Midwifery led care: risk management issues

Midwifery led care: risk management issues Soo Downe Risk management and medico-legal issues in women's health RCOG , London With thanks to all those who feature in the photographs, and especially to the women and staff in Blackburn, and to Denis Walsh

….Risk was/is real.. ‘Childbirth in the late 19th century was both difficult and dangerous. Maternal mortality stood at around 500 per 100,000 births compared with approximately 12 per 100,000 today. Few women had access to trained attendants in childbirth and many of the poor had to depend on local untrained midwives.’ RCM website

…but birth is more than the physical.. ‘...To anyone who thinks about it long enough, birth cannot simply be a matter of techniques for getting a baby out of one’s body. It involves our relationship to life as a whole, the part we play in the order of things… Kitzinger 1987

Valuing wellbeing as well as risk avoidance: Health is… …a complete state of physical, mental and social well-being, and not merely the absence of disease or infirmity’ WHO 1948

Social safety in Brazil …‘Project Luz’ has given many women the feeling of strong confidence in a safe delivery and in child rearing…leading to self-transformation, which empowers them profoundly. This…raises their concerns about society, their lives, and motivates their participation in community activities and development.’ Umenai T 2001

Beware medical (midwifery) nemesis (Illich) -’I had a woman who had a massive haemorrhage at home, so home birth/midwifery led care is inherently unsafe’..

Over-generalisation • Risk management criteria tend to be based on population level evidence • Clinical practice is about individual service users and clinicians working in complex and uncertain environments

What do we mean by midwifery led care? • Antenatal, intrapartum, postnatal? • Team midwifery? • Caseholding? • One to one? • Birth centres, integrated or free standing? • Home births?

Why manage risk specifically for midwife led care? • Philosophical differences (and suspicions?) between systems and professionals • Grey and underresearched boundary issues • ‘Alternative’ techniques and treatments • Geographical distance • Silo mentalities

Elements of clinical governance • Patient, Public and Carer Involvement • Strategic Capacity and Capability • Risk Management • Staff Management and Performance • Education, Training and Continuous Professional Development • Clinical Effectiveness • Information Management • Communication • Leadership • Team Working http://www.cgsupport.nhs.uk/About_CG/

Risk management through clinical governance Clinical governance is the system through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care, by creating an environment in which clinical excellence will flourish http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/ClinicalGovernance/fs/en

Unpacking this… • System: singular? • Accountable: level of accountability? • continuously improving: possible conflict? • quality : judged by? • high standards of care : for populations or/and for individuals? • flourishing clinical excellence…clinical autonomy?

Key risk issues in midwife led care:Clinical governance in NICE intrapartum guidelines (consultation draft) • Focus is on risk management of place of birth (specifically out of hospital birth), and on EFM • Booking criteria, transfer criteria and efficacy, poor outcomes • Specific audit required of transfers that should have taken place (but not those that shouldn’t have, or of bookings that should have been in an alternative setting?)

‘Maternity matters’ …by 2009…all women will have choice in: • where and how they have their baby • what pain relief to use...

The transfer issue: how can we avoid ‘disarticulation’? Safety of mothers and babies is paramount.. …there needs to be absolute clarity around responsibilities and clear protocols governing transfers before, during and after labour…so that women can transfer flexibly and in a timely manner between different levels of care p19

Providers responsibilities… (p28) • adequate staffing levels • audit and consequent action especially following poor outcomes • environment, facilities, timelines of services • transfer arrangements • women-focused, family-centred care • gather and report routine data • development of the workforce, with training and continuous professional development • regular board level reviews of the performance and function of maternity services

Royal Colleges and Professional Bodies responsibilities • Define measurable standards for… skills, competencies and regular continuing professional development… • Support the development of…postgraduate education and training… • Facilitate multidisciplinary learning so that all clinicians train in a way that recognises each others responsibilities within the team to improve care and safety

Elements of effective care 12 key factors in 4 Canadian units with low CS rates (selected five) • Pride in low caesarean section rates • Hospital culture – “birth is a normal physiological process” • Commitment to one-to-one support during labour • Effective multi disciplinary teams (who liked each other) • Effective (? transformational) leadership • Ontario Women's Health Council: www.womenshealthcouncil.com/ (NHS centre for improvement and innovation 2006)

Changing systems doesn’t always (often doesn’t) make much difference… Simpson, Kathleen Rice; James, Dotti C.; Knox, G. Eric 2006 ….’Nurses and physicians shared the common goal of a healthy mother and baby but did not always agree on methods to achieve that goal….’

Design • 4 hospitals (approx 3000-6000 births • Nurse managed labour predominant model • 54 nurses, 8 focus groups • 38 obstetricians, individual in-depth interviews.

Areas of contention: augmentation of labour and interpretation of EFM They [the physicians] like that pit pushed and you'd better push it and go, go, go, otherwise they'll be hot, really mad if it's not going. I would be petrified if at 7 am they [the physicians] walked in and I didn't have the pit going. They'd yell at me and that's just an added stress.

What did the doctors value in the nurse-midwives? The main thing is to have a nurse who is not afraid of pit, who can actively manage the labor and be aggressive in turning it up on a regular basis. When I hear I've got a nurse who will go up on the pit, I know it's going to be a good day.

