ï»żEpisode 77 - The place of Policy with Dr Kirsten Small
Mel:
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host,
Mel:
[0:03] Dr. Melanie Jackson. I'm a clinical and research midwife with my PhD. And each episode, I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth, and postpartum journey. Welcome everybody to today's episode of the Great Birth Rebellion. I'm your host, Dr. Melanie Jackson and today I'm joined by Dr. Kirsten Small who works in her current role as a researcher for the Burnett Institute.
Mel:
[0:38] She's a PhD graduate, a retired obstetrician and overall professional thinker. You can see Kirsten's current work efforts through her blog Birth Small Talk and that's linked in the show notes and today we're talking about the topic of the place of policy in maternity care. And before you switch this episode off, thinking that it's not relevant to you, because you might be a mother or a parent, this episode is actually about understanding the institution that you're about to enter when you're having your baby. So if you're going to a hospital, then knowing this kind of stuff can be really influential as you plan your strategies to get the birth you want at that place.
Mel:
[1:19] So this episode, it will help you understand how a hospital is organized and why they do things the way they do. And throughout this episode, we will just kind of pepper information about how you can understand how a hospital works in order to be able to subvert the strategies that you need to subvert for your own benefit and gain. So this episode is as much about understanding institutionalized medical care
Mel:
[1:44] as it is about strategizing ways to get around them so that you get what you want for your care. So it's a strategic rebellious subversion that we're going to talk about um and you know midwives have been doing this forever subverting things in the hospital that they wish weren't there and now it's you the birthing woman and your advocate's opportunity to have some inside knowledge to be able to do the same so that's what we want to do today with that i'd like to introduce and welcome my guest dr kirsten small to today's episode Hi, Kirsten.
Kirsten:
[2:20] Hello. Lovely to join you again.
Mel:
[2:24] Yes, Kirsten was with us for the CTG episode. So you may all know her from there as well. All right. So Kirsten, I invited you to this particular episode because I read your recent blog post on Birth Small Talk where you talk about why you chose not to participate in hospital guidelines and policy writing. And your particular area of expertise is in continuous fetal monitoring. And you write about not going on those writing groups to write guidelines and policies for CTGs. And so I wanted to talk to you all about policy. So, Kirsten, can you kick us off with what gives you the authority to talk about hospital structure and guideline and policy?
Kirsten:
[3:14] Well, for starters, I've been around. I started work as a doctor in 1991 when the world was slightly different. And so I've got a profession's worth of experience at working in hospitals and seeing changes in how we organise healthcare and the role that policy and guidelines play. And one of the things that I actively looked at during the PhD was around.
Kirsten:
[3:46] How guidelines happen and what kind of effects that they have because the research question was to understand how a particular event related to fetal monitoring happened and very quickly I got to well we do it this way because the guidelines say to so then I had to work out well why did the guidelines say that and what gives the guidelines the authority to say that and where did the guidelines come from and who put them together and where did that information come from? So, you know, you kind of work up and up and up through the system to try and understand where this all begins. You know, it ultimately ended up impacting on whether midwives were giving women a choice about which kind of fetal monitoring method to use during labour or not, and many other aspects of how midwives were practising and how obstetutions were practising in the hospital where I was doing data collection. And it was, as somebody who worked in maternity care for a long time, it was a bit of an eye-opener because, you know, you take a lot of stuff for granted that you just use because it must be the best way. And deliberately actually going and digging about and working out how things happened was quite the revelation to somebody who'd been in clinical practice and on the receiving end of these guidelines for a long time.
Mel:
[5:09] So essentially then, investigating and understanding how policies,
Mel:
[5:15] I guess how clinicians interact with policies in hospital was part of your PhD research. So you've actually gotten to research that particular part of hospital culture.
Kirsten:
[5:26] Yes, and published about it.
Mel:
[5:28] Exactly. And if you're on the mailing list for this podcast, you'll see Kirsten's resources that she's made available. In fact, one amazing research paper that she's written called Midwives Musts and Obstetricians May, she's offered a full-text copy of that so you can have a look. So, Kirsten, what is a policy? Why are we talking about them? Why do organizations choose to write policies to govern their institutions?
Kirsten:
[5:57] Well, there's a collection of documents that get called policies, procedures, guidelines, work instructions. They have different names. There is a little bit of subtle difference between some of them. So guidelines, as the name suggests, are meant to guide people. So at their best, they pull together what is known from research about a particular topic. They settle on some agreed names for what to call things so that people can be consistent in their communication and know when somebody says a thing, you know what they mean. And they make suggestions about what's the best thing to do when you find yourself in this particular situation. At the other end, you've got policy, which is a bit more rules-based, and it's more thou shalt do this or else. And there's kind of a very large extreme range of grey in between the two extremes of we think this is a good idea, but it's really up to you, versus if you don't do this, you'll be in big trouble. And so they all sit somewhere on a spectrum. If you're a registered health professional and you are employed by a health organisation, then you usually, or even if you.
