You've Been Framed!

Last week I was inspired to read the 'Regional Framework for midwives and obstetricians who support women requesting care outside of guidance in Northern Ireland' published by the Public Health Agency in April of this year. I had seen bits of the framework when it was still out for consultation but I hadn't yet sat down to read it in full.

The reason I finally read it is that one of my former colleagues was expressing her hopes that the implementation of the framework might make a difference to women's experiences when it came to declining aspects of routine maternity care in labour. Hopefully it would mean that there was an agreed plan of care documented by a senior midwife and therefore the midwife tending to the woman in labour would not have to bring the woman out of labourland in order to discuss the 'risk' of declining the care.

In my opinion we didn't really need yet another document for the purpose of this but it is published now and I know it has been eagerly anticipated by those midwives hoping to truly support women in their choices. 

In theory the framework looks promising (though it is also problematic and I'll explain why).

If a woman makes it known that the type of care she is requesting will fall out of guideline, then the framework suggests that the woman should be referred for further discussion. As a first step in the pathway 'All women who are referred for discussion and decision making regarding their choices will be seen by a Consultant Midwife or Lead midwife and their named obstetrician where applicable.' During the appointment a full history will be taken where the team would seek to understand the woman's 'rationale' for requesting care out of guideline. 'Complexities' that might bring women out of guidance could be breech or twin births at home or one of many other scenarios that represent a 'risk factor' for out of hospital birth or a woman simply declining interventions in the hospital. 

The maternity team will then explain the rationale for the guidelines that they base their recommendations on to the parents. The woman will go home to consider her options and she will then have a follow up appointment with the consultant midwife where her decision to either go with routine care or to implement an out of guidance care plan will be discussed. This discussion with the consultant midwife will be documented and then the consultant midwife will inform the Head of Midwifery and the multidisciplinary team of the outcome of the discussion. A 'Personalised Care and Support Plan (PCSP) will be finalised and everyone who needs to be aware will be informed of the woman's preferences. 

The document acknowledges that there may be training needs for midwives in order to support births that fall out of guidance. For instance the community midwives may need to have an update on how to support a breech birth at home. It also points out that the parents need to be made aware that certain aspects of their plan may fall outside of the midwives' competencies and comfort zone. 

There are plenty of flow charts (policy makers love nothing more!).

There's a clear pathway for midwives around discussing 'risk' with women. There's guidance outlining the consultant midwife's role and step by step involvement and there's a template for a 'guided conversation' that aids in documenting the discussions with the parents.

The document also offers midwives some data in order to discuss out of guideline care in relation to various scenarios. There is information about VBAC (vaginal birth after caesarean) in a setting other than the medical labour ward; declining IV antibiotics when Group B Strep positive; birth in a 'low risk setting' with a previous 3rd or 4th degree tear, postpartum haemorrhage or shoulder dystocia and out of guideline care for women who have been diagnosed with gestational diabetes.

There's reference to the BRAIN acronym as a guide to effective decision making. The BRAIN acronym is cross-referenced to NHS Lothian rather than to Dr Sara Wickham who to the best of my knowledge is the person who brought this decision making tool into the birth world in her book 'What's right for me' first published in 2003. The cynic in me wonders if the authors don't want midwives, doctors and families to be familiar with Dr Wickham's body of work. Dr Sara Wickham has written in an unbiased and non-judgemental way about topics like Group B Strep, Anti-D, Induction of Labour, Plus Size Pregnancy and Vitamin K for the Newborn. There is no doubt in my mind that women request out of guideline care as a result of reading Dr Wickham's books. Her work exposes weaknesses in our policies and guidelines and it encourages families to do what is right for them (Did you know that only 9-12% of RCOG guidelines are based on high quality evidence?). 

I've linked the article below!

To me this 'Framework' is yet another manifestation of the power dynamics inherent in industrial maternity care. It is well intended and I can see where the authors are believing in its ability to impact positively on women's experiences. I fully appreciate the intention and I can also see that the document is based on a fallacy. 