…philosophical conflict that resulted in (covert) resistance I increase the pit as I need to, but I'm not going to have contractions right on top of each other. I'm not going to cause fetal distress or injure a baby. Cf : anterior rim, Annendales ‘ironic intervention’, apparent shifting in gestational age…

Problems of lack of trust and respect (subtle power games) Sometimes I feel downright unwelcome when I show up on the unit to check my patient without being called. The nurses say … 'What are you doing here? I didn't call you.'

Lack of trust & respect.. Some doctors are a disaster so I make sure I don't call them for delivery until the head is almost out. That way I can try to prevent a vacuum or forceps, I don't have to deal with fundal pressure and I don't have to stand there while they sew up the inevitable fourth degree laceration. The patient is much better off and they don't even know what a favor I've done for them.

And the consequence is…‘workarounds’ (Iedema et al 2006) So it almost becomes like a battle where you think she [the nurse] should be doing this and she has other ideas but doesn't necessarily tell you. Instead of directing all your attention to the patient you end up having to worry about the pit. It doesn't serve the patient well where you're not working really together.

Subtle rules of interaction…a risk? If I really think she [the patient] needs a section and I want them [the physician] to come over, I use key words … "going no where, head is sky high, she's stuck, not changing even with good contractions.“ When I'm busy in the office or in the middle of the night, I'm listening for key words or phrases that mean I have to come … like fetal distress, lots of blood, prolapsed cord, ready for delivery … otherwise I know they don't need me right away. I can't come in for every call.

Nurses' views of "good" physicians • not always in a hurry; doesn't yell or scream at me; • professional; courteous; • patient and kind to the patients; • understands the labor process; knowledgeable; keeps up to date; • doesn't call to tell me to push the pit or get her delivered at a certain time; • respects what we do; asks my opinion; trusts my judgment • nice to the new nurses.

Physicians' views of "good" nurses • can predict when delivery will occur (I like to be called an hour before); anticipates my needs; knows me well; and knows when to get concerned and when to get serious and push the panic button and feed the information to the physician. • proactive; helps patients stay on the labor curve; not afraid of pit; • loving and caring toward the patient; • wants patients to have the best possible outcome; • a selfless kind of attitude; at the bedside; • older; reliable; consistent; knowledgeable, experienced;

Beware false sense of security about ‘teamwork’…. Physician participants had a more positive opinion of the state of teamwork than did nurses

To manage risk effectively we need to move from this….

..to this

‘effective multidisciplinary teams who like (trust, respect, care for, constructively challenge) each other’ Example one: planned homebirth for woman with haemorrhagic problems, and previous caesarean section

Example two: managing intervention positively

‘effective teams’…Learning mutual trust and governance with rather than governance of or over… Example three: planning for the future together (midwives, obstetricians, GP’s, paediatricians, managers, commissioners, service users &etc)

Essential components of risk reduction based on reward not punishment.. • (properly) agreed & updated clinical guidelines applied FLEXIBLY • regularly tested clinical protocols for emergencies/sentinel event • regular training in keeping birth normal as well as in EFM and other labour management skills • for out of hospital birth, ALSO type training and skills • rapid non-judgemental review of adverse events based on collegiate support and learning • regular sharing of insights, novel experiences, and positive successes within and between disciplinary boundaries • on-going audit and regular publication of clinical & service user results • celebration of success, innovation, and constructively critical debate

…and based on mutual respect, ‘heedfulness’ and ‘error wisdom’ • Before it can be effective, an organisation must dismantle its vicious cycles.…(p63)… • The major hurdle is to remove the underlying fear of telling the truth (p 56) • Each person must become a fully responsible autonomous agent who respects the rights of others to assume similar status. (p 66) Kelly & Allison 1998

And if we don’t do this… Agents, frightened of losing their positions, adopt threatening postures and tell 'white' lies to protect themselves. Afraid to report the truth as they see it, they don't provide full and accurate information. Decisions, made in ignorance, backfire, leading to mistrust. People learn not to entrust their individual survival to others in the group. Mistrust amplifies the fear and the cycle intensifies Kelly & Allison 1998 p54

What is the risk of loss of benefit? My life was devastated by my experience and it has made me a worse mother – a barely functioning suicidal mother at times who was deeply wounded by the careless expression of “never mind at least you have a healthy baby” of course I mind!…Of course I am delighted to have a healthy baby but my feelings matter too.Sarah Beech and Phipps 2004

The risk of getting it wrong.. ‘…the way a woman gives birth can affect the whole of the rest of her life - how can that not matter - unless the woman herself doesn’t matter…’ Beech and Phipps 2004

And the advantages of getting it right…(particularly for disadvantaged women & babies) ‘You have given me power in my life that I could never have dreamed of; I have achieved something wonderful for the very first time and no-one can take that from me. Thank you’ (Carol 1st baby, from Walsh 2006)

Midwives, doctors, and maternal mortality I found – and it was not a finding I had expected – that wherever (there was) a system of maternal care…based on trained…and respected midwives… maternal mortality was at its lowest. I cannot think of an exception to that rule. Loudon 1992 p426-7

George Bernard Shaw We are made wise not by the recollection of our past, but by the responsibility for our future.

Midwifery led care: risk management issues