The VBAC guideline went through several consultations and reached the point of ratification. The final document was a true collaboration between midwives and obstetricians and great effort was made to incorporate everyone’s views. I was greatly heartened by everyone’s willingness to engage even where there was difference of opinion.
We had now come full circle, back to the issue of ‘sign off’. As with other organisations, the guideline process required the clinical director to sign off the document. Although in support of the principle of the guideline, it was felt that as this was a midwife-led initiative the consultant midwife should be responsible and the one to sign it off. Although I was and am entirely in agreement with this, the official process dictated otherwise. As a midwife-led initiative, the midwife can and should take full responsibility in partnership with women, because, after all, what is outlined in the guideline is supporting and monitoring a woman in normal, spontaneous, progressive labour. However, in the current litigious climate, it was felt unlikely that the organisation would support the guideline if it does not get ratification through the recognised process.
Finding a way through for the VBAC guideline was a fascinating process as it goes to the heart of decision-making and accountability. A wise colleague suggested we call it a ‘framework’, and as the midwives generally supported the document we could authorise it through midwifery supervision sanctioned by the
head of midwifery, consultant midwife and director of nursing, herself a midwife.
It was after all, midwifery business. This is what happened and the framework has now been widely disseminated and women who now ask for VBAC and birth with minimal intervention can be supported openly, confidently and safely.
Conclusion
In this chapter, I have tried to weave together the threads of the story of one consultant midwife and her role in relationship to evidenced based practice and working in multidisciplinary guideline groups. At the beginning of the chapter, the background to the emergence of evidence was described, as I experienced it in the 1980s. It goes on to outline the development of guidelines and the challenges I and others face in the struggle to get evidence into practice. Issues of power and control and how in some areas midwives are losing sight of the essence of their own profession are addressed.
The chapter then, however, outlines a different story of how transformational leadership and collective and collaborative team working can make a difference.
It demonstrates Biringer et al.’s (2001) assertion that change is more likely to occur when a whole system approach is encouraged and where everyone is steering in the same direction. It may take time winning everyone over, but what helps enormously is a facilitative organisation that encourages people to grow and develop.
Finally, I addressed the difficulty of developing guidance in the absence of evidence as convention would view it, and at the same time supporting women’s choices safely even when those choices do not comply with current recommen-dations. It raises issues around accountability and ultimately who is responsible.
Midwives have a chance, as never before, to embrace the opportunities in a rapidly changing National Health Service (NHS). We have an opportunity to work in partnership with women and obstetric colleagues to ensure women receive appropriate and safe care according to their individual need in appropri-ate environments. It is unlikely we will ever again have the opportunities that are placed at our door as this chapter goes to print, so I urge the reader, if at first you do not succeed, keep trying.
References
Biringer A, Davies B, Nimrod C, Sternberg C, and Yoens W (2001) Attaining and maintaining best practices in the use of caesarean sections: an analysis of four Ontario hospitals. Report of the Caesarean Section Working Group of the Ontario Women’s Health Council. Ontario Women’s Health Council, Ontario.
DH (1993) Changing Childbirth: Report of the Expert Maternity Group Parts 1. HMSO, London.
DH (2004) National Service Framework for Children, Young People and Maternity Services, Standard 11 Maternity. The Stationery Office, London.
Dickson A (1985) The Mirror Within: A New Look at Sexuality. Quartet Books, London.
Donnison J (1988) Midwives and Medical Men: A History of the Struggle for the Control of Childbirth. Historical Publications, London.
Drayton S and Rees C (1989) Is anyone out there still giving enemas? In: Midwives, Research and Childbirth, Volume 1 (eds Robinson S and Thomson MA). Chapman and Hall, London.
Edwards E (2000) Women planning homebirths: their own views on their relationships with midwives. In: The Midwife-Mother Relationship (ed Kirkham M). Macmillan Press Ltd, Basingstoke & London.
Enkin M, Keirse MJN, and Neilson J (1989) Effective Care in Pregnancy and Childbirth, Volumes 1 & 2. Oxford University Press, Oxford.
Hodnett E (1999a) Home-Like Versus Conventional Birth Settings (Cochrane Review). The Cochrane Library: Issue 4. Update Software, Oxford.
Hodnett E (1999b) Continuity of Caregivers during Pregnancy and Childbirth (Cochrane Review). The Cochrane Library: Issue 4. Update Software, Oxford.
Hodnett E (1999c) Support from Caregivers during Childbirth (Cochrane Review). The Cochrane Library: Issue 4. Update Software, Oxford.
Jones O (2000) Supervision in a midwife managed birth centre. In: Developments in the Supervision of Midwives (ed Kirkham M). Books for Midwives Press, Manchester.