Kirsten:
[7:26] Have access rights, so if you're a private obstetrician and you have access rights to a private hospital, you're not actually employed by that hospital, but in order to make use of their services, you will have signed an agreement that says you will abide by the policies of that organisation. So, they're not really optional if you work in a healthcare system as an employee or have some kind of contractual agreement with a health service.
Mel:
[7:54] If a policy gives a practitioner the rules of how you are to work in our facility, Why? I kind of just half answered my own question, but why does a hospital make these policies?
Kirsten:
[8:07] Well, for starters, it's not just hospitals that make policies. There are hospitals that provide healthcare and employ people to provide healthcare that are making policy. There are also other professional organisations that organise the work of health
Kirsten:
[8:23] professionals who also make policy. And the reason that those two different groups write policy is slightly different between the two of them. So it's worth covering both of them. For hospitals, the reason that they're doing it is to protect the organisation. And so they are basically making the health professional.
Kirsten:
[8:52] Responsible for the health outcomes that a person experiences when they have health care. So you will do it this way. And if something bad happens and you didn't follow the policy, you're the one who's in trouble. And the hospital can stand back and go, we have a policy and this person didn't follow the rules and therefore it's their fault, not ours. So it's about it's about making the individual practitioner responsible rather than the organisation as a whole. Interestingly, and it never occurred to me until I was poking about doing the PhD, there's not really, there's not any policies that flip that and work in the other direction. So apart from a bit of, there's some industrial relation laws, but apart from that, there's not really any rules that hold a hospital to account for what it must do on behalf of the people that it employs. But there's lots of rules that hold the people that it employs to account for their actions towards, you know, they're accountable to the institution that employs them. You know, there's not actually a lot that holds the employer to account in the same way that the tools that they've got to judge whether a health practitioner is performing in the way that's expected or not.
Mel:
[10:17] If the hospitals are holding their staff to account by policies, is that because the hospital's being held to account by somebody above them in the hierarchy?
Kirsten:
[10:29] Correct. So hospitals have to be accredited in Australia with the Australian Health Safety Quality Standards. I'm going to get it. It's a collection of words that it's around that. They might not have it exactly right. And part of that is they have to have a quality and safety framework. And part of demonstrating that you have a quality and safety framework is to have a series of policy and guideline documents that set out what quality and safety looks like in the organisations. There's levels of accountability that go up that, you know, so a hospital can't just go, oh, look, we're fine. We're just a little country hospital. We don't, we haven't got the time and effort for that kind of thing. We'll be fine. We just, you know, we all know each other. We're or friends will just make do without, that, you know, they just can't operate like that. They're a bigger fish in the sea that require other levels of accountability within the organisation.
Kirsten:
[11:36] Now, the other group that are responsible for guideline writing are organisations that don't provide health care, but they provide guidance to health care professionals. And in my research, that was the Royal Australian and New Zealand College of Obstetricians and Gynaecologists and the Australian College of Midwives and international equivalents of those. So they don't employ midwives and obstetricians, but they do set professional standards as to what's considered good practice and what isn't. And so they choose to become guideline writing bodies for reasons that are different to the hospitals. And it's about maintaining authority.
Kirsten:
[12:25] And so it's about being recognised for, you know, leadership and having an important role in public safety and maintaining professional standards. And so that's one of those organisations' right policy. So there's some subtle differences between them. And one of the things that really stood out to me when I sat down and thought about it is when it comes to fetal monitoring, RANSCOG has a fetal monitoring policy which is widely accepted in both Australia and New Zealand as being the go-to. And so all of the state level policies, all of the hospital level policies basically
Kirsten:
[13:08] say, see what the RANSCOG guideline says, that's what we're going to do. And then with some minor adjustments to make it work for local equipment.
Kirsten:
[13:18] Ranscog is an organisation that is constituted by obstetricians and gynaecologists for the benefits of obstetricians and gynaecologists, and yet it writes policy that organises the work of midwives. And I think that's overreach.
Mel:
[13:36] They tried to write a home birth guideline or policy not long ago, and I was up in arms. I contacted the Australian College of Midwives. I was like, I can't believe I'm not listening to a single thing that Ranskog tries to tell home birth midwives about home birth. Like that would be the equivalent of me telling them how to, you know, execute the process of a cesarean section. That's not my area.
Kirsten:
[14:04] And if the Australian College of Midwives wrote a set of guidelines about how to do a caesarean section, the obstetricians would be quite cross about that. And yet, when you go and look at the mission statements of the two organisations, the ACM is quite clear that it's about furthering the interest of midwifery in Australia, whereas Ranscog, it's vague and it's about being leaders in women's health. And so they've kind of self-appointed themselves as being this broad authority across multiple professions, as long as it all falls underneath the banner of women's health. And so they therefore consider that it's their role to write policy that organises the work of midwives. But, you know, it gives them additional power and authority as an organisation because they choose to do that and have done so quite effectively.
