From MIDWIFERY MATTERS, Issue No. 100, Spring 2004
The Rules of the Game
Mavis Kirkham
WHEN MIDWIFERY was professionalised, it was contained within rules in a way
which made it unique amongst professions.
In the early years of the twentieth century these rules were very detailed,
covering issues such as how, and for how long, the
midwife should wash her hands. The official Mid-wives Rules have become slimmer
over the years, yet practice has become
beset by rules with other names.
Policies and procedures have proliferated and guidelines are issued by various
bodies. Such edicts define practice and
rapidly fossilise into rules. Guidelines are meant to be the distillation of
evidence based practice but so often guidelines with
no evidence base, such as the frequency of intermittent FH monitoring or when
anti-D is given, attain the status of laws.
Commercial interests are evident, indeed double page adverts for anti-D appeared
in the midwifery and medical press when
the NICE anti-D guidelines were being produced. Yet these interests remain unchallenged.
The founding fathers of evidence based practice saw evidence as being used in
the context of clinical experience. In
midwifery, the rules seem so strong that it is difficult for them to be tempered
by their context.
Normal practice has become 'proceduralised' and there has to be a good reason
for not following the norms. Written
rules are added to the unwritten rules, "what we do in these circumstances
is ..." or "Mr X likes his ladies to have Y". Going
against the procedural flow takes energy, disrupts the system and can alienate
colleagues.
Rhetoric and rules
Despite the rhetoric of woman centred care, the reality of rules is to make
practice uniform. Yet women are not uniform
and the more we listen to women the harder it is to make them fit the rules.
We develop careful techniques for documenting
our deviations from the norms, usually justified as the client's wishes. We
cover our backs and leave women vulnerable to
having 'the right way' pointed out to them forcefully by others.
Routines
Rules create routines because they are usually followed. The more we operate
routines, the less we think and the more
women feel trapped upon a conveyor belt. Routinised practice hits problems in
.the face of the unusual. The NHS response to
this is to routinise the unusual; producing a range of emergency drills. Does
this help us to develop a practice which is
grounded in physiological knowledge and understanding and listening to women?
Rules and relationships
The breaking of rules carries penalties. The proliferation of rules increases
the ways in which things can be done wrongly.
The potential for blame increases vastly with corrosive effects upon working
relationships. Blaming individuals is not the same
as improving practice, though the two are often confused. Midwives are increasingly
fearful, not of harming women or babies, but of doing the wrong thing, being
vulnerable and not covering their backs.
The proliferation of rules is not unique to midwifery. Indeed the increase in
both rules and fear is a feature of modern
society. The proliferation of rules increases the ways in which we can do wrong
without doing harm, just as the increase in
targets increases the ways in which we can do right whilst missing what really
matters. These are features of bureaucracy.
As midwives, I feel we need to consider the effect of all these rules and the
subsequent growth in rule-governed behaviour.
Do they create a minimum standard of good care? Or do they trivialise practice,
drive a wedge between colleagues and create
good reasons for not thinking or listening to women?
Mavis Kirkham January 2004
LW updated July 4, 2004