From MIDWIFERY MATTERS, Issue No. 99, Winter 2003
The debate over CNST
Midwifery Matters Issue number 96 12 June 2003
Jane Evan's original article
AT A RECENT MIDWIFERY GATHERING we were discussing how to keep midwifery skills
alive and also what was leading to the rapid demise of the midwifery profession.
As an independent midwife I was asked to give my personal viewpoint from outside
the NHS as I have access to many units around my area of practice.
For some time it has been of concern to me that the newly qualified midwives
of today are able to qualify without ever having shared a woman's journey through
labour to spontaneous, 'uninterfered with' birth. In some places most women
have epidural anaesthesia and so 'normal' birth is not the norm and support
skills are not developed by midwives or taught by tutors, as they are not relevant
to students' practice.
I have transferred care of a woman into a unit occasionally and found that even
the senior registrar has only 'heard' of expectant management of term spontaneous
rupture of membranes - he or she has not experienced giving the woman information
on active or expectant management so the woman has been unable to make an informed
choice and therefore her care givers have not experienced expectant management
of term SROM therefore the only choice left is active management.
What are the real risks of a woman going post term and when is post term - what
happens with most post term pregnancies? How can a midwife help a woman start
labour spontaneously? These skills and knowledge are being lost; therefore induction
at 41 weeks becomes the only choice.
Most midwives now will never have the opportunity of seeing, let alone helping,
a woman to give birth to a baby who is in a breech presentation. Whatever will
happen now when a multiparous homebirth woman starts to push and that head looks
very bald and proceeds to pass meconium? How can we ask a midwife to cope calmly
with that scene if she has only ever seen breech presentations delivered by
LSCS? Is it not dangerous to be deskilled to this extent?
Twin pregnancies are now pathological and will of course need to be ended by
LSCS - if not for both - certainly for the second twin - but are many of the
problems iatrogenic?
Recently a colleague and I had to go back to research done in the 1950s and
1960s when looking for information to give to a couple who, sadly, had found
their baby had died in utero in the middle of the pregnancy. The information
in use today would be to whip her into hospital and whip it out because of the
risk of disseminating intrahepatic coagulation (DIC) which everyone thought
would rapidly set in. In fact - led by Effective Care in Pregnancy and Childbirth
(ECPC) we found they did have the option of waiting until labour started spontaneously
or they were ready to birth their baby and say goodbye. In the words of ECPC
the only difference was the emotional outcome for each individual family in
such a case. Is this not the most important outcome for the families we work
with? And yet we have lost that knowledge in the face of irrational fear-based
practice and therefore advice, rather than a truly informed choice. DIC has
a slow onset over 6-8 weeks in such a case and can therefore be screened for
by regular blood tests. How have we as a profession descended to this and how
much further do we let our profession go before we and our society realise what
has been lost?
Constantly I see and hear evidence of the narrow parameters of CNST affecting
women's choice and therefore the midwifery skills. Midwives are leaving the
profession because they feel they can no longer practice true midwifery. The
RCM knows that there are at least 5,000 midwives waiting to come back into practice
- if they are allowed to practise. What a terrible waste of knowledge and womanpower
in a time of such staff shortages. Women are given only one choice of 'treatment'
and fear of harm to the baby is used as a Sword of Damocles to bludgeon them
into accepting the care of the lowest common denominator which fits into the
guidelines from the CNST. Level II was stringent enough. Level III is more restrictive
but saves the Trusts millions of pounds in premiums so parameters are tighter
- choice is diminished and experience and skills are narrower which leads to
more fear of stepping out of the narrowing parameters thus making choice less
and experience and skills narrower and so on until we truly only have the choice
of a surgical delivery of the next generation, an accidental rapid vaginal birth,
a medically unattended birth or one assisted by a handy woman/witch or illegal,
antiquated midwife.
Honorary contracts for midwives working outside the NHS have all but gone because
of CNST and yet these in many places benefited the woman, the baby, the midwife
and the NHS staff as we shared our skills and knowledge in a safe supportive
place were everyone's needs were being met.
Why should insurance underwriters direct midwifery? How many births [not deliveries]
have they attended? How many births has an obstetrician attended? How many births
have you as a midwife been privileged enough to attend? When are women and their
families going to recognise the damage being done by our litigious society which
has allowed a body such as the CNST to effectively push midwifery knowledge
and skills, if not underground then certainly to the very edge of normality.
Is it too late to turn the tables and to keep birth a part of life's rich experience
which leads us into parenting the next generation with love, compassion and
strength - knowing they have had an information-based - not fear-based birth?