Mel:
[15:05] And so is it entirely possible that obstetric people and people interested in medicine and more medicalisation of childbirth are actually writing guidelines and policies for midwives to apply when they care for women?
Kirsten:
[15:25] Correct. And I don't think the very nice people who sit around tables and write policy, I don't think that they sit down and go, how can we dominate the midwives this week you know it's not that's not top of mind it's about how can we make outcomes better how can we look after women the the the guideline writers are never going to end up writing guidelines though that go against the interests of the body that is engaging them to write the guideline so you know people who write guidelines for rancog are not going to write guidelines that say obstetricians should stay out of the room and just let the midwives get on with it, because that's counter to the reason for the existence of the organisation in the first place. So the social structures in which these policies are created obviously have an impact. And it's not necessarily visible at surface value either, which is where the paper it came in.
Kirsten:
[16:33] Because I had this flash of insight when I was, because I read the Ranskog fetal surveillance policy back to front, inside out, line by line in a way that no human being probably ever has done before to try and work out how is this put together? What are the social values that are embedded in the way that it's written? That, you know, what are the beliefs that are coming through about the people who put this together? And one of the things that I noticed is that some of the guidelines are clearly directed towards the work that midwives do, even if they don't specifically say that this is a midwife's job. And some of them are clearly directed at the work that I as an obstetrician would do. So for example, one of the guidelines is that when the CTG is abnormal, that care should be escalated. Now, it doesn't say the midwife should escalate care, it just says care should be escalated. Now, one of the jobs that I've done has been a director of obstetrics and gynaecology. I'm not ringing somebody else when the CTG is abnormal and going.
Mel:
[17:48] Hello i think what
Kirsten:
[17:50] I think the cdg's abnormal well you come and do some i'm the person on the receiving end of that it's it's the midwife or the junior doctor who is the person who's being told what to do in that situation and the the it's quite rules-based you know it was thou shalt under these very specific situations, you must. So midwives must escalate care. But the kind of things that only obstetricians do, like fetal blood sampling, that's a doctor's job and midwives don't do it. And when you read the policy, it's like, well, the hospital should have the equipment so that it can be done. And if you're going to do it, then we recommend these particular cutoff points as being normal or not. But there's no, you have to do it when this situation happens, or you should never do it in this situation, or it has to be done this particular way. It's just, look, you can if you want, and you probably should make sure, if you're a hospital, you probably should make sure that the gear is available. So if the doctors want to, they can. So, you know, hence the title.
Kirsten:
[19:04] Midwives Must Obstetricians May, because the policies basically were setting these really tight rules where midwives had very little wriggle room in terms of decision making about whether this was actually in the woman's best interest and the right pathway.
Kirsten:
[19:21] Whereas all of that still remains very open for obstetricians. And you have to kind of read in between the lines a little bit to see it. And once I'd seen it, I see it everywhere now. Any healthcare policy I'm looking at, I'm now looking to see who is this actually directed at, and to what degree is this person being given space to make decisions about how to apply this information or is, you know, being told you shall do it this way and exactly following these set of rules. And, you know, it reinforces the relationships between professions that we see happening in healthcare that midwives and nurses are the ones that are, you know, told what to do and don't have an awful lot of autonomy and freedom in their professions. And the medical professions are allowed much more range of motion in terms of the decisions that they make. It's not absolute, you know, there are certainly things that I as an obstetrician, I couldn't just go off willy-nilly and do whatever it was that I wanted, but there were less controls on my practice than there were on my midwifery colleague's practice.
Mel:
[20:31] When it sounds like, as you said before, that policy's been, I think, like you said, subconsciously used to maintain a hierarchy within the maternity care system where midwives are supposed to do what they've been told to do and we're going to put in place these policies that will dictate the type of care that midwives are going to give and then also then start to define the scope of midwifery when they say well if this happens then you must escalate and refer on and that purposely puts a line as
Mel:
[21:09] to what's the midwifery scope and what's not the midwifery scope. And aside from RANSCOG and obstetric bodies making policies, do hospitals also generate their own policies?
Kirsten:
[21:21] They do, though if there is a larger organisation like RANSCOG that already has a policy or there's a national government policy, then they will tend to not reinvent the wheel. They'll use that policy and then ratify it and say, you know, this is what we're going to do and they'll reproduce material directly out of that, rather than contradict it or come up with something that's fundamentally different.
Mel:
[21:54] And do you think that the policies that are written, do you think they comb through the research and objectively evaluate the research and then use evidence and research to create a policy or is there other things that input into that policy?
Kirsten:
[22:09] It's a really wild spectrum because it depends on the profession and depends on the particular, issue that we're talking about and whether or not current practice aligns with what we know from research. And that's one of the reasons why I've been so interested in fetal monitoring is that there is this huge difference between what we do and what the research tells us is true. But that's not always the case in other parts of healthcare. You know, if the best antibiotic to treat chlamydia is doxycycline and the guideline says you should use doxycycline, you know, whew, fabulous. You know, sometimes they work as they're intended to, but other times they don't because, you know, organizations, hospitals aren't necessarily going to come up with something that radically changes what is considered the way to do things in light of evidence.
