Clinical culture clash

This story first appeared in the Halifax Chronicle Herald in Feb 2011:

TWO FORMER IWK midwives say the hospital’s rejection of some of the principles and practices of midwifery — particularly the right of the mother to make informed decisions about the birth environment and methodology — forced them out of the program, which was suspended in December.

Karen Robb, a veteran midwife who moved back to Nova Scotia from Newfoundland to practise, blames territorialism and mistrust of midwives by the Health Department and the IWK Health Centre.

“IWK management didn’t understand midwifery and they didn’t treat midwives as experts,” she said on the phone from Alaska, where she moved after being fired in December 2009.

Rather than learn from successful midwifery practices elsewhere in Canada or act on input from local midwives, the Health Department was “determined to reinvent the wheel.”

Robb said that Halifax midwives were excluded from crucial early meetings, from which IWK administrators emerged not knowing the basic rules governing midwifery practice.

“Our exclusion created unnecessary delays and encouraged entrenched positions.”

Jocelyn Vine, the IWK’s vice-president of patient care, admitted that midwifery needs to be better understood at the hospital but said the IWK strives to provide every patient with informed choice.

“Quite a few of our health-care professionals were working with a midwife for the first time in their career,” she said. “There is a great deal of support for midwives but it’s a new profession. It was the same with nurse practitioners 10 years ago. We anticipated a few growing pains.”

Vine said that the hospital conducted “broad consultations with community members, including midwives and other birth professionals.”

Rachel Godwin, a U.K.-trained midwife and nurse who came to Nova Scotia in 2008 and was eventually hired by the IWK’s midwifery program, said that another major factor in the collapse was the appointment of a nurse as chief of midwifery over the objections of all four midwives.

Other primary health-care providers — physicians, obstetricians, pediatricians — work with a practice chief who shares their respective specialty. This helps prevent conflict between administrators and primary health-care professionals.

Robb further blamed the general “autocratic management style” at the IWK.

“There was a lot of bullying. I was repeatedly threatened with dismissal. The attitude of managers filtered down to some providers and I went home crying on a few occasions.”

She recalled a meeting with Vine in which “the midwives were sequestered in a room and called out like school children. She suggested three times that I quit if I didn’t like the way things were being done.”

“I’m not familiar with any bullying,” Vine countered. She said that the IWK has a respectful workplace policy and is committed to a healthy work environment.

Godwin noted that after Robb left tensions increased. “We found that nurses would enter a room with a midwife and ignore her judgment,” Godwin said.

She felt relief when her contract with the IWK ended in November. “We were all so burnt out because there was so much scrutiny. The IWK was not prepared for implementation. Regulation happened in six weeks and there was nothing to help people know what midwives were.”

A recently released report from the Health Department, Implementation of Midwifery in Nova Scotia, echoes some of the midwives’ complaints. It compiled feedback from midwives and other health-care providers, clients and administrators.

It says women with access to midwives “felt empowered and confident in their abilities to give birth and to be a good mother; were involved in all decisions related to their pregnancy and birth; felt comfortable asking questions, discussing their options and making decisions free of judgment.”

But some, particularly those using the IWK’s program, were dissatisfied. The report states: “Some women sensed tension between the midwife and other health-care providers.” That seems an understatement, given that the four IWK midwives have quit, been fired or gone on indefinite leave.

The report further states: “The philosophical differences between midwifery and traditional maternity care was a notable issue, as there continues to be a lack of understanding, trust and respect for midwifery practice among a range of providers.”

But Vine felt the report is also positive and points to “a number of options for midwifery to become better understood.”

Godwin and Robb both felt that their time at the hospital was so micromanaged that it became hard to focus on the work of midwifery.

It was in that environment that they learned they would not be able to conduct home births. Choice of birth location is considered fundamental to midwifery. The challenge was that the IWK had no policy on home birth. To create one, administrators conducted an extensive hospital-wide consultation.

“It could have been done in a week but instead there was a five-month process of everyone having a say,” Robb recalled. But the midwives had already accepted women wanting home births.