Jane Evans
Midwifery Matters Issue number 99 Winter 2003
Dear Ms Kirkham
In response to the article `On Midwifery Practice and Knowledge' written by
Jane Evans in Issue number 96, the NHSLA would like to set the record straight
on the comment that CNST has pushed midwifery knowledge and skills underground!
The Clinical Negligence Scheme for Trusts (CNST) was established, to provide
a means for NHS Trusts to fund the cost of clinical negligence litigation and
to encourage and support effective management of claims and risk. The promotion
of clinical risk management is an integral component of CNST. The standards
provide a framework which will help maternity services to focus their clinical
risk management effectively, thereby improving care for women and babies.
The CNST Clinical Risk Management Standards for Maternity Services have been
developed and implemented to assist practising midwives and clinicians in supporting
women through a safe and uneventful pregnancy and childbirth. The Standards
have been developed by midwives within the Willis team who have worked very
closely with the Royal College of Obstetrics and Gynaecology (RCOG) and the
Royal College of Midwives (RCM) who have endorsed the standards. The evidence
that the Trust would need to produce at an assessment to demonstrate compliance
with the Standards is drawn from recommendations made by recognized bodies such
as NICE, RCOG and the Confidential Enquiries and are areas that the Trust should
already have considered and implemented.
Following the recent benchmarking of the Standards the initial feedback to the
Willis assessors from Trusts has been very positive and Trusts feel that the
Maternity Standards have supported the development of midwives skills and knowledge
and assisted with better working relationships and promoting multi disciplinary
team working.
I would be grateful if my comments are relayed to your readers. Yours sincerely
Steve Walker
Chief Executive
NHS Litigation Authority
Jane Evans replies:
30/9/03
While I am pleased that Steve Walker, the Chief Executive of the NHS Litigation
Authority reads Midwifery Matters I am disappointed that he appears to have
missed my points. In the article I wrote about "The Implications of the
Central Negligence Scheme for Trusts on Midwifery Practice and Knowledge ".
I was talking about the social model of midwifery and the CNST is obviously
set up for the medicalised model of obstetric care. CNST had been operational
for some time before there was any midwifery input at all so a ,firm obstetric
base was already formed. I am also interested to find that no one that I have
contact with has heard of the Willis Committee nor any of the members. We would
be very keen to arrange .for one of the midwife advisors to come to talk to
ARM at the next national meeting in Shrewsbury or as soon as is feasible. Meanwhile
I feel I must stand by the views I published in Midwifery Matters Issue number
96.
Jane Evans
Mavis Kirkham replies to NHSLA:
CNST and its Effects
I am grateful for the letter from the NHS Litigation Authority. It gives Jane
Evans and me the opportunity to clarify our thoughts and raise issues for discussion
in Midwifery Matters.
The letter states that, "The CNST Clinical Risk Management Standards for
Maternity Services have been developed and implemented to assist practising
midwives and clinicians in supporting women through a safe and uneventful pregnancy
and childbirth." None of us would disagree with the aim of supporting women.
I have read the CNST Clinical Risk Management Standards for Maternity Services
carefully and, in my view, they raise two problems: firstly, the effect of standards
in standardising practice and secondly, the effect of focusing on problems/pathology
rather than normality and support.
We live in an era of rules and targets. The problem with standards, guideline
and procedures is that they rapidly fossilise into rules. Indeed, CNST standards
are rules because they are crucial for insurance purposes. Compliance with rules
is measurable and there are penalties for non-compliance. Obeying the rules
comes to be of paramount importance. The means thereby become much more important
than the ends. I work, on the bank, in a birth centre which does not have CTG
equipment. This is a deliberate choice by the midwives there to enhance physiological
and active labour. Yet I am required, and paid, to do CTG updating in the consultant
unit twice a year, "as a CNST requirement". This is not the fault
of CNST, which makes allowance for such circumstances in its standards (Criterion
5.1.5, p87). But what is monitored and enforced is attendance not the appropriateness
and flexibility of training sessions.
Such standards model standardisation of practice, rather than flexibility and
support for individuals. The measurement of compliance with rules makes rules
very important and reinforces habits of compliance. If we obey the rules we
are doing the right thing. If this does not have the desired effect, the modern
response is to create more rules. Yet rule governed behaviour is so different
from the knowledge of physiology and respect for the individual in which good
midwifery is grounded and which enables midwives to support the subtle feedback
between the woman's body and her social self that underpins normal childbearing.
