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Midwives should be aware of climbing the hierarchy and losing their skills at the bedside. Caroline Flint argues for a radical rethink of how the profession should be organized When we midwives separate ourselves from women we do ourselves harm - after all the term midwife means `with woman'. I'm thinking about the management of our profession and the damage we have done to ourselves by adopting the hierarchy of nursing - and in so doing we have separated ourselves from our reason for existing: pregnant women and their babies. At the moment midwives are led, administered or `managed' by people with such ambiguous titles as chief nursing officer, district nursing officer, director of nursing studies (midwifery), nursing officer, special projects officer or sister. Some units, aware of the loss of identity of the midwife which is present in these titles, are now appointing senior midwives instead of nursing officers or even midwifery specialists, but as far as I can see the change in title does not necessarily go with a change in perception of what the job entails. Practitioners in a clinical speciality need regularly to see the receivers of that care, and when they separate themselves from the recipients they can become out of touch with both the women who receive care and also with the providers of care. Doctors have a lot to learn from midwives, but one thing that they can teach us is how to stay as clinicians, even at the top of the tree. The professor of obstetrics, surgery or medicine is recognized to be an excellent clinician and as such his expertise is utilized. Once a midwife has risen above the rank of sister, she is unlikely to do any clinical practice again. Only if she has determinedly maintained her clinical involvement, often with great difficulty, against the expectations of her colleagues, the mountain of `urgent' tasks with scant relation to the care of women, and the demands and needs of those she works with, can she maintain her clinical practice. How could we run our service differently? Could we run it better? Someone must act as co-ordinator and there is a need for someone old and wise to act as a consultant for the less experienced practitioners. Many reading this will suggest that there is also a need to `manage' the less able practitioner, but I would refute this suggestion. When people are given the responsibility of being autonomous and accountable, they grow into that responsibility. Because we have adopted the nursing model which treats everyone as if they are on the lowest level of attainment, we are in danger of not allowing the most able to flower and to practise fully. Perhaps this is one reason why only one in five qualified midwives is practising, and why so many excellent midwives leave the profession to become health visitors, supervisors in Marks and Spencer, teachers or social workers. Nursing `procedures', showing us how to act by rote in our care of each, very individual, mother can only harm our spontaneity and ability to think creatively. Perhaps it isn't only our nurses' clothes that are harmful to midwifery. Perhaps it is many of the other aspects we have imported from the nursing field which we have taken on. How could we structure ourselves in a different way? How could we be a midwifery profession and practise as such? Let us start at the grass roots and look at the person who is actually doing all the care now - the midwife. The midwife is a practitioner, she has learnt during her education to provide care for pregnant women, labouring women and the family during the puerperium. Each midwife works within a small team of perhaps four or six. This team has responsibility for the care of a certain number of women and the women are all booked under a particular consultant obstetrician or consultant midwife.Because each team of midwives has responsibility for a named group of women and the care of these women depends on the midwives concerned, their sense of responsibility would be greatly increased. If a woman did not come to a clinic when she was expected, one of the midwives would make it her business to contact the woman, because she would be aware that the care of this woman depended on her and her partners. The midwives in the team would not be community or hospital-based midwives, they would be woman-based midwives, able to go where the woman happened to be. Each team would be a team of equals, but it is likely that different members would have different skills. One would take on the responsibility of organizing the holiday rota, one would organize the time sheets and claim forms for payment, one would keep tabs on all equipment and arrange for repairs, one would take responsibility for giving thanks for the presents received. All these professional equals would meet regularly every week to plan their work and the care of the women they are responsible for. They would report regularly to their consultant who would either be a consultant obstetrician or a consultant midwife who would also be a supervisor of midwives. The midwives attached to a consultant obstetrician would also need to relate to one of the consultant midwives who would be the supervisor of midwives for all the obstetrician-attached midwives. The concept of a consultant midwife may seem strange, but she would be the chief clinician for women who wanted, or for whom a natural, unmedicated birth seemed appropriate. I envisage for a unit with 3000 deliveries a year that four consultant obstetricians and six consultant midwives would be required. Each consultant could have two teams of four midwives or maybe one team of six with some back-up staff in each area. The consultants would, as at present, refer to each other and all the midwives would practise their unique skills - in touch with, listening to, talking to and hand in hand with women. Ju1y 10, 1985 |
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