Standardisation of Care: a contradiction in terms

“There have always been usual and routine ways of doing things in midwifery, derived from how things were taught, local practises or the individual midwife’s experience of what worked well. Routines are needed but used to be accepted as tempered by midwives’ efforts to meet the needs of individual women and to work in very different domestic situations. The differences between obstetricians (“Mr X likes his ladies to have Y”) highlighted different ways of doing things and made varied approaches an everyday part of clinical practice. It was only with the imposition of a business model upon the health service that efforts really began to standardise care. The centralisation of care into large units on the economic grounds of efficiency also served to standardise and control services. Those who work on a conveyor belt must work to the same rhythm.”

Note from Sara: the first time I featured a guest post by Professor Emerita of Midwifery Mavis Kirkham, it became the most popular post on the site for days! So I am delighted to be sharing another of Mavis’ articles, again illustrated by one of Becky Reed’s beautiful photographs. This article has also been published in Midwifery Matters and, with thanks to the Association of Radical Midwives, we are delighted to be sharing it here as well in the hope of it reaching as large an audience as possible. Back to Mavis…

Standardisation separates midwives’ work into a series of defined tasks and this creates the assumption that when all the tasks are competed the work is done.

Nurturing and monitoring

It seems to me that there are two parts to the modern midwife’s role: nurturing and monitoring. The monitoring aspect of the role is easier to measure and control but hasn’t really been evaluated. Midwives’ work in monitoring mothers and babies has been standardised, which helps managers to monitor midwives for maximum efficiency. Monitoring has grown and resources have shrunk, leaving little time, or management interest in the nurturing aspect of the role, which is much harder to measure and control.

Research shows the excellent outcomes of nurturing carried out through emotion work, relationships and skilled communication, especially where relationships can develop with continuity of carer. The subtlety of this important work makes it difficult to measure or to define in terms of specific tasks. It requires that midwives are trusted to do midwifery, which does not fit well within the controlling business ethos of the NHS. Thus real care is neglected or becomes the work of the doula.

Prioritising defined tasks to be carried out in particular situations limits our opportunities to learn from our clinical experience. It does not develop the attention and curiosity which encourages midwives to say “Have you noticed how …?” and which thereby opens up new possibilities for research and practice. Standardised practice does not allow for preventative care and the power of midwifery care grounded in relationships to prevent complications in pregnancy. It thus denies the essence and the potential of midwifery.

Evidence based?

The movement for evidence based practice undoubtable sought to improved care and managed to remove some damaging practices. The pioneers of evidence based medicine saw research evidence as fundamental but tempered by other factors (Sackett et al 1997). With strong managerial pressure towards standardisation, evidence based guidelines have rapidly fossilised into rules and at best deviance from them has to be carefully justified.

Few guideline are based on the “gold standard” randomised controlled trials (RCT) (Prusova et al 2014) and RCTs can only be used to examine straightforward alternative courses of action. “They are less suitable, and often seriously misleading, for complex problems, where the outcomes depend more on the web of interactions between the care, the individuals concerned, and the context in which they occur” (Enkin et al 2006). I think that effective midwifery care is largely of this degree of complexity.

In the absence of research on many aspects of care, a hierarchy of evidence was established, the wide base of which rests on the opinions of established expert clinicians. So evidence based guidelines are firmly grounded in the status quo, sometime despite actual research evidence to the contrary as demonstrated by the still widespread practice of continuous fetal heart monitoring (Sartwelle et al 2017) and rising rates of caesarean section.

Research cannot tell us exactly what to do in the care of any individual. Research produces generalisations which can inform us and occasionally show what not to do, but cannot address exactly one woman’s circumstances. Midwifery is more complex that standardisation allows for.

Time is money

In modern centralised maternity units midwives have to fit with the standards of the institution which employs them. These standards involve moving women smoothly through the services and not blocking beds and now there are fewer beds and greater economic pressure these standards control midwives’ behaviour.

Antenatally and postnatally women are seen less frequently by midwives than they were years ago. This has been shown not to increase the likelihood of some clinical complications. However it neither helps women to know their midwife nor eases the anxiety of a woman with particular reason to feel apprehensive. Rules can be bent to help women and they frequently are but staffing is worked out on standardised practice so where a midwife thinks more care is needed she is likely to make more work for herself.

Helen Shallow’s recent research (Shallow 2018) has clearly demonstrated how midwives are the gatekeepers of the labour ward and have to keep out women in early labour, telling them that research shows they are better off at home. Yet no research covers the impact of a particular woman’s fear on the rest of her labour.

The standardisation of care makes the rationing of midwifery time become normal and routine. Yet we know from the work of independent midwives and from studies of continuity of care that time invested antenatally in getting to know a woman and allaying fears really bears fruit later when she is well prepared for labour and early motherhood.