A climate of conformity and rule-governed behaviour is rapidly transmitted to
the women in our care. Eager to please the midwife, they usually do what is
"allowed" and 'expected'. Thus we modify women's expectations rather
than responding to their needs.
The CNST standards ensure that emergency skills are stressed, drilled and practised
regularly. We must all have these skills but they are not all the skills we
need. The frequency of such drills emphasises their importance and severely
limits the resources available for education concerning more subtle preventative
skills. In stressing the prediction of emergencies and appropriate response
in emergencies, there is a danger that we neglect the more diverse skills of
prevention and support.
The multidisciplinary nature of CNST standards and of the clinical guidelines
required by CNST, reflects the dominant medical model of birth. Yes, "the
provision of continuous care of the mother for the duration of an epidural blockade
is imperative, and this care should not be carried out if one to one care cannot
be provided." (Criterion 8.2.2, p120). But such statements, and basing
staffing calculations on medical concepts of dependency, mean that women are
choosing epidurals because they cannot have continuous support in coping with
normal labour. Surely, all women have a right to one to one care in labour.
The medicalised values underpinning CNST are evident in its emphasis upon staff
as active. They are portrayed as carrying out treatments, following guidelines
and doing what must be done. Such an approach renders women passive, if only
out of sympathy with staff who are seen as so busy that, "You don't like
to ask". (This statement recurs in every study of women's view of maternity
care). Passivity is not a healthy way to deal with pregnancy, labour or new
parenthood. If women are to be active and have confidence in their own bodies
and their own potential, they need the support of midwives who themselves have
confidence and autonomy. There is no evidence that this can be achieved by standards,
rules or rhetoric concerning either communication or empowerment, if practice
is within a bureaucracy with very different values.
Behind medicalised standards there are commercial interests. The emphasis on
CTGs is strange considering that they do not improve outcomes for most women.
Yet vast numbers of women in 'normal labour' are still tethered to CTG monitors
and many clinicians are dependent upon them. We have been convinced that CTGs
are highly important for us as clinicians. Similarly, the current anti-D guidelines
were developed amidst massive commercial input and an unprecedented advertising
campaign. This could be linked to the fact that we now have guidelines without
a sound research base and 'expert opinion' has chosen to advocate giving far
more doses of anti-D to all rhesus negative mothers, with consequent expense,
rather than targeting anti-D more effectively. There are no commercial profits
to be made from good midwifery care and no commercial interests supporting a
social model of birth.
There are some excellent things in the CNST Standards, particularly concerning
communication and women's involvement in decision-making. It is important that:
"There is information available to women and their partners which describes
the alternatives, risks and benefits of their proposed treatment in pregnancy
care, treatment and delivery." (Criterion 3.1.1 p48) Yet research shows
that NHS clinicians usually have a clear picture of the 'right choices' that
women should make and information about alternatives often resembles shroud
waving. Leaflets should certainly be given, but I am chastened by having done
the research evaluating the excellent MIDIRS leaflets. This research showed
how leaflets can be distributed by busy midwives in such a way that their value
is undermined and informed compliance is achieved rather than informed choice
(Kirkham and Stapleton 2001). Women's knowledge of alternatives to and the risks
of the locally defined 'right choices' are not the things I see being monitored
in practice. Yet the presence of leaflets cannot be equated with real choice
for women.
The highly medicalised values underpinning CNST are worrying. We need a flexible
and responsive service, not a rigid and rule-governed one. Women and midwives
deserve a service that aspires to excellence and is audited. The New Zealand
model of standards review may bring us nearer to achieving this at the level
of individual midwives and mothers. In this model the practice of each midwife
is reviewed by lay women and midwifery peers. Before such possibilities can
even be explored, we need radical changes in the system of insurance in maternity
care. The current work of the Independent Midwives Association gives us reason
to hope.
The CNST Standards are, in many ways, as good as such standards can get. Amongst
other changes, we need a very different system of insurance/ recompense if we
are to truly work with women rather than following the rules and covering our
backs. Without such change, midwives will continue to leave and rules will proliferate.
REFERENCES
Kirkham M and Stapleton H (eds). (2001) Informed Choice in Maternity Care: an
evaluation of evidence based leaflets, University of York, NHS Centre for Reviews
and Dissemination.
NHS Litigation Authority (2002). Clinical Negligence Scheme for Trusts. Clinical
Risk Management Standards for Maternity Services. London, Willis.
These responses were originally published in Midwifery Matters ISSUE 99 Winter 2003
AH updated 15 October 2001