton pregnancies were classified as low risk antenatally. So whose fault is it? Should those who care for pregnant women be responsible, and if so, can they up their game? Who are ‘‘they’’? Should ‘‘they’’ be doctors or should ‘‘they’’ be midwives? Or both? The problem starts at that first antenatal visit. Classifying mothers at the beginning of pregnancy, to categories of high risk or low risk is the trigger. This system is favoured by midwives, general practitioners, politicians and apparently, many obstetricians, alike. Two apparently clear cut categories allowing midwives to care for ‘‘normal low risk pregnancy’’ while their obstetrician colleagues see the ‘‘abnormal high risk’’ ones. The problem is that there is a tendency for midwives to encourage their mothers to be normal, and
ARTICLE IN PRESS Guest Editorial / International Journal of Nursing Studies 45 (2008) 809–811
there is a tendency for obstetricians to over-interfere when they become involved. In general terms, I believe obstetricians medicalise too much in what is, in retrospect, normal, and midwives probably under-interfere in what is found later to have been an abnormal situation. Thus, many potentially salvageable diagnoses, such as IUFGR, are left undetected till too late. In the western, developed, resourced world, good health is increasingly becoming the major desire, and indeed demand, of every nation. As each family in the UK has a fewer numbers of babies, the desire to have a consistently successful outcome has, rightly so, increased. Dealing with uncertainty is difficult for health professionals and women alike. However, we have to deal with what we know, and in terms of the fetus, that is still relatively little. Intervening in the face of uncertainty may help us to feel in control, but it is not necessarily best for mother and baby. For example, the large number of inductions of labour that are carried out throughout the UK for a pregnancy that has reached 10 days past a date calculated from when a women last menstruated is using a sledgehammer to crack a nut, albeit an important one. It is a spectacular waste of resources, when we could and should be focusing on trying to determine the few pregnancies that do indeed require our timely and appropriate intervention for impending fetal compromise, and leave the extremely large number of perfectly healthy pregnancies to a carefully observed mother nature. Likewise there is a need for expert midwifery care in pregnancies with complications, and more explanation provided for these mothers on the role of midwives. There is also a need for expert medical care in apparently normal pregnancies, in order that normality can indeed be confirmed, and ‘‘abnormality’’ detected. To address the dichotomization which currently exists, in the first instance, we need a complete reorganization and rationalization of education of those involved, both midwives and obstetricians, whose responsibility is the care of child bearing women. With the present trend towards the modularization of educational material and curricula, there should be combined modules of learning for medical students, student midwives, midwives, and obstetricians in Specialist Training. Inter-disciplinary working should not be something that just happens at the end process with qualified personnel doing drills together, but indeed should be occurring throughout the learning process of anatomy, physiology and the approach to normality and disease. In the UK we should move away from risk assessment at the beginning of pregnancy as it perpetuates the profession focused model. Rather, we should treat all women equally with a team approach, which will improve the skills of the midwife, with regards to abnormality, and the obstetrician with regards to normality. Both midwives and obstetricians need, to a
811
great extent, to abandon professional positioning. We need to focus on the goal of a successful outcome for the mother, her offspring, and her family, while we train and work together caring for all women, at all time, in all situations. Finally, all the above applies to the developed world. We need to remember that only one third of our world is developed, and when writing in an international journal we must remember that over 60% of women in the world delivery without a trained birth attendant at their side. If we are going to address this problem we have to stop using our developed world models in a developing world scenario. We need to encourage the development of a completely new health professional to help mothers and babies in their time of need. This person should be chosen primarily because of their apparent vocational strengths, and should not require the same high stringent academic entry criteria that are needed by midwives and obstetricians in this country. This health professional would be a multi-skilled person rather than be part of a multi-skilled team. They would have the appropriate skills of the obstetrician, midwife, anaesthetist, paediatrician, pharmacist and haematologist, which would allow them to cope with the vast majority of the problems of childbirth and neonatal care. But then that would be another editorial altogether!
Conflict of interest At the time of writing, the author was Senior Vice President/International Officer of the UK Royal College of Obstetricians and Gynaecologists. The views expressed are personal and not necessarily those of the College.
References Cameron, J., Taylor, J., 2007. Nursing and midwifery: reevaluating the relationship. International Journal of Nursing Studies 44 (5), 855–856. Norman, I., Griffiths, P., 2007. ‘y And midwifery’: time for a parting of the ways or a closer union with nursing?. International Journal of Nursing Studies 44 (4), 521–522. Thompson, J.E. (Ed.), 2007. Response to Thompson D, Watson R, Stewart S (2007) Guest Editorial: Nursing and midwifery: time for an amicable divorce?, International Journal of Nursing Studies 44 (4), 651–652. Thompson, R.T., Watson, R., Stewart, S., 2007. Nursing and midwifery: time for an amicable divorce?. International Journal of Nursing Studies 44 (4), 523–524.
Jim C. Dornan Queens University, Belfast, UK E-mail address: [email protected]