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 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 use CTG monitoring (Chuey, et al., 2020). Let’s look to see what we can learn about why midwives (and 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 why using intermittent auscultation for women considered to be low-risk was uncommon. The other paper by Ford and colleagues was literature review. It 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 overlapped were these from Chuey et al.,
• Guidelines
• Fear of liability, and
• Providers as members of the healthcare team
And from Ford et al.,
• Damaged reputation
• Collegial conflict, and
• Intimidating disciplinary processes
Guidelines define appropriate, and therefore by extension, inappropriate care. Providing care outside guidelines can threaten reputations and relationships in workplaces. There are significant cultural powers that aim to keep people in line and following “the rules”. Conflict with colleagues might favour reporting to regulatory authorities. At the centre of all this – is the guideline.
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 decision about her care, it must have been because a midwife talked her into it, because women don’t make decisions. This happens when women’s place as a decision maker is undervalued and deprioritised in maternity care.
Fear of regulatory or legal consequences was also described in both papers. This is another area where guidelines play a central role, because they are often used to define whether care was professionally appropriate or not.
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 shape 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 is happening (Smith, 2004).
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 in all maternity services. 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 others 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.
So now what?
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 to detect and manage these. 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 expert 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 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 someone else calls 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 guideline writers should not assume they have the authority to control healthcare users decisions. In my research (Small, et al., 2022) I encountered two documents that did precisely this. They said:
• “risk factors that increase the risk of fetal compromise require intrapartum CTG”
• “medical and midwifery staff are responsible for decision-making regarding identification of women and babies who require Electronic Fetal Monitoring”
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 them not doing as the guideline said. 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.
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 maternity professional. We sometimes even blame birthing women for not having been proactive in educating themselves and communicating clearly. But as the research shows, 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.
I need your help…
I’m working on a plan for a workshop on getting the best out of your fetal monitoring guideline. Possibly a series of workshops so I can cover different guidelines one at a time. I want to understand the challenges you face when you are using your local fetal monitoring guideline so I can build something that is practical and problem-solving.
Help me out…
References
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
- Who makes decisions about fetal heart rate monitoring and how does it happen?
- Ready for some new insights?
Categories: CTG, EFM, Feminism, New research
Tags: conflict, fear, guidelines, litigation, midwife, regulation, reputation
Birth Small Talk 
This is spot on Kirsten. I was talking to a colleague the other day and it’s true that if a woman chooses care outside the guideline there is a belief that her MGP midwife has manipulated her into that decision. Not that women have the ability to think and choose for themselves! As an MGP midwife it is not unusual to have to spend time trying to explain to our colleagues that the woman has chosen these options and it is not appropriate to try and discuss the ‘risks’ when she is in labour, as they do not believe she understands! I think this is not only disrespectful to the woman but the midwife also.
I was also interested in your comment about a new way of developing guidelines. How good would that be if it was all about explaining options and supporting the woman accordingly and women respected for their decisions as they should be. However, I do think it is changing slowly, certainly the language has changed from a few years ago, guidelines tend to say ‘recommend’ rather dictating orders, so I think we are getting there slowly (still a long way though!). We just have to keep questioning and looking at new ways of doing things. Thanks for being one of those people Kirsten.
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Thanks Bethan. I’m sure you could whip up a decent guideline for the use of water immersion for women during VBAC.
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Thank you, Kirsten, for verbalising so clearly and in your simple but candid fashion the “overuse” of guidelines or quoting guidelines when one should look at the clinical situation more holistically, listen to the woman and perhaps select options ( outside the guideline) TOGETHER with the woman also understanding the issue. When I look back at my career as a young obstetrician, I was “committed” to protocols and guidelines and looked upon things as carved in stone. When I began my journey with midwifery and became a strong advocate for natural birth, which also led to a radical change in our childbirth practices in the hospitals, I began to look at intrapartum care, intelligent intermittent auscultation, admission CTG/ use of CTG in a whole different light. Your articles resonate with me very strongly. While I continue to listen to the constant refrain from colleagues about our “large volumes and inadequate staff”, I wish to still persist( while also working on solutions for the challenges we face) in trying to change practices- every small step contributes to the larger picture. Keep ’em coming, Kirsten- your blogs challenge us, and YOUR VOICE needs to be heard. I add my own small voice to yours😊
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Thanks Evita – and I’m glad to see you made it home safely from Denmark.
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As an LMC (Lead Maternity Care) midwife in Aotearoa, New Zealand, discussions with birthing women around guidelines and whether or not a woman may choose to follow them or not, are a regular feature of my practice. Thank you for articulating so well the issues this may sometimes causes amongst colleagues and pointing me in the direction of research to further my understanding. I so appreciate and look forward to your informative emails. Ngā mihi (appreciation and acknowledgement) to you!
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Thanks Fiona, I’m glad you found it useful.
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