Since the publication of the Kirkup (2015) report, midwives have expressed concern to me that the recommendations will impact negatively on their ability to practice autonomously. This concern has, in part, arisen from statements made about inappropriate risk-assessment and the failure to refer in a timely manner.
Let's look at the recommendations (Kirkup, 2015: 185):
- ‘The University Hospitals of Morecambe Bay NHS Foundation Trust should draw up a protocol for risk-assessment in maternity services, setting out clearly: who should be offered the option of delivery at Furness General Hospital and who should not; who will carry out this assessment against which criteria; and how this will be discussed with pregnant women and their families. The protocol should involve all relevant staff groups, including midwives, paediatricians and obstetricians and those in the receiving units within the region. The Trust should ensure that individual decisions are clearly recorded as part of the plan of care, including what risk factors may trigger escalation of care, and that all Trust staff are aware that they should not vary decisions without a documented risk-assessment.’
- ‘The University Hospitals of Morecambe Bay NHS Foundation Trust should audit the operation of maternity and paediatric services to ensure they follow protocols on place of delivery, transfers and management of care, and that effective multidisciplinary care operates without demarcations between professional groups.’
On the face of it what have midwives got to worry about? These recommendations only emphasise the importance of what is known. Team-working and quality communication between all professionals are fundamental to safety in maternity services. Surely most maternity services already have these protocols in place? Surely these are agreed by a multidisciplinary team and describe a dynamic framework in which midwives discuss choices and care needs with women antenatally and during labour; a framework in which midwives and medical staff work together to ensure timely consultation and referral.
Evidence suggests that not only are such protocols in place, but that they are working. While many women choose to give birth in our obstetric units despite being low-risk, many more are there because they have been identified, usually by midwives, as having care needs that make this the safer choice for them. The transfer rates of women in labour from midwifery-led services confirm that every day skilled midwives are assessing that referral is necessary.
So why worry if all we are being asked to do is something that we are already doing? It strikes me we are looking for hidden agendas. Do they exist? Having met Dr Bill Kirkup I do not suspect an intention to undermine our role. I also trust from what I hear that our medical colleagues do not wish to that to happen.
But that does not mean I am complacent. All the protocols in the world will not ensure the safety of women unless they are implemented. As I say, it can be argued that this is usually the case, but it is not only the tragic outcomes at Morecambe Bay that suggest this might not be a universal truth. For this to improve there has to be more interprofessional trust. For this to exist, every professional group must feel they have had an equal say in the genesis of protocols, in their implementation and in their audit. I once worked with an obstetrician who advocated multidisciplinary working but the sub text was ‘but I will be captain of the team and have the final say’. Equally, I have met midwives who treat their medical colleagues as a fire brigade, barred from any discussions about low-risk women and only involved to rescue the situation at disaster point. Neither is appropriate.
I believe that the safety of women and babies requires that every aspect of a maternity service whether midwife-led or obstetric-led is owned by all professionals as ‘our homebirth service, our midwifery-led unit, our obstetric unit’.
So midwives, let's stop worrying about our role being undermined. Let us instead take a positive stance and demonstrate through our own respect and trust for the entire maternity team and the different expertise we all have that we too deserve that respect. A quality midwifery-led service is, in my opinion, as much dependent on the appropriate involvement of medical staff as a quality obstetric service is dependent on the involvement of midwives.