Association of Radical Midwives
From MIDWIFERY MATTERS, Issue No.103, Winter 2004
Being an Advocate for your Clients in the Antenatal Period
Sally Randle
ADVOCACY - promoting and protecting the interests of the client, providing information to give confidence in decision making, providing support if a patient refuses treatment or care - is a recognised midwifery role (UKCC, 1996). Midwives are used to being a woman's advocate on the labour ward, becoming aware of her wishes by listening to her or reading her birth plan. So how can advocacy work in the antenatal period? One way is by accompanying the woman to her antenatal medical appointments. This has advantages and disadvantages to the woman, the midwife and other health professionals, but how possible would it be for this to become common practice in the current maternity service? This role was part of my job as a caseload holding NHS midwife in London and it continues now I am an independent midwife in Bristol, so I have some experience of how it works in practice.
Politically and idealistically my philosophy of care was already firmly in place by the time I started training as a direct entry midwife. I had had both my children at home with independent midwives and I was part of the generation of women proud to call themselves feminist. Advocacy featured strongly in my midwifery aims: supporting women in achieving positive and life affirming experiences of pregnancy, childbirth and motherhood, whatever their circumstances or history.
As a student, I had spent time with the Albany midwives and had gone to consultant appointments with the woman and her midwife. I felt from that experience that this was a valuable role for a midwife, for a variety of reasons, which I shall explore below. Once qualified, I started work in the community for the same unit. After about a year, some colleagues and I submitted a proposal for a new caseload midwifery practice which was accepted (Randle et al, 2001) and we included this role in our working practices.
Most independent midwives offer to accompany women to medical appointments, but it is not so common a practice in the NHS. Three of the group practices at the hospital I worked for in London do it, as I believe the Torbay midwives do. It is certainly not widespread in the NHS. I have not been able to find any research into this practice, nor can I find any evaluation of existing practice. Any discussion of advantages and disadvantages is therefore opinion based and theoretical.
Kathy, whose pregnancy and birth story you can read in this journal (page 7) was one of my first clients as an independent midwife in Bristol. As someone who had had a previous caesarean section and was then seeking a homebirh, she experienced first hand the sometimes very difficult experience of consultations with obstetricians about her choices. Once she booked with me, an independent midwife, she was very pleased to know that I would accompany her should she need to attend any further medical appointments.
Kathy's description of her experiences with the medical profession are a good illustration of how frustrating, frightening and soul destroying an experience it can be. You only have to read some of the emails on the ukmidwifery list (ukmidwifery@yahoogroups.com) to see that for many women an appointment with a health professional, often an obstetrician but, sadly, also a midwife, is seen as confrontational and stressful. The woman has to psych herself up and arm herself with assertiveness training catchphrases and detailed knowledge of her problem, to defend her own opinions and wishes.
In an ideal world she would be going to seek an opinion from a health professional who would give her all the information available, listen to her feelings and wishes, and send her away to make her own choices and decisions. I hope this is what I do as a midwife but, in a maternity system which promotes the 'masculine' medical model over the 'feminine' midwifery one (Kirkham, 2000), where, in the hierarchical structure of the hospital, the doctors are seen to hold the knowledge and therefore the power (Pilley Edwards, 2000), we are often far from the ideal world. Pilley Edwards describes the professional's knowledge as: "being considered superior and authoritative and the patient's knowledge largely irrelevant" so "the professional role is one of decision-making and action, and the patient's role is one of passive acceptance".