Mel:
[23:19] So say a paper comes out that says doxycycline is no longer the best drug and we need to use, and this evidence shows we need to use a different drug. How long will it take to rewrite a policy and roll that out?
Kirsten:
[23:35] Probably somewhere more than a decade. You know, there's some research that shows that it takes about 17 years to translate research through into practice. The bigger the organisation you're trying to change, you know, it's like trying to turn an ocean liner around instead of a kayak. You know, it just takes a whole lot longer to get things on board. And then, of course, if it's complicated with vested industry interests, You know, if the makers of doxycycline sponsor your hospital, but the makers of the new drug don't, it just makes the whole thing a lot more difficult to actually generate change in the system. So there's always more going on than just the pure relationship between evidence and practice. There are always other influences that are impacting what gets done.
Mel:
[24:29] So essentially then, the hospital staff are governed by a set of policies, which may or may not be based on evidence. And if they are based on evidence, there's a good chance it's older evidence, potentially 10 years or longer old. And then these policies end up dictating the activities of people who are caring for women.
Kirsten:
[24:58] Correct. I think the important thing to point out, though, is that policies organise the work of health professionals. They don't tell women that they don't have to follow policy.
Mel:
[25:12] Correct. Yes.
Kirsten:
[25:14] And so if you're a woman or a parent entering the healthcare system and you want a particular standard of healthcare and the healthcare provider says, well, our policy says, it doesn't mean you have to do it. It means they have certain responsibilities towards you. And if it's a well-written policy, then they will be things like offer, advise, recommend, and suggest support, you know, badly written policies say you will make sure this person gets this treatment or else you will lose your job. And that becomes, you know, problematic then because people won't offer choice under those circumstances where it's a matter of, well, if this person picks something that's not in my policy, then I'm the one that gets held to account for that, not them. But yeah but that's that's the health professionals issue not yours as the health consumer you get to make the decisions about what you want for your health care, that's not to say that individual health practitioners and in the private sector even even health organizations can decide that they're not going to offer you the care that you want.
Kirsten:
[26:32] In the, at least here in Australia, in the public hospital system, people can't refuse you basic care, but they can refuse to provide interventions if they don't feel that they're appropriate. So if, for example, you walk through the door and said, I demand to be induced and somebody said, well, we're not doing that because we think that's a bad idea, then it's not going to happen if it if it if it comes to to declining an intervention then you have much more control because no one can do the thing to your body that's required for that to happen without your permission to do so.
Mel:
[27:11] Yes. And so you're right. Everybody else at the hospital is obliged to abide by policy, except for the woman when she turns up. She's got all the freedom in the world. Pardon me, covering from a cough.
Mel:
[27:31] And I suppose we've been talking a lot about the sort of the negative aspects of having policy, But at the very basic level, like myself, as a, you know, I run a company, right? If I didn't have a standard operating procedure for almost every single thing that goes on in my company, nobody who works for me would have any idea what I want them to do for me because there's no operating procedure. If I say, go and check my email. So like, what do you mean? What do I, who do I respond to? What should I say? Are there templates? Are there, you know, what's your job? What's my job? So at one level, I think we've got also got to understand that hospitals are a massive workplace slash factory slash institution slash like they have to do something. There's got to be a way of organizing all the people that work there because when you absolutely need a hospital in an emergency, you know, there has to be a streamlined process where everybody knows what they're supposed to do in an unexpected circumstance. So I guess I want to take this juncture, yeah, to kind of remind him.
Kirsten:
[28:43] And guidelines and guideline writing organisations, it's easy to demonise them and go they're all bad, they're all evil, it's all about power. But even power itself is a mixed bag. You know, some authority over bad situations so that they don't happen is actually a really good idea and we should have it. And so guidelines are all of the rainbow shades of fabulous to awful and everything in between. And, you know, an individual guideline can have bits that are fabulous and bits that need some improvement as well. So, yeah, I'm certainly not suggesting that we should toss them all out into a big pile and light a bonfire or that organisations should stop doing them. I am blessed enough to now be old enough to have entered healthcare at a time when guidelines weren't really a thing, which for younger practitioners, they kind of go, like, what?
Mel:
[29:41] Tell us about that. Tell us, okay, so, yeah, the history of guidelines is only as old as Kirsten's career. So, like, tell us, like, when you started, you're saying there was no guidelines. Yes.
Kirsten:
[29:56] I knew early on that I wanted to go into obstetrics and gynecology. So I had a year as an intern doing a bit of this and a bit of that. And then I started to focus. So I worked as a junior house officer and a senior house officer just in obstetrics and then got a registrar post in the, so it was my fourth year out of medical school that I started my obstetric training. And so I hit labor ward. It was called labor ward at that stage. at the hospital I was working at as a junior doctor, and you were literally just chucked in the deep end.
