to development. Archie Cochrane awarded the wooden spoon to obstetrics for recommending a wholesale move from home births to hospital deliveries without sound evaluation (Cochrane 1972); but one wonders if the same could not be awarded to the health professions that have adopted the move into higher education, including initial education at diploma or degree level, without sound evidence that this would improve the delivery of health care. And yet, more and more initiatives are being developed to deal with the changes in the health-care services, but without necessarily taking on board their effects on the quality of care delivery.
Educational developments at the European level aim to harmonise the quality and levels of higher education qualifications across Europe. The Bologna Dec-laration (European Ministers of Education 1999) laid down basic principles that ultimately aim to harmonise undergraduate and graduate education throughout Europe. Midwifery lecturers in some countries, including France, seem keen to adopt the principles of Bologna, and in particular, the principle that suggests that a minimum of 5 years in higher education after the baccalaureate should be rewarded with a Masters degree. So we would have the relatively nonsensical sit-uation of beginners qualifying with a Masters! Universities would have to accept that this level should be one of the relevant entry requirements to a higher research degree, such as a PhD. I believe I have come across enough midwives who have achieved a Masters qualification without studying research methods in depth and would be quite disadvantaged if they were to use this as an entry to a PhD. So here too, we shall have to be careful that the words used do not promise something that is different from what is normally understood. Certainly what is usually promised is the truth, but not quite the whole truth and nothing but the truth!
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11. The Potential of Service User Groups to Support Evidence Based Midwifery
Belinda Phipps and Gillian Fletcher
Introduction: losing the link
In the beginning, your health was your business and you were helped to stay healthy and were treated when you were ill by the elders of the tribe or society to which you belonged. Midwifery, probably the oldest profession, was carried out by women you knew, and you as a user of their services, fed back to them directly. If you liked what they did and the results were good you recommended them and you used them again. If not, you did not. Their status or their living depended on your happiness with their service.
As health care became part of organisations and particularly since the advent of the National Health Service (NHS), those who provide health services to you began to act in a way that was driven by those far away from the user’s personal experience of the service, without the benefit of your thoughts. Those who care for you are no longer paid according to how satisfied you are with their service.
Those who manage, train and govern the actions of those who treat you are no longer paid based on your satisfaction. Instead, insulated from the feelings of users, they become driven by the views of their masters and their staff. Status and pay depend on position in the hierarchy, not the skill with the user of the service. Being seen to be an expert by your peers became more important than being appreciated by those for whom you care.
As a result of this separation, the heath service became a place where those needing its services were done to. They were passive recipients of care designed and delivered by ‘the experts’. The health service became a society in its own right with its own way of doing things, and patients, a very anonymising disempowering term, had little or no say.
Carry on Matron, although a gross parody was amusing precisely because elements were true to life. Non-evidence based treatments and rules were unques-tioningly applied in a hierarchical structure where the views of those at the top
of the pyramid were more important than those for whom the service was being provided. Patients were almost an inconvenience to the running of the hospital.
This development is not unique to the health service. The bus and train services still struggle to develop and run their services in order to meet the needs of their passengers; they are also noted for a belief that their services would run more efficiently and on time if passengers did not get in the way.
This contrasts significantly with the statement, written over 50 years ago by Mahatma Gandhi, proposing a different approach to patient care and found on a wall in a Bombay (now called Mumbai) hospital.
A patient is the most important person in our Hospital. He is not an interruption to our work, he is the purpose of it. He is not an outsider in our Hospital, he is part of it. We are not doing a favour by serving him, he is doing us a favour by giving us an opportunity to do so.
For maternity services, this led to births where women were drugged into semi-consciousness and were not allowed to have partners or close family with them at the birth and for days afterwards; where babies were separated from their mothers and where women were encouraged to spray their nipples with antiseptic before rigid 4-hourly feeding; a service where enemas were compulsory and episiotomy routine; where dignity was removed along with one’s pubic hair and yet, at the same time, one was expected to behave nicely, keep quiet and do as the doctor required, in passive grateful patient mode.
My baby was kept in the nursery and only brought to me every four hours for feeding.
When I went home ten days later, I didn’t have a clue what my baby did all day and breastfeeding was a nightmare. Because of concerns about ‘infection’, he was ten days old before his dad even got to hold him once. Two years later when his brother was born, Andrew, aged 2, was not allowed to visit me in the hospital for the eight days of my stay. Hardly the best start to family life!
(One of the author’s experiences [GF] – first baby born 1971.)
Many of the elements that drive this behaviour are still built into the service today. Those in senior positions are paid more, much more than those providing the services. A chief executive officer can expect to receive a salary six or seven times that of a midwife working with mothers. Traditionally many consultants received substantial merit payments that were based on their standing among their peers and their reputation in research, rather than on their effectiveness with those they treat or the views of those who use their services.