There is clear research evidence that women are not consistently informed that they have a choice of fetal heart rate monitoring method in labour, are not provided accurate information about the benefits and harms of each option, nor asked what they have decided. (I have written about this here.) A recent literature review about midwives’ experiences of providing care to women who decline recommended care caught my eye (Ford, et al., 2022). While the literature they explored was not about fetal heart rate monitoring, I saw significant overlap between the themes Ford and colleagues described and those from a previous paper that was about why maternity professionals choose certain forms of fetal heart monitoring (Chuey, et al., 2020). Let’s look to see what we can learn about why midwives (and by extension other maternity professionals) might not support women to have a choice when it comes to fetal heart rate monitoring in labour.
Comparing the two papers
The earlier paper was the work of a team of researchers from Michigan, USA (Chuey, et al., 2020). They interviewed 41 nurses, midwives, and doctors, aiming to understand the facilitators and barriers to using intermittent auscultation for women considered to be low risk. Ford and colleagues’ literature review sought evidence from research specifically about the experiences of midwives who worked in continuity of care models as they provided care for women who chose care outside of recommendations (Ford, et al., 2022). The themes that seemed to overlap were these from Chuey et al.,
• Policies, procedures, and evidence-based protocols
• Fear of liability, and
• Providers as members of the healthcare team
And from Ford et al.,
• Damaged reputation
• Collegial conflict, and
• Intimidating disciplinary processes
The research question structuring Ford and colleagues paper assumed that policies, procedures, and protocols (I’m going to lump all these sorts of things together and calling them guidelines from here on) existed and had legitimacy to shape care provision, and that there can therefore be such a thing as care that doesn’t align with guidelines. Chuey et al., described a relative absence of guidelines to protect and promote intermittent auscultation as an option, which was not the case for CTG monitoring. When women chose intermittent auscultation, in some hospitals they were asked to sign a waiver documenting their refusal of CTG monitoring, while no formal documentation of consent was needed when CTG monitoring was chosen.
Guidelines define appropriate, and by extension inappropriate care. This idea comes into play as we look at the other commonalities in the two papers. Both papers described of the importance of maintaining collegial relationships and how providing care outside guidelines (easily misinterpreted as inappropriate care) threatened these relationships. Conflict with colleagues had the potential to lead to loss of professional reputation and might favour reporting to regulatory authorities.
Ford and colleagues noted that one reason for loss of reputation was the conflation of women’ decisions with decisions made by their midwife. In other words, if a woman made a choice about her care, it must have been because a midwife talked her into this choice, because women don’t make such decisions. When women’s autonomy is undervalued and deprioritised in maternity care, a woman’s role as the primary decision maker in her own care becomes invisible like this. It is then easy to assume that care outside a guideline can only occur because a midwife (or another professional) chose that option.
Fear of regulatory or legal consequences was also described in both papers. This is another area where guidelines play a central role, because they can be used to retrospectively define whether care was professionally appropriate or not. Fear of a poor outcome related to chosen fetal monitoring method was mentioned by participants in the research by Chuey and colleagues, while Ford and colleagues found that midwives concerns were about the “fear of judicial processes in the event of a poor outcome, rather than the poor outcome itself” (p. 9). This may relate to differences in legal and regulatory processes in the USA where Chuey and colleagues were gathering data, and the countries where the research in the Ford et al. review was conducted (mostly the UK and New Zealand).
Why does this matter?
While Ford and colleagues were interested to understand midwives’ experiences, Chuey’s research team set out to identify reasons that prompted a decision to use CTG monitoring rather than to offer intermittent auscultation. Fears about relationships with other maternity professionals, and legal or regulatory consequences were identified as issues for midwives and others. Rather than simply being unpleasant experiences that are an inevitable part of professional life, the authors of both papers showed how these fears had the potential to directly impact women’s choices (or lack thereof).
So here’s the thing…
It might be tempting to look at these two items of research, each confirming important aspects of the other, and decide that maternity professionals are the problem. You might argue that maternity professionals should set aside their personal anxieties, and always provide woman-centred care no matter how tough the going gets. I don’t see that a lack of backbone in maternity professionals as the problem, nor telling them to pull up their socks as the solution here. There is another way to interpret the findings from both these research teams, and that relates to the role that guidelines play in healthcare systems.
Institutional Ethnography (the approach I used in my doctoral research) shows us that when groups of people do similar things, particularly in different settings and at different times, you can understand how this happens by looking for texts that structure what people are doing. By studying how the texts are used and looking at the values, beliefs, and assumptions embedded in the text you can begin to make sense of what happens on the “ground floor” (Smith, 2004). And this understanding can sometimes help to make sense of all the “ground floors” where the same sorts of things are happening.
Every high-income country has one guideline, and sometimes more, that shapes what maternity care professionals do, or do not do, in relation to fetal heart rate monitoring in labour. That nurses from the USA, obstetricians from Scotland, and midwives from New Zealand can describe similar ways of providing care to women in labour is testament to the organising effect that guidelines have on all of us. Because these guidelines exist, and share similar structures, it becomes possible for a maternity professional in most parts of the world to be singled out as a bad egg and pressured to conform. That pressure might take the form of tattling in the tea-room, cross words in corridors, reports to regulators, or suggestions of sackings. The pressure can come from people in positions of authority, or take the form of “horizontal violence” where people with similar status attempt to keep people in line. While these individual actions may not be effective every time, over a lifetime of practice they can grind people down until they comply, or leave their profession.