Kirsten:
[30:32] And I had no clue what I was meant to do, how I was meant to do it, what equipment I needed to do it with, what were the things that I shouldn't do, who do I talk to when I need help. There was very little guidance. The only guideline that I remember was an insulin sliding scale, because nobody could remember the doses and what sugar levels were the cutoff. So there were some things that existed that were really useful and still continue to be really useful but like every single obstetrician had their own regime for how you ran an oxytocin infusion wow so you had to know yeah you had to know that dr m likes this dose and dr b likes this dose and that it goes up they put it up every 10 minutes they put it up every half an hour there was no standardization and it was a bit of a nightmare quite frankly and so one of the things that I did because I've always been a bit of an educator at heart was as I started to figure out this what the secret rules were that nobody had actually written down I started writing them down and so I produced a document which was meant as an educational and supportive tool as junior doctors joined the team as to these are your responsibilities.
Kirsten:
[31:48] This is where the equipment lives. This is who you need to go to talk to, though. It was kind of the start of some guideline writing for that organisation. And they did take the document that I'd started and use it as a starting point then for doing guideline development from that point onwards.
Kirsten:
[32:07] So, as I said, guidelines are not necessarily evil. It actually, you know, They do have an educative role and they do help, particularly when you're brand new in the area and trying to work out, okay, now what do I do? They can be really useful. Less useful for us as experts, senior practitioners who know that the answer to every clinical question is, well, it depends.
Mel:
[32:33] Yes. And I think you're right. That's where, you know, for entry level clinicians who were kind of like, just tell me what I need to do right now. And then as you develop expertise and knowledge, then you can start to be a bit nuanced and play with that a bit.
Kirsten:
[32:52] Yeah. And there was quite a lot of discussion around during my time as a trainee about the risks of what was called cookbook medicine, which was these strict guidelines with flow charts that said, if A, then you do this, if B, then you do that. And then if C happens, this is the next thing that you do. And people objected to that because it didn't allow for an individualised approach, either in terms of the clinician's preferences for how they wanted to provide care or for what women wanted from their care. And that's rolled on and it continues to be an increasing issue that we now have care pathways where we risk assess people early on in the pregnancy and they get put into particular piles and offered particular shaped care because of the label that they've been given at some point during their journey through their contact with the healthcare system. So it has come to pass. A lot of what we do now is cookbook style approaches to care, which, you know, as I said, great if you're new and you haven't yet quite got across the subtleties of the range of possibilities.
Kirsten:
[34:10] Not all that helpful for those of us who are older and have been around the traps and read a lot and learned a lot. And I do wonder how this is going to pan out for the people who are 20 years behind me. Will they acquire the same level of expertise that I have because I've had to experiment and learned from Dr. M and Dr. B with their different drug regimes for running an oxytocin infusion, you know, are they going to not develop that same level of expertise or do they anyway over time if they've just, doing, you know, option A because that's what the guideline says.
Mel:
[34:57] Yeah. And I call it, you call it cookbook care. I call it birth by numbers. You know, when you get those little paint kits and they say put color B here and color C there and then, whoa, there'll be a baby. So it's birth by numbers. But, oh, cookbook. Yeah, you know.
Mel:
[35:15] And actually, interestingly, Kirsten, I'm where you were when you started your career because private midwives, we don't have a set of guidelines or policies or anything about anything. We have the Australian College of Midwives has the consultation referral guidelines, but all that does is says if your client develops this condition or this condition or this condition, we suggest you refer on to another person for another opinion or for some additional care. That's as far as it goes. and so actually we as private midwives have basically only got the capacity to make clinical decisions based on every single woman's clinical picture and your own personal scope and knowledge which now that I think about it's pretty extraordinary for women who have hired a private midwife versus who have sought care in a hospital to know that in hospital you might be getting completely policy-based care and at home you might be getting or with a private midwife you might be getting completely clinician and woman-led care where we're using lots of different things to make decisions.
Mel:
[36:31] Next question. Let's have a look. I feel like we've talked a little bit about, I was going to talk about general institutional structure, but I feel like that's unfilled as we did it. How is policy written? We kind of, do you feel like we've done that? We've got a nice flow.
Kirsten:
[36:52] Yeah.
Mel:
[36:55] Do we think they're an appropriate way of deciding care strategies? Let's. So let's see if we can enter in now to the next level of things. So I kind of want to talk a bit about â so, yeah, I guess the next thing I want to do is talk about do we think that policies are an appropriate way of deciding care strategies for women?
Kirsten:
[37:26] Are we going to take this from the perspective of the woman or from on behalf of the organization is the next question.
Mel:
[37:33] Oh good one let's go okay let's go on behalf of the organization do we think that policies are appropriate way of deciding care strategies and then let's completely ask that question again of do we think that they're appropriate for women yes
Kirsten:
[37:51] You'll see you'll see very quickly where the rub starts to happen between the two.