Midwives are used to practising advocacy on behalf of clients on the labour ward or in day assessment units and other places where we have direct contact with medical practitioners. In the antenatal period, however, this is unusual. We are required by our rules (UKCC, 1998) to refer women to the appropriate expert when a woman's pregnancy deviates from the norm and, for most midwives, this means writing a referral letter or filling out a form for an appointment. The woman goes, a decision is made and, ideally, the woman continues to see her midwife who may now share care with the consultant team. The midwife either supports any decision made about future care, along with the woman, supports that decision against the woman's feelings or tries to support the woman against the doctor's opinion. In the system I am suggesting, the midwife attends the appointment with the woman. If she also attends the consultation, the midwife can remind the woman of questions she has forgotten to ask; she can provide support by interpreting, developing and discussing what the doctor says; or her mere presence may be useful, listening and documenting and sometimes asking a question to bring out a piece of information that is relevant to the discussion. Finally and importantly, she can remind everyone that time is needed to digest what has been said and that decisions do not have to be made straight away. I think this is an important part of informed consent: that the woman and her partner are given time alone to digest and consider what has been said (Adamson, 2004) before they make any decision.
Advantages to the Woman
The woman would feel supported by the presence of a midwife whom she trusts and views as a professional friend (Pairman, 2000) and might gain confidence and a sense of wellbeing from this support. The midwife would be there as a witness to all that was said and her very presence might help to change the atmosphere at a consultation and reduce the likelihood of bullying behaviour. The midwife is also an interpreter, someone who understands the language of both parties. She will be familiar with medical obstetric jargon and familiar with the woman's wishes and level of knowledge; the midwife has important skills in interpreting (Chesney, 2000). There is also an openness about this way of communicating which may be of benefit to the woman. When a midwife writes a referral letter it is usually private and the women doesn't see what is being written about her, unless the midwife writes it in her notes. This way the women is part of the discussion and there is no hidden agenda. Finally this practice, should improve her relationship with her carers and help to increase trust between them. The woman knows the midwife is 'with her' and not 'with doctor', she no longer feels alone and unsupported in a system that can appear stacked against her (Pilley Edwards, 2000).
Advantages for the professionals
There are also advantages for the midwife and her medical colleagues. The midwife is always up to date with what is happening to her client and she is able to make valuable contributions to discussions about her care. The midwife and doctor interract on an equal level and such meetings can be an opportunity for an equal exchange of knowledge and opinion (Marsh, 2004) which could help to break down barriers between midwives and obstetricians, as well as being a potential learning experience for all parties. I remember a consultation with a client wanting a homebirth after a caesarean and a consultant obstetrician; the obstetrician admitted that she didn't know the current statistics on the risk of scar rupture and turned to me for the information.
This way of working helps the midwife to get to know individual doctors better, improving each one's understanding of the other's role. When shared antenatal care is necessary, this practice can lead to better teamwork. Each member of the team knows what is happening, can make plans together, involving the woman at all times. In today's litigious world this practice reduces opportunities for misunderstanding and omissions (Marsh, 2004).
Disadvantages
Firstly, many women may not want the midwife to accompany them, either because they do not feel it necessary or because they do not feel their midwife is the right person to do this. A woman may not have a trusting, confident relationship with her midwife and may see her as an adversary too (Pilley Edwards, 2000). She may prefer to take her partner, a friend or to hire a doula for this role, although, doulas seem to see their most valuable function as being during labour (Mander, 2002). She might have a very good relationship with her obstetrician, who may well be her lead professional. Having said all this, I have not found many women who refuse this opportunity.
It could be seen as infantilising and patronising the woman, to assume she needs a midwife's help to deal with other health professionals. To avoid this, this way of working must be discussed with the woman and offered as an option available to her. At the appointment, I feel it is better to remain in the background, offering one's presence as a support, as a witness and to speak when asked to by the woman, or to ask a question to elicit further information. I don't think it helps to argue with your colleague in front of your client, neither to appear to collude with him or her against your client, nor to 'take over' the meeting and do all the talking for your client.
This way of working presupposes that you have a relationship with your client and that you know her well. I am able to offer one to one care both in the NHS and as an independent midwife. A midwife who carries her own caseload often doesn't have clinics and has time to get to know her clients. She knows she is going to see them at every appointment, she can organise her working day as she wishes, and is therefore able to attend clinics (births willing) with women. Could this be done in a team or traditional community setting? A colleague of mine used to work in a team where four midwives shared a caselaod and they were able to do this. If a team is fully staffed it should be possible, although with team midwifery the continuity of carer is less good and therefore the midwife may never have met the woman before.
