Myself and my co-authors have a new paper, freshly published with Women and Birth (available here). One of the questions I asked while generating data from my doctoral research was – who made the decision about the approach to fetal heart rate monitoring that any individual woman would use during her labour? At first glance, the answer seemed to be that no one was actively making decisions.
I didn’t interview women who were in labour or after their births, so I don’t have their perspectives to draw on. I did observe midwives and obstetricians as they worked with women, and I interviewed people from both these professional groups. Midwives and obstetricians I interviewed acknowledged that women had a “right” to make decisions. But they also told me, and I observed, that they weren’t always taking an active role in sharing evidence about the options for fetal heart rate monitoring nor in supporting women to play an active role in decision making. There were some exceptions to this, particularly among midwives working in continuity of carer models.
This was interesting to me. Both obstetrics and midwifery considers that “informed choice” is an important principle. How was it that when it came to fetal heart rate monitoring in labour that offering information and choice to women were not routine practices? At the same time, obstetricians and midwives didn’t really own the decision making as their own either. I set out to understand how these practices happened as they did, and this paper covers what I found.
I won’t spoil your enjoyment of the paper as you can discover for yourself what the key findings were. What I want to share with you instead, is the sense of both relief and renewed purpose that I personally found when we figured it all out.
In my own practice, I too have struggled to get the balance right between having detailed discussions about the evidence base, and achieving the expectations set out by my employer and my professional body when it came to CTG monitoring. When I had detailed discussions about fetal heart rate monitoring in labour, and women decided on an option that was different to hospital policy, I found myself more than once being asked to account for myself by hospital management. Did I continue to risk censure from the hospital board, or continue to aim for the goal of “informed choice”?
I was left feeling that no matter what I did, it was not right.
Learning then how powerful the forces shaping clinical practice around fetal heart rate monitoring were was a relief. It wasn’t that I just wasn’t trying hard enough or was missing some magic trick. In my observations I could see that some of the professionals I was observing were also trying, mostly unsuccessfully, to navigate the same issues I had faced. This was not just a “me” problem, but a wider issue. I hope that those of you who share similar experiences will also feel a sense of relief that our recommendations were not to “try harder”.
Why renewed purpose?
Understanding the way that policy documents, research findings, and professional education structure clinical practice in relation to fetal heart rate monitoring helped identify a target for action. While none of us can change the past, we can work to achieve reform of the policy environment we work in, with the goal of achieving a better future. None of this is easy, and I often feel overwhelmed and inadequate in the face of such a mammoth task. Despite this, I remain committed to pursuing change. I encourage you to do the same.