Mel:
[37:57] I think so go ahead do we think that policy is an appropriate way of deciding care strategies if you are of the perspective of the hospital to to practitioners is.
Kirsten:
[38:09] Yes. Let's take, say, induction of labour, for example. So, you would write a policy that sets out what you think are the appropriate reasons why induction should be offered, at what gestational age it should or should not be offered to people. You would write policy about what the approaches are. So, you know, are you going to use Cervidil? Are you going to use Prostant? Are both going to be available. Are you going to use Cook catheters or are you going to use a different brand?
Kirsten:
[38:43] And then some of the process work, you know, you go to rupture membranes and then put prostitin in or is that against the rules for here and you're going to do it the other way around? And how long are you going to leave it after membranes have ruptured before you make the offer to start oxytocin? What's your drip rate going to be at and how quickly you're going to increase it? And are you going to put CTG monitoring on at the same time? It helps in terms of purchasing decision and if the hospital decides we're only ever using Cervidil and we're not using Prostan, then we just won't stock Prostan. We won't have to set up an account with the company that sells it. And, you know, it's just easier for pharmacy to manage one drug agent instead of two different drug agents. So let's just do it that way. You know, we'll use one brand of catheter for cervical ripening rather than having three different options because every doctor likes a different thing. No, we'll just decide what's the cheapest one and we'll go with that for the hospital. And we'll decide when women are admitted in the morning so that it happens to coincide nicely with change of shift for our midwifery team and when the doctors typically do their ward rounds. And, you know, it'll all flow smoothly. Everyone will know what they're doing and, you know, we'll make the best use of the resources that the hospital is required to provide in order to deliver care to people. So that makes sense.
Kirsten:
[40:09] Now, if you flip this, you're the woman on the other side of this, it can start looking rigid. But I don't want to come in and be induced at seven o'clock in the morning. My husband didn't get home from work until nine. Can I come in a little bit later? No, you can't. That's not what the policy says.
Kirsten:
[40:28] I had a really bad experience with Servadil when I was induced last time. My friend had Prostin. Can I have Prostin and said, no, we don't stock it at this hospital. It's not in our policy. We'd have to, you know, make special arrangements to get it in. That's too hard. We're not doing it for you. Can I wait six hours after I've had my membranes ruptured before I start oxytocin? Well, no, that doesn't suit because we're a little country hospital and that means that we're starting at a shift change in the afternoon when we don't have the staff for it. And it means that, you know, if things go pear-shaped, then you're going to be having a cesarean section at two o'clock in the morning instead of at 10pm. And that creates issues for us, for our staff, for fatigue for the next day. So, it limits women's options and choices in a way that can be really difficult for them to work around.
Kirsten:
[41:19] So, it makes sense at one level, but it also doesn't make sense at another level. And it really depends on whose priority it is that you're focused on. And as I said, guideline writing organisations don't typically write guidelines that will make life difficult for the organisation.
Mel:
[41:39] So, So policies are written for the purpose of good function of the hospital and organisation of staff. They probably aren't written with the woman's experience in mind. No, so Kirsten's shaking her head no. And I have to agree with that. They're not thinking how would this affect the woman. And I do, yeah, and I hear what you're saying. And so this is, at the beginning of the episode, I was saying to people, it's important to understand how policies dictate your care and how this whole system works. This is how the system works. This is how institution works.
Mel:
[42:22] This is how your, this is the massive organization behind your care provider who's just walked into your room and said, hi, my name's Mel.
Mel:
[42:32] I'm your midwife today. what's behind your midwife is all these institutional pressures that they are expected to impose upon you as a woman and so knowing that you have a whole lot more questions to ask when your midwife comes in and says hey it's been four hours since your last vaginal exam is it okay if I do another one all right the only reason your midwife just came in to ask you that question is because the policy says that you're supposed to offer slash do a vaginal exam every four hours for every single woman in the hospital do you need the vaginal exam probably not if we look at the research you probably don't need the vaginal exam unless you're having an induction you might still not need it but you know that's part of the induction process and so for women who are sitting there going oh whoa what's happened do i need a vaginal exam the midwife might say well yeah we do them every four hours i mean that's true but do i clinically need one am i currently in danger is my baby currently in danger what will you find out what will you do if my if my cervix isn't behaving as the policy says it should because this is the other thing is the policy is vaginal exam every four hours the policy is also if you haven't progressed a certain amount of centimetres since your last vaginal exam,
Mel:
[44:01] A new policy is activated and there's another rule around that.
Mel:
[44:07] So it's not only, you know, the other day we talked about the cascade of intervention. I feel like there's a policy cascade. Like if this policy, if you get to the end of this policy, start the next policy, like you move to this policy. And so for women who are receiving care, a lot of midwives and care providers are operating off policy-based care because they have to. That's the requirement of their employment at that facility.
Mel:
[44:34] Now, for midwives listening, there is a way around this.