'The key concern for health professionals is upholding their professional obligations whilst recognising and responding to the human rights of women within maternity services. This framework aims to ensure that these responsibilities can be met in a meaningful way.' 

In my mind this is impossible to achieve. You cannot be answering to women unconditionally whilst also answering to your regulator regardless of how many documents you publish. Over-regulation will not solve the fundamental problem which is that the 'midwifery model' operates to uphold the 'obstetric model'. And what if a woman wants to access 'outside of Framework care'? She may not wish to commit to a PCSP. She might want to be able to change her mind in labour. Will we need another document to regulate this?

Our Regional Framework here in Northern Ireland is almost identical with the Royal College Of Midwives recommendation paper published just over a year previously in March 22.  Both documents refer to 'The seven principles of informed consent' issued by the General Medical Council in 2020. The first of those principles is this:

'All individuals have the right to be involved in decisions about their treatment and care and be supported to make informed decisions if they are able'

Wow! Can you see how this is totally upside down? This tells me all I need to know about where the woman (apparently at the 'centre of care') is really positioned in the established hierarchy in The System. It also tells me about the status of the midwife given that midwives are allegedly 'with woman'.

Women don't have full bodily autonomy in their pregnancy and birth like they are led to believe!  No, they have 'the right to be involved in decisions' about their care. They don't invite midwives and doctors in the sacred journey of bringing new life into the world, the doctors and midwives involve them! If you are intending to decline aspects of routine care, you get to outline your rationale (often to more than one 'professional'). What if your rationale is based on a gut feeling? How do you think this conversation would go?

Sadly there are certain health care trusts where women frequently get railroaded despite this new framework. The stories I hear about these conversations are truly disappointing.

Their 'involvement in the decision making' is represented by going through the motions. This framework can absolutely be implemented by simply disagreeing with the woman's rationale and I have seen this in action too many times than I would like. Some of the comments from health care professionals I have recently been made aware of are nothing short of cruel.

In my experience clinicians (yes, even doctors) are not often aware of the wider bodies of evidence around the interventions they are pushing because the guidelines says so. Very few midwives and doctors have taken the time to study physiology informed care. The art of midwifery has been handed over to the medical model, the associated benefits of a hands-off, relationship focused approach have been forgotten about. Midwifery is hardly different to obstetrics anymore. The fact that the Royal College of Midwives references the General Medical Council to set the scene for their own recommendation is telling of the historic hijacking of the way of midwifery by the industrial medical complex. 

If you are currently pregnant and you would like to decline continuous monitoring of your baby's heart rate when it is 'indicated', you will find that very difficult, particularly if you would also like to give birth on a medical labour ward for example. This is despite the fact that there is no demonstrable benefit of continuous monitoring over listening in with a sonicaid, even if there is a risk factor. 

Check out the Birth Small Talk blog. It explores the evidence around monitoring a baby's heart rate in labour and it is written by Dr Kirsten Small, a retired obstetrician who specialises in evidence around continuous monitoring of the baby during labour. The link is in the references.

If you would like to decline routine vaginal examinations if you are 'high risk', you might also have a hard time 'explaining your rationale' depending on which health care trust you'll give birth in. Framework or no framework, it's pot luck!

Even before the publication of this framework I have witnessed exemplary personalised care planning and since its publication I have seen the same familiar issues that have ultimately made me feel uncomfortable about remaining on the midwifery register.

In the end it depends on the people you talk to.

References:

Royal College of Obstetricans and Gynaecologists guidelines: How evidence-based are they? https://pubmed.ncbi.nlm.nih.gov/24922406/

Reviewing the evidence for intermittent auscultation. Birth Small Talk Blog.  https://birthsmalltalk.com/2023/11/01/reviewing-the-evidence-for-intermittent-auscultation/