You won’t find me arguing for the wholescale abandonment of guidelines. I started practice when guidelines were a new-ish idea, and they really did make life easier and care better. You also won’t find me arguing that there is no such thing as bad practice and no need for systems of governance to detect and manage these. There clearly is – a quick read of the Ockendon review or a similar investigation makes this clear. The problem with guidelines is not that they exist nor that they play a role in structuring good practice. The problem is when guidelines over-reach their purpose.
In their ideal form, guidelines would collate and analyse all forms of authoritative knowledge on an issue and provide easy to understand interpretations of this evidence. Guidelines should set out the responsibilities of healthcare organisations to provide sufficient staff and adequate resources to provide care, in a way that makes the organisation (rather than individual staff members) accountable for poor outcomes. Guidelines should provide a shared language so that professionals can communicate effectively with one another (is what you call a variable deceleration the same as what I call it?). Guidelines should include standard protocols (what paper speed should be used on the CTG printout?). Guidelines should set expectations about what healthcare professionals are doing when they are providing professional care (keeping records, maintaining confidentiality, being respectful and honest).
What guidelines should never do is to dictate decisions that healthcare users must make in relation to their care. That is overreach. Healthcare users are not employed by nor accountable to healthcare systems and therefore guidelines should not assume they have the authority to control healthcare users decisions. In our recently published research (Small, et al., 2022) we encountered two documents (one a “guideline”, the other a “procedure”) that did precisely this. They said:
• “risk factors that increase the risk of fetal compromise require intrapartum CTG” (the guideline).
• “electronic fetal surveillance is commenced as per the recommendation”, and later that “medical and midwifery staff are responsible for decision-making regarding identification of women and babies who require Electronic Fetal Monitoring” (the procedure).
While at first glance these statements appear to be about what is expected of the maternity professional, they are both based on the assumption that women do not get to decide on the type of fetal heart rate monitoring they will use. Midwives and doctors were the ones that had to make sure that CTG monitoring was used and asking women what they wanted to do would have risked not meeting this goal. This type of guideline recommendation sets up the problem that Ford and colleagues described, where the midwife was seen as the accountable party when a woman made a decision that was at odds with the guideline.
Having spent most of my professional life in maternity care, I don’t know what goes on with guidelines in other parts of healthcare (let me know in the comments!). It has been my experience that guidelines making decisions for birthing women like the examples above are common in maternity care in many parts of the world. If this were not the case, then the review done by Ford and colleagues would not have generated consistent findings across different bodies of research.
I’ll even go so far as to suggest that if we had good guidelines (feminist, woman-centred, evidence-based ones) then there would no longer be such a thing as “care outside the guidelines”. This concept exists only because of the belief that it is the role of a guideline to direct healthcare users to one (or rarely more than one) correct choice. If guidelines said here is the evidence of the advantages and disadvantages each of the available courses of actions, and this is what health professionals should do when people chose any one of these options, no choice would be on the outside. All choices would be inside the guideline. Imagine what that would be like….
Moving from blame to reform
It is easy to lay the blame for women not being given information or choice about fetal heart rate monitoring at the feet of the individual clinician. We sometimes even blame birthing women for not having been proactive in educating themselves and communicating clearly. But as the research reviewed in this post including our own has illustrated, bad guideline design exerts strong pressure on clinicians to behave in a way that limits women’s autonomy. This is a system problem, not a people problem. The solution should never need birthing women to turn up to care with a degree in critical analysis of research, armed with a birth plan, a doula, and a medical defence lawyer on speed-dial to get what they want. The solution is also not to ask maternity professionals to try harder. The solution is to have a good long hard look at our guidelines and fix them.
Chuey, M., De Vries, R., Dal Cin, S., & Low, L. K. (2020, Jan/Mar). Maternity providers’ perspectives on barriers to utilization of intermittent fetal monitoring: A qualitative study. Journal of Perinatal & Neonatal Nursing, 34(1), 46-55. https://doi.org/10.1097/JPN.0000000000000453
Ford, P., Crowther, S., & Waller, N. (2022, Jul 19). Midwives’ experience of personal/professional risk when providing continuity of care to women who decline recommendations: A meta-synthesis of qualitative studies. Women & Birth, in press. https://doi.org/10.1016/j.wombi.2022.06.014
Small, K., Sidebotham, M., Fenwick, J., & Gamble, J. (2022). The social organisation of decision-making about intrapartum fetal monitoring: An Institutional Ethnography. Women & Birth, in press. https://doi.org/10.1016/j.wombi.2022.09.004
Smith, D. E. (2008). From the 14th floor to the sidewalk: Writing sociology at ground level. Sociological Inquiry, 78(3), 417-422. https://doi.org/10.1111/j.1475-682x.2008.00248.x