Mel:
[44:38] You can use wording that makes women aware of what kind of things are policy-based care and what kind of things you actually believe are clinically necessary for this woman. So if you go in and you say, hey, and the woman's sort of just laboring just fine and she's low risk and you can't see any issue with this birth, and you say, look, it's time for your vaginal exam and instead of saying hey it's time for your vaginal exam you say hey in this hospital we have a policy where we do vaginal exams every four hours how do you feel about that would you like to know where you're up to would you not like to know where you're up to and then if the woman says I don't want to know where I'm up to there's a really great opportunity for the midwife to just write in the notes woman declined like woman offered vaginal exam as per policy, woman has declined vaginal exam, plan to re-evaluate in however many hours, right? Midwives can give women the opportunity to decline and to inform them that I'm coming to you with this because this is the policy that I'm obliged to, that I'm responsible to this policy. Would you like this? And so, for the woman, she gets an opportunity to find out, am I getting policy-based care or actually individualized care?
Mel:
[46:04] And then the midwife gets an opportunity to inform the woman of, I'm about to offer you a policy.
Mel:
[46:10] There's actually six or seven other options that you could take outside of this policy.
Kirsten:
[46:17] And a good question for people to ask if something's being offered is, why are you offering this to me at this particular point in time? And that'll usually start to get you to the point where it's because that's the way we do things at this hospital, rather than I'm actually really concerned because I've noticed that you're bleeding and your blood pressure's falling. You know, you'll soon get some answers that sort out whether this is just because we think it's a good idea because that's what the rules say rather than actually my spidey sense is telling me that something's not right here and we really need to do something quite quickly.
Mel:
[47:00] Yeah. So that question was, why are you offering me this at the moment?
Kirsten:
[47:05] At this point in time.
Mel:
[47:06] At this point in time. Why are you offering me this at this point in time? And then midwives who there's a massive collection of midwives out there who don't agree with a lot of the policies that they're required to work to and that's a dream question to be asked if you're that midwife and somebody says why are you offering this to me at this point in time they'll say well this is what we do for every single person and then the woman knows I'm getting the cookbook treatment or the paint by numbers treatment I'm not getting the treatment that's required for me individually manually.
Kirsten:
[47:39] And midwives and obstetricians do need a little bit careful. And this is, you know, you need to be really across your policies. You need to read them. You need to know exactly what's in them and not just rely on somebody else telling you what's in the policy. So do go to your policy libraries, download them, familiarise yourself with them. And as new policies come out, read the updated ones and pay a lot of attention.
Kirsten:
[48:09] Obviously, I did that as part of the PhD. I was looking at the fine print of what was in them. And at the national level, the guidelines say things like you should recommend and you should advise that people do this particular thing. What I found when I went and looked at the local hospital policy was that the wording said women must have CTG monitoring if they have risk factors. The midwife will ensure that a CTG is used. And so when you've got wording like that, that creates a real problem because if you then say, well, actually you have a choice and you don't have to have a CTG, you actually have just gone outside of that policy and you are at risk of your employment. So that's why you do need to know specifically what the policy says. And obviously, if you're seeing policy that doesn't recognise that women have bodily autonomy me and must consent to interventions, then you probably want to bring it to the attention of the guideline writing team or volunteer to take that responsibility as one of your, you know, professional improvement projects to change the wording and make sure that it has things like strongly advise, recommend, suggest in the language so that, you know, You do have the space to actually do precisely that.
Mel:
[49:32] Does this then add another layer? Because we know from all the birth trauma inquiries and birth trauma research that women often feel exposed to coercion from their care providers to do things that they didn't really want to do but that they did because their care provider created a coercive environment. This seems like another layer of opportunity for care providers to firstly build some fear into their work. And then as a result of that fear adopt some coercive behaviors that will encourage women towards policy-based care so that the clinician is not in breach of their employment requirements. And maybe it's a completely separate issue to being fearful that the woman's going to make a decision that they believe is dangerous and more that the woman's going to make a decision that endangers their employment.
Kirsten:
[50:30] Correct. And there's some really good research on this around fetal heart rate monitoring that people do use information sharing approaches that are designed to achieve a particular outcome, which by definition is coercion, rather than saying, here's the range of options. The evidence suggests that this one is better because of X, Y, Z, and that's what we recommend that you have. How do you feel about that? And, you know, support and provide further information as required rather than if you don't do this, your baby will probably die.
Kirsten:
[51:08] And, you know, in the CTG world, the research talks about this thing called the dead baby card, which is precisely that. It's telling people that there's a high chance that their baby will die if they don't comply with the treatment that's on offer. You know, in spite of the fact that all of the evidence shows that CTGs compared to intermittent auscultation don't reduce death rates at all. So it's complete fabrication. You know, that's not to say, I mean, there's some people who genuinely are at much higher risk of stillbirth or neonatal death than another woman. There may genuinely be an increased risk and it's absolutely appropriate that that should be shared with people, But in a way that's designed to support them to make a decision, not to instill so much fear that it overrides their capacity for good decision-making.