Despite the exhaustive consultation, Robb said no one checked on policies in other jurisdictions. She said she gathered information on policies from other hospitals using a national maternity electronic mailing list.

“I gave what I found to the IWK policy writers, who treated me like I had done something naughty.”

The hospital’s eventual policy, said Robb, “made home birth look a lot like hospital birth. There was no water birth, no complementary therapies, and labouring women were not permitted to eat or drink anything except clear fluids. Their partners or supporters were not allowed to photograph the birth. If women ate to keep up their strength in labour or documented their baby’s birth, we were to punish them by dismissing them from care.”

Vine disagreed. “The consultation was an accelerated and very comprehensive process,” she said. “The results are seen as quite exceptional. We gathered literature and looked at best practices in other jurisdictions — quality, safety and best evidence were driving factors.”

The home birth dispute is symptomatic of the culture clash between midwives, who hold birthing mothers’ right to make informed decisions as a sort of prime directive, and the IWK, which Robb said follows the letter of its policies.

“The first day we were given the policy binder — ‘slap, here you go girls’ — and they contravened a lot of our standards.”

Godwin said there were so many policies — dictating what women can eat during labour and on what days to weigh newborns — midwives would often learn of a policy only after violating it.

After many disputes with management, Robb was fired based on a complaint that remains mysterious to her. She said she was fired based on a nurse-manager’s opinion of her clinical care in two postnatal cases. No official reason was given for her dismissal. Her manager filed a complaint with the Midwifery Council of Nova Scotia, which was dismissed four months after she was fired.

Vine said that while she can’t discuss an individual termination, the IWK always provides an explanation for dismissal. “There is a major focus on recruitment and we’re very much looking forward to getting the program back up and running,” she added.

Although Robb has no interest in returning to the profession here — she is now a registered nurse in Alaska and studying a nursing sub-specialty — she has continued to urge the Health Department to intervene.

“This could not happen to midwives in the other two model sites in Nova Scotia,” she wrote the department last May, “as their district health authority managers appropriately leave decisions about clinical standards to senior clinical leaders.”

(Those two sites are operated by South Shore Health in Bridgewater and the Guysborough Antigonish Strait health authority in Antigonish.)

Robb feels the Halifax program will succeed only if it is moved out of the IWK, either to Capital Health or within the North End Community Health Centre. The centre has a solid reputation in north-end Halifax and works closely with the IWK on a number of other programs. Midwives would still have hospital admitting privileges but under family medicine. “This is how it works everywhere else in Canada,” Robb said.

Jane Moloney, the centre’s executive director, wants to expand the centre’s primary natal care. It recently acquired additional space to accommodate more primary health-care services like midwifery. “I see a need to put maternity resources into our community,” she said, “but only in a way that is collaborative. We’re not suggesting we take the program from the IWK.”

But if the Health Department follows the recommendations of the implementation report and hires additional midwives, the centre would be interested in hosting them. “We have no preconceived ideas about how it would work,” Moloney said. “We would want to sit down with funders and health-care providers to discuss it.”

Leslie Niblett, a midwife at South Shore Health, feels midwifery could still work at the hospital but only with a “major paradigm shift in how midwives function in the IWK structure so they can follow our code of practice.”

While many in the health field still fear home births, for example, current evidence indicates it is at least as safe as hospital births.

Midwife births are far less likely to involve C-sections and other invasive interventions. Godwin, who is currently happy as a stay-at-home mother expecting her fourth child, said that midwife clients are far more likely to successfully breastfeed and less likely to suffer post-delivery medical challenges.

Niblett suggests that different IWK primary health-care providers teach each other, in a non-hierarchical setting, about what they do and how they operate. The implementation report recommends gathering “Canadian data about (midwifery’s) cost effectiveness.”

Robb and Godwin recall complaints about the cost of their provincial program — about $500,000 a year — from hospital colleagues who didn’t understand the benefits and potential for savings due to reduced hospitalization time and fewer birth interventions.