Having drawn on the work of Etzioni and Greenfield, which relates to organ-isational accountability, it is appropriate to begin my examination of who
To whom is the midwife accountable? 135 holds the midwife accountable. I begin by considering the institutional and legislative context within which he/she works.
Institutional accountability
Although not every midwife in the UK is employed within the National Health Service (NHS) or self-governing NHS trusts, a large majority are and some form of institutional accountability is required of them. It is possible that even the midwife who practises independently may be held accountable to those alongside whom he/she practises.
The role of midwives as employees inevitably requires them, through their contract of employment, to adhere to the policies of the organisation.
Although they may perceive their role as being solely to provide care to the woman experiencing uncomplicated childbearing, their employers may require them to ‘extend’ their expertise in a particular direction.
An example of this phenomenon is illustrated in the writing of Hall (1999), who recounts and analyses two experiences of home birth. One of these was marred by the midwife’s lack of confidence in the woman’s ability to give birth healthily and happily without a room full of hospital technology. This midwife is likely to have been required by her employers to extend her prac-tice in the direction of less technologically-based care. Even though it is fundamental to midwifery, this may not have been her area of choice.
In historical terms, the major organisational development which affected the midwife’s accountability was the introduction of the NHS in 1948 (Tew, 1995). Prior to becoming employed by local authorities and hospital boards at this time, a large majority of midwives had been relatively inde-pendent practitioners, fully accountable to those whose births they attended.
The advent of the NHS meant that more women were able and willing to give birth in hospital and that obstetricians began to become routinely involved in the care of healthy pregnant women. Thus, the orientation of midwives was changed. Their accountability came to be to their employers, who now paid their salary, and more and more to their obstetrical colleagues.
Increasing obstetrical involvement soon lead to the ‘as if’ or ‘just in case’
routines and the ‘cascade of intervention’, which is associated with escalat-ing medicalisation of the birth (Goer, 1995).
The need for more hospital facilities, including labour wards and post-natal beds, soon became apparent. Perhaps to justify the increasing number of maternity beds in the presence of a falling birth rate, a series of Government reports recommended increasing levels of hospital confinement. This scenario escalated and the numbers, status and power of obstetricians increased cor-respondingly and exponentially. So the scene was set for the ‘technological revolution’ which burst on to the obstetric stage in the early 1970s. This led to the observation that the midwife’s accountability had been reduced, to the extent that she had been transformed into an ‘obstetric nurse’ (Walker, 1972, 1976).
136 Where does the Buck Stop? Accountability in Midwifery
The hierarchical organisational structures within which midwives continue to work serve only to diminish their accountability, as mentioned by Etzioni.
A House of Commons Report (1992) and the Government’s response to it (Department of Health, 1993c) do not appear to have fulfilled their promise to reverse this trend (Rothwell, 1996).
Accountability to the woman
Legislative accountability was originally intended to protect the public, and the legislative framework within which the midwife currently practises continues to have this aim. Although Jones (1994) attempts to distinguish them, accountability to the public and accountability to the client are synonymous. This is because, logically speaking, the public benefit must include, but is not equivalent to, the welfare of the individual woman for whom the midwife is caring. This may not be an easy concept to accept when the overall standard of that woman’s care appears to be being determined by a book of Midwives Rules (UKCC, 2002) and a Supervisor of Midwives.
It may be that accountability to the woman operates in two ways. The mode of operation discussed below, via the professional legislative framework, may be said to act indirectly, by the intervention of human and other agencies.
A more direct form of accountability is that which midwives exercise in their day-to-day hands-on practice, involving the care of women, babies and families.
Personal accountability
It is cogently argued that in ethical terms the main form of accountability to carry any weight for midwives is their accountability to themselves. Jones (1994) indicates that this form of accountability is an unalterable fact of care.
Caring according to one’s own philosophy of life and acting consistently according to the demands set by one’s own value system may call for a dif-ferent standard of care than that required by any external agency. Tschudin regards this intensely personal sense of responsibility as comparable with the way ‘religious people would say that they have to answer to God’ (1989).
Smith (1981) supports the crucial and fundamental nature of personal accountability, because it operates at all times, throughout the life of any healthcare provider, unlike the few occasions on which the midwife may be asked to give account of her actions to an outside body. I would argue that this personal form of accountability is the highest form, underpinning all other forms of accountability, in that being accountable to oneself is an essential prerequisite to being able to be accountable to any other person or agent.
