By Caroline Flint

All midwives are allocated a supervisor to oversee their practice. Independent midwife Caroline Flint presents her case against this system

Everyone in a professional role, whether lawyer, doctor, teacher or midwife, must be able to practice autonomously and use his or her professional judgement. However, with that freedom also comes a huge responsibility to the public and the necessity to earn the trust of those to whom the professional provides a service.

Within each service, therefore, a mechanism must exist whereby an aggrieved recipient of care or services can complain about the actions of the professional concerned and be assured that the professional will face some form of enquiry which may, if the fault is serious, lead to him or her being deprived of professional status.

For complaints against a solicitor, members of the public can contact the Law Society. The Royal Institute of British Architects is the body that deals with complaints against an architect. Complaints against a doctor are dealt with by the General Medical Council, and those against a midwife or nurse by the UKCC. All of this is right and proper, but for the midwives there is the potential for far greater scrutiny than this mechanism - via the supervision system.

One theory in favour of the supervision of midwives is that parents aggrieved at the care (or lack of care) they have received from their midwife have someone to complain to who is more accessible than a distant statutory body. In every health authority in the land there are, by statute, `supervisors of midwives'. These august beings are there in a twofold role: to protect the public against unsafe midwifery practice but also to act as professional support to those midwives under their jurisdiction.

It sounds laudable, but it is an issue that causes passionate debate within the profession and not a few unfair situations. For instance, I believe, a woman can be happy with the care she has received from a midwife; the father can be happy with the care his partner has received; the baby can be healthy and well. The GP can be bowled over with admiration at the actions of the midwife. The hospital doctors can be happy to have worked with the midwife and respect what she has done. The midwife herself can feel she has done a good job. But at any time at all this same midwife may be summoned to see her supervisor and the care she has provided will be critically scrutinized by someone who was not there at the time and whose philosophy she may not share.

The system can, however, work to the midwife's advantage and leave her feeling extremely supported in her professional life. If the midwife has had a difficult experience - for instance, if a baby has been born extremely limp and unresponsive, very difficult to resuscitate-the midwife may be distressed and feel guilty, thinking it was her fault. The supervisor, eagle-eyed at detecting mistakes, goes through the documentation on the case and pronounces: `As far as I can see there is no cause for criticism here. You acted appropriately at all times.' The midwife breathes again; her practice has been supported. She is not being blamed. But is this the best way of dealing with this type of problem?

As a midwife specializing in home births I have often been relieved to talk over the phone to a supervisor who has soothed and supported me in difficult clinical situations. With a woman at home the midwife can feel isolated and afraid. The voice of a sympathetic supervisor over the phone can boost a midwife's confidence and lift her spirits. `Could you negotiate with her to come into hospital if there has still been no progress in four hours' time?' Have you thought about a change of scenery and a piece of toast? That sometimes does the trick.' Another view can be all a midwife needs.

Supervisors of midwives have the right to inspect all equipment, all documentation, the premises from which the midwife practises and to scrutinize clients' notes. The principle is good, but the logistics can be ridiculous.

Our private practice is in central London. The M25 is our chosen boundary; consequently we register our `Intention to Practise' in 28 different health authorities. In each health district there are four or five supervisors of midwives. We estimate that in our practice is supervised by at least 126 supervisors, all of whom have the right to inspect our equipment and scrutinize our registers and notes. We overcome this problem by inviting the supervisors to lunch every year- we hold two lunches over a two week period because there are so many. The lunches are great fun, with them looking at our equipment, our records of study days attended, books read, our statistics and a presentation of how we work- but to have so many supervisors of midwives is a particular problem in independent practice.

Even more complications arise when we have booked a woman from one area who is going to have her baby in a hospital in another area. We need to negotiate with the supervisor in each area and, having done that, if the women then delivers at home we have further discussion and negotiation with the supervisor of the area in which the woman lives, having probably had much more discussion previously with the supervisor of the area in which the woman was going to deliver.

Midwives' practice is overseen by a book of rules. Questions arise over any profession which has a book containing a total of 44 rules, but the rule which is seen by many midwives as a catch-all is Rule 40. `In any case where there is an emergency or where she detects in the health of a mother or baby a deviation from the norm a practising midwife shall call to her assistance a registered medical practitioner.'

This rule has come down almost unaltered from the 1902 Midwives Act when doctors did not want midwives to be autonomous practitioners, and the 1902 Act was only passed as long as doctors could be those people who ruled the profession and made up the majority of members of the Central Midwives' Board. This rule makes midwives vulnerable at every turn.

Obviously a thinking midwife will refer to a doctor in the case of an emergency that she cannot deal with herself or where there is an abnormality. But what is abnormal? Who defines abnormality?

The issues surrounding supervision need to be addressed by the profession. For this reason the Association of Radical Midwives has set up a working party to address them.