Think of a number then set it in stone

Sometimes guidelines are based upon an aspect of research which was used for comparative purposes and not designed to become a detailed requirement of practice. This is clear in the frequency with which midwives are required to auscultate the fetal heart (FH), which is derived from research comparing continuous electronic monitoring of the FH with intermittent auscultation. I know of no research comparing different frequencies of auscultation or even whether auscultation is worth doing at all.

Ruth Martis (2013) wrote a very perceptive article on her dilemmas in this regard in a particular case where she did not wish to “disturb the serenity” of a woman who was coping beautifully with her labour. Mindful of her professional obligations to monitor the well-being of mother and baby and the guidelines from NICE and other national bodies, she asked herself “Could it be that listening to the baby’s heartbeat is actually an intervention which could potentially be harmful in normal labour?” She followed the woman’s cues and stopped auscultating. After the birth the mother described the initial intermittent monitoring as “being ripped away from my peaceful place”. This midwife thought through her situation and I think she did the right thing, she certainly did what the mother wanted. Other midwives have been criticised and disciplined for just that.

Timing around cord clamping is another area in which very different numbers have been turned effectively into rules in different places and many questions remain unanswered (Barnes 2013).

Could it be that guidelines stop us thinking through situations? Sometimes I think that efforts are being made to make a guideline, or policy or procedure for every situation. But humans are complex and effort to standardise practice by creating a rule for every situation denies people’s differences and their different needs. There is a danger that too many rules either make us fearful or turn us into something resembling robots.

Containing or creating anxiety?

I have heard it said that standardisation of practice serves to contain the anxiety of clinicians. Yet fear and anxiety amongst midwives, and I suspect obstetricians, has increased greatly at the same time as increasing standardisation.

Where policies, procedures and guidelines are strictly enforced, as is increasingly the case, midwifes are anxious in case they fail to observe the growing number of “rules”. Lack of staff, alongside the proliferation of “rules” means that midwives may have to take some shortcuts to get through the work. Highlighting where “rules” were not kept enables management to blame individuals rather than contest their lack of resources. Blame and fear of blame then escalate.

Standardisation aims to cover all eventualities even though this is not possible. This greatly limits the extent to which midwives can exercise their clinical judgement and without that exercise midwives can become rigid in their practice and fearful of the uncertainly which is inherent in birth and in life (Mander et al 2018). This fear is tragic. It can exacerbate the bullying and other ‘toxic behaviours’ (Hughes 2017) which are so prevalent in NHS maternity services and it directly opposes the motivation to help which brought midwives into their profession.

Anxiety and fear are contagious and midwives’ anxiety rapidly transmits to women in their care with a negative impact on the fine hormonal balance which optimises pregnancy, labour and breastfeeding. It also scars student midwives.

Contradictory language

Where care is standardised, midwives are required to speak a language which contradicts the reality of their actions. Care is about responding to the needs of another and needs vary as do people. Yet what midwives do is called midwifery care and midwives continue to describe it thus even when looking after so many women that all they are doing is recording clinical observations (Shallow 2018). Indeed, the whole conveyor belt is called maternity care. The use of such contradictory language can prevent us from reflecting upon the reality of our situation. This is demonstrated by the way in which “doing the obs” has long been seen as the visible essence of what midwives do and the actions to which students aspire so they can pass as midwives (Davies and Atkinson 1991) or fall back on in challenging circumstances (Rountree 2016).

At the policy level this contradiction is even more apparent. The use of phrases such as “woman centred care” seem to have increased just when care has become more standardised and therefore less responsive to individuals. Rhetoric and reality move further and further apart.

These contradictions also influence clinical records. For instance, it is surprisingly common for vaginal examinations to record a cervix as not quite fully dilated in settings where the length of second stage is limited. In many written ways midwives endeavour to create leeway for women within a standardised service. Thus different truths are recorded within what appear to be standardised records, in situations where midwives feel they can only do good by stealth. Such distortion in clinical records can be seen as one way in which midwives resolve the “moral conflict between a drive for obedience and their role as advocate” (Hollins Martin 2007)

Recent developments

Midwives who really stand up for the women in their care are usually perceived as difficult by managers. Such stroppy midwives are dedicated to their work and until recently they tended to be seen as willing workhorses. Thus midwives who championed home births were allocated community jobs where homebirths were requested by women and the home birth rate rose in such areas. In Sheffield, one such midwife, Ann Garner, did just that and educated a whole generation of GPs and student midwives about the potential for home birth (Aspinall et al 1997). I have often seen services organised in such a way that stroppy midwives are allocated to women who insist on care different from that normally offered, thus preventing complaints and making the service look responsive.

