When policy makes safety worse

Originally written in 2021, I’ve revised and updated this blog post. It serves as a powerful reminder of what can go wrong when you don’t get the right people around a table when making policy.

For my doctoral research, I used an approach called Institutional Ethnography. It’s not a common one, with not much research having been done using it specifically relating to maternity care. In 2020, I was introduced a team of researchers in Canada who were using Institutional Ethnography to understand how relationships between midwives and obstetricians at one hospital worked (or in their case were not working well). They went on to publish that research and it makes for a really interesting read (Brydges et al., 2021).

What was the aim?

The research started from a situation many of us in maternity care are familiar with: patient safety reviews into a cluster of poor outcomes had identified problems with communication and teamwork. The usual response is to try to address this through “shouty” policies (YOU MUST COMMUNICATE WITH EACH OTHER!!) or through inter-professional emergency education sessions that are somehow meant to improve teamwork in non-emergency situations. Fortunately for us, this group of researchers decided to dig deeper and uncover what was really going on underneath the surface.

What did they do?

They started by analysing hospital records relating to issues for consultations and transfers of care from midwives to obstetricians. They also interviewed sixteen midwives, nurses, and obstetricians and spent 75 hours watching people working in the birth environment. The observations and interviews set out to understand work processes and flows of information between the three professions. They were particularly interested in the way that policies and protocols shaped what people did, and the cultural expectations that related to how professionals worked together.

What did they find?

In this hospital, midwives provided independent care to women during pregnancy, labour, and after birth; consulting with obstetricians when needed. One of the factors the researchers uncovered as contributing to poor outcomes was a hospital policy known as the “Three Consult Rule”. This policy required midwives to formally transfer care of the birthing woman over to an obstetrician when they had consulted three times with an obstetrician for advice during that woman’s labour. Once care was handed over, the midwife could no longer provide any 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 in circumstance when it wasn’t actually appropriate to transfer care. They often deferred consultation in the hope that situations would resolve, meaning that consultations tended to occur late in the evolution of the clinical situation. The authors noted that the consequence of this rule “was the reinforcement of obstetricians’ perspectives that midwives often struggle when providing care, and only reach out when in considerable need, or far too late” (p. 19).

Fetal monitoring played an important role

I noted with interest (but absolutely no surprise) that CTG monitoring was identified as a common thread in the issues described in the paper. A central monitoring system was in place at the hospital. Some of the sorts of problems I saw emerge in my research into central fetal monitoring were also seen at this hospital. The authors described 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

What next?

The authors research provided opportunities to rethink the policy environment, not only at their hospital but at several others with similar policies. Policy changes were made by a multi-professional team, ensuring that they would work for everyone. This is an important lesson from the context where the research was conducted. Midwives had admitting rights at the hospital but were not employed there, and so where not previously included in policy-making work. Similar issues affect endorsed midwives in Australia when they provide care to private clients in public hospitals.

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. Having a detailed understanding of the problem opened up the possibility of different, and more effective, ways to go about solving the problem. It seems to me that shifting from an approach like Root Cause Analysis to Institutional Ethnography might get maternity systems out of the rut they have been stuck in for quite some time.

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Reference

Brydges, R., Nemoy, L., Campbell, D. M., Meffe, F., Moscovitch, L., Fella, S., Chandrasekaran, N., Bishop, C., Khodadoust, N., & Ng, S. L. (2021, Jun). “We can’t just have a casual conversation”: An institutional ethnography-informed study of work in labour and birth. Social Science & Medicine, 279, 113975. https://doi.org/10.1016/j.socscimed.2021.113975