While contemplating the significance of personal accountability we should consider the effects of the dichotomy between personal accounta-bility and external accountaaccounta-bility on learning. In the event of a mistake by
To whom is the midwife accountable? 137 a care provider personal accountability might, through reflection, facilitate learning, personal growth and greater maturity. On the other hand external accountability, through a legislative framework, may lead to little more than disciplinary action.
Professional accountability
Tschudin (1989), in discussing the various forms which nursing accountability may take, describes the legislative framework through which the nurse’s accountability to the public operates. In the opening years of the twentieth century the equivalent midwifery framework reached the statute book two decades earlier than that for nurses, against a background of jingoistic pub-lic concern at the lack of suitable manpower to fight popular colonial wars.
Midwives were considered essential to solve the problems of infant mortal-ity and morbidmortal-ity, in order to lay the foundations for a healthy population from which recruits could be drawn (Robinson, 1990), but the public still needed protection from unsafe and incompetent practitioners. Legislation was sought which would provide adequate protection.
This legislation eventually emerged for England and Wales in the form of the first Midwives Act (1902). In spite of its well-known flaws (Donnison, 1988), this legislation recognised the special position of the midwife com-pared with other carers, in terms of her accountability for her actions. Since the beginning of the twentieth century the solitary nature of the midwife’s practice and her role in prescribing and administering certain medicines have been regarded as putting the midwife in need of a specific regulatory framework.
This framework is in the form of the statutory Midwives Rules and the non-statutory but otherwise equivalent Code of Practice (UKCC, 2002). Such a framework causes one to question the extent to which the midwife is truly accountable, as these rules relate to clinical care decision making, among other areas. Newson (1986), having established the original need for the Midwives Rules as relating to training needs and the protection of families from unsafe practitioners, recognises the questions they raise about the midwife’s accountability. She further asks whether these rules continue to be necessary. In answer to her question, she indicates the variation in mid-wives’ competence ‘from excellent to less than satisfactory’. The continuing practice of ‘less than satisfactory’ midwives is a sad reflection on midwifery supervision and our systems of basic and continuing midwifery education.
It is hardly a justification, though, for what may be perceived to be a legislative straitjacket. Although midwives such as Newson clearly regard the rules as a supportive framework within which the midwife may practise safely, it may be that the existence of this framework constitutes more of a threat to midwifery, by limiting accountability, than a support to safe practice.
Closely linked with the Rules and Code of Practice is the role of the Supervisor of Midwives, described by Duerden (2002):
138 Where does the Buck Stop? Accountability in Midwifery
When practice problems are identified, Supervisors of Midwives provide support and guidance to midwives creating an opportunity to develop practice. This is through the facilitation of a period of supervised practice during which the Supervisor of Midwives ensures that the midwife has the necessary knowledge and skills.
The potential and real difficulties in the relationship between the midwife and the Supervisor of Midwives are well known (Hunter, 1998; Beech &
Thomas, 1999).
Isherwood (1988, 1989) maintains that in a supportive situation this relationship may be ‘close and cooperative’. It is easy to understand, how-ever, that it may deteriorate into being ‘confrontational’ when the midwife is called to account to her supervisor for the standard of her practice.
Isherwood relates that, in such destructive relationships, it is not only the midwife who suffers, but also the client, through the more restricted service which she may be offered. The questionnaire survey by Burden & Jones suggests that the midwife’s perception of the judgemental nature of midwifery supervision is gradually beginning to change (2001).
It may be that midwifery supervision is the more acceptable face of the midwife’s professional accountability. The other side, that is the disciplinary procedures, is detailed by Symon (2002). Serious complaints by clients, police and employers are screened and dealt with by the NMC, to assess whether the charges against the midwife are proven. If so, the Professional Conduct Committee must decide whether they should be cautioned or their name be removed from the professional register on a temporary or a permanent basis.
There is one question which inevitably arises out of this examination of the midwife’s accountability. This is whether, for traditionally autonomous practitioners such as midwives, the very existence of these statutory bodies and the associated legislative framework serves by to reduce the need for them to regard themselves as accountable?
Hierarchy of accountability
It may be argued that personal accountability, through which one has to jus-tify one’s actions to oneself, is the highest order of accountability. This may be because of the continuing nature of personal accountability or perhaps because of the tendency for the demands we make of ourselves to be higher than those other people make of us. Does accountability in such circumstances equate with our conscience? The lower order forms of accountability, such as the organisational form, may have more easily apparent consequences in terms of the potential for disciplinary action and implications for employ-ment. For this reason they may be more readily discussed and reported. It is being suggested here that they certainly pale into relative insignificance com-pared to personal accountability.