In the current climate of staff shortages, where home birth services are being cut (for example, in Peterborough, reported in The Guardian, 2004) and management and midwives are struggling to provide a basic service, this initiative may not be welcomed or seen as a priority. Antenatal advocacy also presupposes that all midwives are keen to practise 'with woman'; that midwives feel willing and able to support women's choices which may go against hospital guidelines. Midwives who prefer to stick rigidly to guidelines or to defer to obstetricians cannot be advocates for women in this way.
For the obstetrician, this practice could feel time consuming, the presence of a midwife could lengthen the time a consultation takes. However, in my opinion, a consultation with a woman should consider all the issues and give her time to ask questions; it should not be constricted by unrealistic time constraints. Also, spending the time at this point, would probably save time at later appointments or encounters on labour ward (Marsh, 2004).
I haved now moved from a job and a hospital where this was normal practice, to independent midwifery in a city where it definitely does not happen at either main hospital. I have encountered bewilderment and confusion that I should be there at all and a little hostility, probably because it is an unfamiliar practice. Interestingly, at a third unit in this area, where antenatal advocacy is also new, the obstetricians have been welcoming and relaxed and it has helped us develop relationships with them. I think that the attitudes we have encountered at the different units in the area reflect the relationship which exists between obstetrician and midwife at each of those units and also reflect the amount of autonomy most midwives appear to have.
One difference I have noted is that I no longer feel I am walking a tightrope between my client and my work colleagues. Before, I would sometimes feel a conflict between supporting my client and not alienating a work colleague although I always felt that I worked for the women. However, now that I am retained by the women directly I no longer have that problem, and this makes the relationships with other health professionals more straightforward. The downside is that as an independent midwife my caseload is smaller and spread between three different hospitals; it is harder to build relationships with obstetricians who I do not see very often. Also, it has to be said, sometimes the women we look after have been so traumatised by previous experiences that they do not want to see an obstetrician at all, even with the support of our presence.
Conclusion
The practice of accompanying women on medical antenatal appointments has many advantages, but could be seen to be unsustainable in the present system of maternity care, with its inability to provide good continuity of carer amidst current staff shortages. Midwives would need to be given the opportunity to choose to work this way, because they would have to feel comfortable with the idea of being there as a woman's advocate, sometimes supporting her in choices that might go against obstetric opinion or hospital guidelines and policies. However, it has great advantages in improving working relationships between health professionals and increasing midwives' autonomy.
email: landerandle@magic-tree.com
REFERENCES
Chesney M (2000). 'A three-way relationship', in: Kirkham, M (ed) (2000) The midwife-mother relationship, Palgrave Macmillan, Hants.
Kirkham M (2000). 'How can we relate?' in: Kirkham, M (ed) (2000) The midwife-mother relationship, Palgrave Macmillan, Hants.
Mander R (2002). 'Is the doula merely the answer to an obstetrician's prayer?' MIDIRS, 12 1 8-12.
Marsh M (2004). private email communication.
Pairman S (2000). 'Women-centred midwifery: Partnerships or professional friendships?' in: Kirkham, M (ed) (2000) The midwife-mother relationship, Palgrave Macmillan, Hants.
Pilley Edwards N (2000). 'Women planning homebirths: Their own views on relationships with midwives', in: Kirkham, M (ed) (2000) The midwife-mother relationship, Palgrave Macmillan, Hants.
Randle S (2002). 'The Oakwood Practice', The Practising Midwife, 5, 7, 20-21.
UKCC (1996). Guidelines for Professional Practice, UKCC, London.
UKCC(1998). Midwives Rules and Code of Practice, UKCC, London.
(ik) updated (10 December 2004)
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