Who decides what is right?

Like many, I’ve been dismayed by the on-line report of the RCM’s recent legal birth conference.

And I’ve been so thankful for the very clear-headed response of Birthrights.

As a midwife I regularly work with women who decide that continuous monitoring (CTG) is not the ‘right’ choice for them, despite our guidelines and recommendations that it is advisable for breech-presenting babies in labour. Of course I have the skills and competency to care for them without it, and of course I would strongly recommend they reconsider if the clinical situation were unclear without it. I felt completely deflated that a leading barrister was quoted as saying something which suggested that if I offer women the choice to do what they, rather than the professionals, feel is ‘right,’ I could be putting my registration at risk.

In offering women real choices and standing by them when they make unpopular ones, I might now be accused of promoting an ‘ideology of normality.’ Did those words really come out of the mouth of someone who sits on the NMC panel, at an RCM conference? Someone wake me up.

How could anyone who talks to student midwives today get the idea that they are only exposed to normality? While universities are doing their best to ensure they get some exposure, the students I meet across the UK are usually gagging to see more ‘normal’ births. If they are graduating with no understanding of how to read a CTG, it is definitely not because they haven’t seen them used. It is likely because their mentors are overstretched and have not had the time to mentor them fully during placements. If they cannot cope with a PPH, it is probably because they have been sent running after the ever-increasing paperwork while the PPH’s are happening, rather than being facilitated to gain experience and understanding in the moment.

I originally trained in the US, mostly in out-of-hospital settings, freestanding midwifery led units and home births. Exclusively ‘normal’ settings where almost all women chose physiological third stages. My experience of managing the not infrequent PPH’s in these environments, and having the time to debrief, reflect and consolidate those skills with continuity from my mentors over time, gave me great confidence in my own midwifery fundamentals. My experience of managing shoulder dystocias without an emergency buzzer arm’s reach away did the same.

To speak of an ideology of normality is almost sinister next to the claims that the NHS is not obligated to provide a home birth service, and that women should be told they may not have this choice. The Birthplace in England study demonstrated clearly that home births for low-risk women are significantly more cost effective than births in a consultant unit, for all women they significantly decrease levels of intervention (improving outcomes for women), and for women who have previously had a baby the outcomes for baby are just as good as in hospital.

So why is it that home birth services across England are frequently unreliable or unavailable to women, when at the same time non-evidenced-based, expensive uses of technology or other interventions are being used? For example, routine third trimester scans. They do not improve outcomes, and they increase unnecessary interventions (more cost). Yet they are still being used in some Trusts, requiring resources to schedule, administer, interpret and counsel. There are many other examples, reflecting a pervasive ideology and resource allocation agenda very divergent from what most midwives understand as ‘normality.’

So don’t be surprised if midwives, frustrated by unfair and non-evidence-based resource allocations and increasing cut-backs, start doing weird things like attending home births on days off because they cannot bear to keep letting women down. A friend of mine is fond of quoting Ina May Gaskin in times like this: “People are often punished for doing the right thing.”

Reminder: This is my personal view, and not that of the Trust that I work for (which incidentally is not one of the many Trusts which currently offer routine third trimester scans).

Update: 19/7/13 Turns out the RCM doesn’t endorse the comments made by the speakers they invited to their Legal Birth Conference who were quoted without challenge in the only report published about the conference on the RCM website. Somewhat confusing, but Cathy Warwick clarifies. Good to have the salient points clarified, but when the home birth service is unreliable about 50% of time (as reported in an MSLC meeting) in your local area (not my workplace), it’s hard to share the view that resource shortages which jeopardise the HB service are an ‘extreme situation’ with which women should have patience.

Further clarification: I still love the RCM and I’m still a member, still hanging in there, hoping for better for midwives, midwifery and women.

2 thoughts on “Who decides what is right?

  1. Karen Law

    I too was shocked at the comment that student midwives are only exposed to normality! That is not what I am hearing at all. As a doula I was stunned to realise, when talking to student midwives, that I have supported more physiological births than many of them manage to care for on their 3 years training.
    We need to consider language…. What is normal these days in the hospital settings, at least, is intervention. Physiological births are what women are trying to achieve, is what pockets of midwifery in the UK offer.

    1. midwifeshawn

      Absolutely, Karen. If the quotes are accurate, those who made them are dreadfully out of touch with current realities of maternity services and midwifery training.


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