Newsletter number 7
May 2023
Informed Choice
Is Informed Choice too dangerous?
I have been reading “Closure”. It is the account of the destruction of the Albany Midwifery Practice in Peckham by the Chief Executive/ the Obstetricians/ the Neonatologists and most sadly of all, the Director of Midwifery at Kings College Hospital. I say I have been reading, I have actually been consumed by this dramatic and powerful book. So sad, so tragic, so unbearable that our future as a Profession should have been cut down and ended by blind and stupid people suggesting, completely untruthfully, that the Practice was unsafe – when according to all measures, all figures, its outcomes were exemplary and in fact much better than any other within the hospital.
It had me remembering all sorts of insights that I had forgotten. When I ran the Birth Centre, (it was just called “The Birth Centre” because there were no others then). A small Birth Centre in a small house rented from St George’s hospital, with women getting to know their midwife. Every six months we went over to the main hospital and delivered a presentation of our figures for the previous six months. At first we had a very supportive Professor of Obstetrics. When he retired, we carried on presenting our figures, but now they were criticised – Too perfect. Impossible. Why were we not suturing women? There couldn’t really be that many intact perinea. Where were our third and fourth degree tears? Where were our PPHs? I ended up getting an obliging Obstetrician from another hospital to come and trawl through our notes and registers in order for him to verify our figures. With his support, our figures were believed but there was great scepticism.
The thing that has stuck out for me about this account of women being cared for by midwives that they knew and were able to form a trusting relationship with, was the issue of “informed consent”.
When you go and consult a lawyer, he/she/they explain the different courses you can take and what might be the consequence of choosing each option. They then leave you to decide which option you are going to take. They are an uninterested bystander, they have no role in the actual decision.
Unfortunately, within medicine and especially maternity, there is no concept of “informed consent”. It is “ My suggestion would be induction at 38 weeks”, or “My advice would be to have a planned caesarean”, often with a bit of quasi scientific “research” thrown in to add weight to the “advice”. Often a bit of shroud waving included. This is not informed consent.
The poor midwives in the Albany Team had people sitting in on their Consultations, their Birth talks, their Classes making sure that the “advice” they were giving followed hospital guidelines. The women were getting too bolshie, too confident in their own decisions. They were assertive.
When I was working at St George’s I looked after a couple who gave birth to a baby with unexpected Downs syndrome. Within minutes of the birth the hospital rumour machine had ramped up. Everyone in the maternity department knew that the poor couple had given birth to a baby with Downs syndrome because Caroline Flint had persuaded them to refuse all scans. I was fascinated to think that people could be so naïve as to think that firstly, anyone could influence people that strongly, as if people are mindless and don’t have their own opinions. And also, why on earth would I try and dissuade anyone from having a scan?
It reminded me of the women in the “Know Your Midwife Scheme” 1983-1985. They were ordinary, working class women from Tooting, but they also became bolshie. They might refuse to have a medical student in their labour, or they might decide against advice and make up their own mind, it was extraordinarily refreshing to see the effect that being listened to and forming a relationship with their midwife had. Women became assertive, powerful, decisive. They became strong.
And this, I suggest is the core of the problem. Doctors and Midwives generally like compliant women, who are grateful for the care they receive – however mediocre. When women become strong, feisty, even argumentative, midwives and Obstetricians find it threatening. It may be the sense of threatening huge numbers. If you are herding sheep through a sheep dip, you need them all to comply, shut up, and go where they are supposed to go. Any bolshie buggers who don’t want to go through the sheep dip are just a nuisance and you don’t have time to give them special treatment, give them a good whack and they’ll soon submit. Pregnant women are treated much the same, this way to the sheep dip!
So my suggestion is that continuity of midwifery care doesn’t only reduce preterm births, or the need for pain relief, or reduce instrumental deliveries and caesareans, or increase breastfeeding rates, it also does something very powerful. By listening to, and respecting women because they have become your friends – you have a relationship with them, women become more powerful, more assertive, and more likely to make their own decisions -whether the decisions include hospital policy or not.
Is this what caused the Albany to be destroyed? The women were too bolshie? Too much trouble?
Is this the root of the reluctance to roll out continuity of carer? Keep women down. Keep women submissive. Don’t rock the boat. We white middle class men (and women) don’t want to have to face a generation of bolshie, demanding women. Send them to the sheep dip.
“Closure” by Rebecca Reed & Nadine Edwards published by Pinter & Martin
