From MIDWIFERY MATTERS, Issue No.98, Autumn 2003
Jane Munro
I HAD ENTERED 2002 with mixed feelings for our profession. I was very enthusiastic about what Soo Downe was describing as the zeitgeist that was gaining attention and power in defending normal birth. I was also wary and rather cynical about the anticipated celebration and glorification of 100 years of supervision of midwifery. It appeared to me a significant year with great potential for moving forward dramatically or for resting on our laurels and getting stuck in the obstetric haze in which we would lose more midwives.
I was involved in several events in 2002 that have supported both these visions.
In April I went to the two main conferences: the ICM 26th Triennial Congress in Vienna and the RCM Annual Conference: Turning Tradition into Progress. Both these events were exciting - it was particularly wonderful being with lots of midwives from all over the world and placing midwifery in an international context. They were both very good for networking for my own work and for ARM and I felt very privileged to be there. However, from neither event did I come away feeling that I had got the good global vision of where midwifery could or should be going.
On 2nd July I went to the House of Commons launch of the NCT report From Audit into Action (RCOG, RCM and NCT 2002). This is a very valuable document with powerful key messages that we could be working with. The launch was well attended and many positive things were said about working towards the social model of midwifery, but there was an extraordinary lack of the midwifery voice. This was a great opportunity to be asking the new Minister of Health the important questions about government intentions for the maternity services - but none of them were asked by midwives. The questions were asked by NCT, Maternity Alliance, AIMS and a member of the House of Lords.
I don't remember any year when we have had the weight of quite so many government directives that have been heralded as the great change agents that would improve our working lives in the way we want to go - Making a Difference (DoH 1999), The NHS Plan (DoH 2000), Shifting the Balance of Power (DoH 2001), Improving Working Lives (DoH 2002), Delivering the NHS Plan (DoH 2002). In the repeated rhetoric we heard the Government's commitment to respond to our retention and recruitment problems.
2002 also saw the publication of research on Why Midwives Leave (Ball, Curtis and Kirkham, 2002). This is a very important document to have in the RCM publications list, but it really did not tell those of us who have been in clinical practice in the last 10 years anything that we did not already know. However, when it is so clearly written down in black and white, it definitely makes you wonder where our leaders have been. What have they been doing for us when, "While the need for greater flexibility in working patterns within the Trusts was frequently articulated, the need for profound cultural and organisational change has also to be recognised"
We are also awaiting what we imagine will be the most significant government document for us, the National Service Framework for Children. This is due to be published at the end of 2003. I went to the first seminar on this in October 2002 in Bradford. I felt very inspired by the leadership of this project from Al Ansley-Green (the National Clinical Director for Children) who was asking the important social conscience questions about why English society has developed such an ambivalence to children and young people. This NSF is clearly our opportunity to set standards that reflect the midwifery role in advocating for children from the "very beginning of life". I went to two workshops there and got lost in trying to find the midwifery voice. The first was on mental health - where I was very surprised and disappointed to find there was no discussion on maternal mental health. The second was on "the maternity services", which was equally surprising in its lack of development; it appeared to be just a muddled collection of post-it points.
I am sure it would be very useful if ARM members contributed to the thinking around the maternity services through the website: www.info.doh.gov.uk/doh/nsfrusers.nsf. This is the discussion forum, but it appears to be very little used to date. Here again, I suppose, is my point is about leadership. Why have we not been more encouraged to be actively involved, or even aware, that this is the important consultation period on a document that should have a very significant impact on our profession? Yet again, we seem to be struggling even to play a reactive role in all this. It is interesting that, when these documents are finally published, managers disseminate them with some power - but it is shocking how little discussion there appears to be at the time for consultation.
Behind all this government action has been the continued development of clinical governance. After complicated un-packing, it seemed that clinical governance offered the great potential for creating a positive environment of "colleagues working together with a minimum of hierarchies and boundaries, in order to learn and evaluate collaboratively" (Scally and Donaldson, 1998). However, as a profession, we do not seem to have taken up this potential. We have definitely taken on clinical risk and CNST recommendations and preparation for CHI visits. But I do not readily see the collaborative working and learning together that it could have brought and I am worried about it fostering our well-established culture of blame and litigation.
Overall, I am very alarmed that we seem to be drowning in bureaucracy in modernising the NHS. We have been inundated by large amounts of paper and some of us have struggled through it in an attempt to pick out key bullet points that may be a way to take midwifery forward. However, it seems that the leaders in midwifery have lacked that vision. This begs the question: who are our leaders?
I found some inspiration in December's RCM Journal which suggested where we should be looking for these leaders: "The consultant midwives, the educationalists and researchers. those with specialist skills - the breastfeeding advisor, the teenage pregnancy advisor and the HIV counsellor .. and the labour ward midwife with 20 years' experience - who has seen everything and is utterly unflappable... and those newly qualified midwives, whose enthusiasm sometimes exhausts you.. Midwives working on the community who are connected to all the local support networks, both within and beyond the health services" (Davis 2002). I think this is clearly where our leaders should come from, but I don't yet see many from these groups filling that role. In the meantime, it seems that we have developed multiple tiers of 'more prestigious jobs' both in education and practice, that have set some of us apart with over-confidence in a status which has perhaps lost appropriate respect for our colleagues.
I also agree with Rosemary Exton (2002) that we should be making a union led response to some of the Government initiatives. For example, demanding that the Improving Working Lives standards are met. If our employers were really committed to: "flexible working patterns; staff benefits and child care; communication and staff involvement; healthy working practices; equality and diversity; training and development; human resources strategy and management; staff attitude surveys", I am sure that we would all be much happier in our work. Enhanced job satisfaction would probably also mean us taking the lead on interpreting the "needs of the service" rather than leaving such matters to the local discretion of managers.
I feel that we did not make great use of the political opportunities in 2002. Some of those opportunities are still here in 2003, and if the zeitgeist hasn't left us, perhaps we will move a few steps forward with women by the end of this year.
REFERENCES
Ball L, Curtis P and Kirkham M (2002) Why do Midwives Leave? RCM and DTI Partnership Fund, London.
Davis K (2002). 'A most memorable year', Midwives, 5, 12, 400.
Department of Health (2002). Delivering the NHS Plan, DoH, London.
Department of Health (1999). Making a Difference: strengthening the nursing, midwifery and health visiting contribution to health and healthcare, DoH, London.
Department of Health (2000). The NHS Plan, DoH, London.
Department of Health (2001). Shifting the Balance of Power: Securing Delivery, DoH, London.
Department of Health (2002). Improving Working Lives: National Audit Instrument, DoH, London.
Exton R (2002). 'Midwives to take the lead - not leave', Midwives, 5, 12, 430-432.
National Childbirth Trust (2002). The Rising Caesarean rate - from audit to action. Report of a joint conference organised by the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives and the National Childbirth Trust, NCT, London.
Scally G and Donaldson L (1998). 'Looking forwards: Clinical governance and the drive for quality improvement in the new NHS in England', British Medical Journal, 317, 61-65.
LW updated February 4, 2005