In recent years, I think the response of managers to stroppy midwives has changed, probably because midwifery managers are themselves under pressure from general management. Deviance cannot be tolerated and tall poppies are scythed. This fear of difference, even in the form of excellence, was clearly demonstrated in the closure of the Albany Practice in London (Kirkham 2010). I know wonderful community midwives who listen to women who are now forced to work in hospital where management can keep an eye on them. Midwives who excelled in specialised posts find these posts disappearing because of cuts; they join the disillusioned general workforce and their special skills are largely lost. This is not true everywhere and I know a few stroppy managers, but they are very few and their lives are hard.

The impact of standardisation

This emphasis on numbers and on standardisation is bad for mothers and for midwives. Growing numbers of women choose to reject the monitoring of midwives and freebirth, often with the support of a doula. Others stay in the NHS but see midwives there as “checking not listening” (Kirkham et al 2002).

NHS midwives feel increasingly worn out and alienated in what can be the most satisfying work and therefore they leave. Midwives leave because they cannot give the care they wish to give (Ball et al 2002, RCM 2016) or they keep their heads down and calculate when they can retire. Some leave midwifery to work as doulas.

Standardisation facilitates the fragmentation of care and means midwives can be moved to plug the gaps in any part of the maternity care system. This helps a failing system but distresses midwives (Ball et al 2002) and prevents them from developing relationships with clients and colleagues. But midwifery is about relationships (hence the name). Denying women the benefits of a developing relationship with a known midwife flies in the face of all the research evidence. Relationships with clients and colleagues also sustain midwives (Fenwick et al 2018, Kirkham et al 2006) and student midwives (Rountree 2016).

As midwives we need to stretch ourselves, to give good responsive care which creates satisfaction in all concerned. We need to think, not just follow rules. Routines are needed but they also need to be questioned. Gentle, non-confrontational questioning can achieve much and is a skill student midwives certainly need. Skills in questioning, listening, supporting and creating safe space for women can only be learned in practice and with good role models. They can only be practiced with sufficient staff. Standardised care has gone a long way to take the care out of midwifery, for mothers and for midwives. I see this as a tragedy.

References

Aspinall K, Nelson B, Patterson T and Sims A (1997) An Extraordinary Ordinary Woman: the story of Ann Garner a Sheffield midwife. Sheffield, Ann’s Trust Fund.

Ball L, Curtis P and Kirkham M (2002) Why Do Midwives Leave? London, Royal College of Midwives.

Barnes A (2013) The minute that changes the world. Essentially MIDIRS 4;5, 17-22

Davies RM and Atkinson P (1991) Students of midwifery: ‘doing the obs’ and other coping strategies. Midwifery 7, 113-121

Enkin, MW et al (2006) “Beyond Evidence: the Complexity of Maternity Care”, Birth; 33:4, 265-269

Fenwick J, Sidebottom M, Gamble J and Creedy DK (2018) The emotional and professional wellbeing of Australian midwives: a comparison between those providing continuity of midwifery care and those not providing continuity. Women and Birth 31;1, 38-43

Hollins Martin C (2007) A Difficult Choice. AIMS Journal 19;2, 9-11.

Hughes D (2017) Midwives – still eating their young. Midwifery Matters 153:13

Kirkham M, Stapleton H, Thomas G and Curtis P (2002) ‘Checking not listening: how midwives cope.’ British Journal of Midwifery 10; 7, 447-450

Kirkham M, Morgan RM and Davies C (2006) Why Midwives Stay London, Department of Health and University of Sheffield.

Kirkham M (2010) In fear of difference, in fear of excellence. The Practicing Midwife 13,1; 13-15.

Mander R and the Birth Project Group (2018) The BPG Survey: fear. In Edwards N, Mander R and Murphy-Lawless J eds Untangling the Maternity Crisis London, Routledge

Martis R (2013) Intermittent auscultation – ‘ripped away from my peaceful place’. Essentially MIDIRS 4;5 p46-49

Prusova K, Tyler A, Churcher L and Lokugamage AU (2014) Royal College of Obstetricians and Gynaecologists Guidelines: how evidence-based are they? Journal of Obstetrics and Gynaecology

Rountree TC (2016) Student Midwives’ Experiences of Clinical Placements in Secondary and Tertiary Hospitals unpublished Master of Health Science thesis, Auckland University of Technology.

Royal College of Midwives (2016) Why Midwives Leave – Revisited. London, RCM.

Sackett DL, Richardson WS, Rosenberg W and Haynes RB (1997) Evidence-based Medicine London, Churchill Livingstone

Sartwelle T P, Johnstone JC, and Arda B (2017) A half century of electronic fetal heart monitoring and bioethics: actions speak louder than words. Maternal Health, Neonatology and Perinatology 3;21

Shallow H (2018) When midwives become other. In Edwards N, Mander R and Murphy-Lawless J eds Untangling the Maternity Crisis London, Routledge