Birth Small Talk

Talking about birth

Three strikes and you are out!

An interesting case of how a great idea can backfire and make maternity care less safe.

Photo by Johnny Wang on Unsplash

Last year a Google Scholar alert introduced me to a team of researchers in Canada who have also been making use of Institutional Ethnography to understand how inter-professional relationships in maternity care work (or don’t). They have now published their research and it makes for a really interesting read (Brydges et al., 2021). The research started from a situation many of us in maternity care have encountered: patient safety reviews had identified problems with communication and teamwork leading to poor outcomes. Unlike many when faced with this situation, this group of researchers decided to dig deeper and uncover what was really going on. 

In this hospital, midwives provided autonomous care to women during the antenatal, intrapartum, and postnatal periods, consulting with obstetricians when needed. One of the factors the researchers uncovered that was contributing to poor outcomes was a hospital policy known as the “Three Consult Rule”, which required midwives to hand care of the birthing woman over to an obstetrician when they had consulted three times with an obstetrician during that woman’s labour. Once care was handed over, the midwife could no longer provide clinical care for the woman. While this policy was intended to support safe care, it backfired. Midwives had to decide which situations were important enough to consult for as they might use up their three consults when it wasn’t appropriate to transfer care. The authors noted that the consequence of this rule “was the reinforcement of obstetricians’ perspectives that midwives often struggle providing care, and only reach out when in considerable need, or far too late” (p. 19).

I noted with interest that CTG monitoring was identified as a text which pervaded all the issues described in their paper. A central monitoring system was in place and I was interested to see that some of the sorts of problems I saw emerge in my research were also seen at this hospital. The authors describe how the visibility of the midwife’s work at the central monitoring system generated anxiety for nurses and obstetricians who could see the CTG.

“Nurses and obstetricians expressed tension around the EFM: they saw it as a window into the situation for the midwifery client, yet were fearful of their medico-legal accountability once they looked at the tracing and did not act on any concerns. … The obstetrician was not meant to interfere with the midwife’s care unless asked:

“It is a bit tricky, because on the one hand I think medical legally we’re ultimately responsible for anything that’s happening on the labour floor while we’re on call. But at the same time, if they’re [midwives] not talking to me about it, I don’t really know what my responsibility is to watch these tracings or see how their labours are progressing and things like that.” (OB003)

Thus, throughout all work processes, the EFM served as a “window” for surveillance of the midwife’s work and muddied the waters in terms of consults being initiated at the midwife’s discretion and the obstetrician’s accountability.”

p. 24 – 25

This paper sets out some of the basic concepts in Institutional Ethnography and does a really good job of explaining how these were applied to the research work. If you are a budding Institutional Ethnographer it is a paper worth reading. If you work in maternity care and wonder why, after all these centuries of animosity between obstetricians and midwives, we still can’t just get along, then this paper is worth reading. It helps to make visible the ways in which policy guidance reinforces and recreates these historical fault lines – and as usual, birthing women and their babies pay the price in the form of poor outcomes. 


Brydges, R., Nemoy, L., Campbell, D. M., Meffe, F., Moscovitch, L., Fella, S., Chandrasekaran, N., Bishop, C., Khodadoust, N., & Ng, S. L. (2021). “We can’t just have a casual conversation”: an institutional ethnography-informed study of work in labour and birth. Social Science & Medicine, in press.

Categories: CTG, EFM, New research, Obstetrics

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