Kirkham M (1999) The culture of midwifery in the National Health Service in England.
Journal of Advanced Nursing 30(3): 732–739.
Kotaska A (2004) Inappropriate use of randomised control trials to evaluate complex phenomena: case study of vaginal breech delivery. British Medical Journal 329(7473):
1039–1042.
Manders R (2001) Supportive Care and Midwifery. Blackwell Science, Oxford.
McCourt C and Page L (1996) Report on the Evaluation of One to One Midwifery. Thames University, London.
Munro J and Spiby H. (2000) Evidenced-Based Midwifery – Guidelines for Midwifery Led Care in Labour. Sheffield University Hospitals, Sheffield.
National Institute for Health and Clinical Excellence (2007) NICE Clinical Guideline 55 Intrapartum Care Care of Health Women and their Babies During Childbirth.
Nursing & Midwifery Council (2004a) The NMC Code of Professional Conduct: Standards for Conduct, Performance and Ethics. NMC, London.
Nursing & Midwifery Council (2004b) Midwives Rules and Standards. NMC, London.
O’Driscoll K and Meagher D (1986) Active Management of Labour: The Dublin Experience.
Balli`ere Tindall.
Romney ML (1980) Pre-delivery shaving: an unjustified assault? Journal of Obstetrics and Gynaecology 1: 33–35.
Royal College of Midwives (1988) Successful Breastfeeding A Practical Guide for Midwives.
RCM, London.
Sleep J (1991) Perineal care: a series of five randomised controlled trials. In: Midwives Research and Childbirth (eds Robinson S and Thomson AM). Chapman and Hall, London.
Stephens L (2006) Campaign for normal birth: Jane’s story. RCM MIDWIVES Journal 9(12): 475.
World Health Organization (1996) Care in Normal Birth: A Practical Guide. WHO, Geneva.
10. Unpicking the Rhetoric of Midwifery Practice
Marianne Mead
Introduction
‘Unpicking the rhetoric of midwifery practice’ – the title demands some explana-tion before the concepts that it contains can be explored in the context of evidence based midwifery practice.
Like most midwives, I am neither a philosopher nor a linguist, but the wonders of my secondary education taught me that the etymology of the word rhetoric has a Greek origin, and that rhetoricians (Greek origin) and orators (Latin origin) played an important role in the development of politics from antiquity to our days. Indeed, rhetoric (from the Greek ρ´ητωρ, rhˆetˆor, orator, teacher) is the art or technique of persuasion, usually through the use of verbal or written language. It has historically been concerned with persuasion in public and political settings such as assemblies and courts of law, and flourishes in open and democratic societies. Its origin goes back to ancient Greece, and philosophers such as Aristotle, Plato and Socrates. The organisation of democracies has evolved in the last 2500 years, and so has the concept of rhetoric. Today, rhetoric is described more broadly as the art or practice of persuasion. The term can also be used today in a pejorative or dismissive sense, when someone wants to distinguish between ‘empty’ words and action; or between true or accurate information and misinformation, propaganda; or ‘spin’; or to denigrate specific forms of verbal reasoning as spurious. Nonetheless, rhetoric, as the art of persuasion, continues to play an important function in contemporary public life (Wikipedia 2006). Rhetoric has also been identified as playing a role in identification, in as much as it can serve to establish a shared sense of values, attitudes and interests (Burke 1969).
Therefore, in its broadest sense, rhetoric concerns both the practice and study of effective communication in literature and in social discourse (Nordquist 2006), but can also be a catalyst for the development of some political, professional or other group identity.
The questions I propose to address in the context of the midwifery profession are, is there such a thing as midwifery rhetoric, and if there is, how does it fit
reality? Given the positive, but also the potentially pejorative use of rhetoric in general, is it possible to suggest that midwifery rhetoric has its strengths but also limitations, its truth but also its spin? If there is a gap between rhetoric and reality, I propose to examine the steps that could be followed to narrow it and ensure that what women are promised could be delivered.
It might be useful at this point to state that several of the opinions I shall put forward here have not necessarily been the subjects of systematic research and evaluation, but are often the product of my own reflections at a point where my midwifery career has exposed me not only to clinical practice in the United Kingdom and in Belgium, but also to contacts with midwives from most of the European Union and European Economic Area member states, through my participation in the work of the European Midwives Association. These experiences have led me to believe that midwives often demonstrate paradoxes between what they profess to believe and the actual care they provide. I shall therefore occasionally draw on personal experience rather than on systematic empirical research evidence, and for the sake of comparison, I shall use my knowledge of the British and French systems; but, midwives in other countries may well recognise similarities with their own situation.