Mel:
[52:01] Yeah. And so then, I guess people, doctors, I mean, I'm sure anaesthetists and everybody across the whole hospital has these policies that, So really, it's our responsibility as clinicians to firstly be across the policy and understand what that says, but then secondly, to be across the research and what that says so that when you do come face-to-face with a woman and present them with their options, you've actually given them the full menu of options, not just the policy option, not just the research option, not just your opinion, but actually you're presenting them with the whole range of things and that the woman's aware.
Kirsten:
[52:44] The next level after that is to have good research interpretation skills and to understand that research is done in a particular time, place and context. And when you take that information and apply it in a different time, place and to a completely different context or a different population, you may not get the same results. And that's not necessarily captured well when it comes to, you know, people might apply research to writing guidelines, but not really get the nuance of it. And that's when expert practitioners who are really well across the evidence can really come to the fore in terms of individualising care and saying, well, look, you know, this research was done, but it was only done in women having their first baby whose babies were headfirst and they had a normal BMI. You're having your third baby and you've got a BMI of 32. so that doesn't necessarily apply to you, So I can't actually say that doing that is going to be a good idea or a bad idea because we just really don't know.
Mel:
[54:00] And also, when you get a policy document, they've got references on them. They've got all of the resources that they use to make that guideline or policy. And so as a clinician, you can actually go into those resources and have a look at the quality of them yourselves. I love doing this because so often you come to the end of a policy and they've referenced the policy from last time and then three other policies from some other facility and then you go back to those policies and those policies are referring back to another policy.
Mel:
[54:36] Before you know it, there's hardly any actual research papers on the bottom there in the reference list and even if there is a research paper in the reference list, you read it and you think, how did they use that resource to make that document it doesn't check out and so that blows the whole thing wide open and the next thing you can do is is hospitals can print off policies and give them to women and I've done this before when I've gone into hospital with a client and the staff's talking about oh well our policy oh well our policy and I said to them could you please print off those policies so that my client can understand what expectation there is that what she can expect from you guys so that she now can make decisions and so you can ask that if you're if you know obviously this isn't really the time to do it during actual labor but if you're planning something for example like a v-back or breach hospital at a breach birth at your hospital Or
Kirsten:
[55:40] You've got gestational diabetes or, you know, twins or something where there's plenty of planning time in advance.
Mel:
[55:49] Yeah, you can get a hold of that hospital's policies so that you understand what you're up against and then you can also understand what evidence has gone into that policy and that can launch you into your next stage of planning and next stage of research.
Kirsten:
[56:04] So, yeah, not necessarily up against because, you know, some of them might be fabulous, but there may be some really useful elements. The policy might specifically say that you need to support women's decisions irrespective of what they are and that you need to treat women with respect and that you need to give women time to make decisions. And so if you're being hassled and pushed into a corner, you can say, actually, your policy says that I'm supposed to be provided with good information and time to make a decision. I'd really like that to happen now.
Mel:
[56:40] Yes, we'll flip the script on that. Do you know what else I find interesting? Is hospitals also have an opportunity not to accept certain policies? Like there's a policy directive about hospitals actively seeking to collaborate with private midwives and offer visiting rights. It's a New South Wales policy directive. So when that came out, I took that to our local hospitals and I said, hey, there's a new policy. When are we going to set up visiting rights and they said that's never going to happen here And I was like, that's interesting for a place that really values policy-based care. We've now got this policy which says, hey, let's start collaborating with private midwives and let's get some visiting rights in place. Nobody's ever going to agree to do that. So just let's not even bother.
Kirsten:
[57:32] So for the people who started this thinking, policy, this is going to be dull, hopefully you've gone, that was really interesting. I never realised. I didn't think it was like that. Yeah, knowing that the policy landscape gives you some of your power back so that if you understand how you can get the system to work in your favour, it opens up some opportunities to improve your chances that you're going to get the kind of care that you want to get through your labour. It means that if you actually know the fine print, It also enhances your opportunities to be able to broaden the range of ways in which you practice whilst not putting your employment at risk at the same time, because you can actually function within the policy environment to your best effect. Grow your knowledge, grow your skills so that you can get to the point where you can creatively break the rules in order to improve outcomes. Not just ignore them because you don't like them um you know it needs it needs to be done with the right intent um the other thing i'd like creatively.
Mel:
[58:51] Great i'm just going to say that again because creatively break rules to improve outcomes for women that's the aim isn't it
Kirsten:
[58:57] Yes yeah yeah the other thing i'd like to add is that like the blog post that prompted this conversation was my explanation as to why I don't participate in guideline writing around fetal monitoring. And I want to say I am not advocating that health professionals don't participate in guideline writing. Do. If you spot a policy at the place that you work or at the organisation you work with and you think that it needs improvement, then absolutely volunteer to do that. You know, the blog sets out the reasons why I've made the decisions that I have about that particular one. And it's largely because there is such a profound gap between the evidence base and what happens in practice. And I know that if I turn up and go, come on, guys, the evidence says this, we really should write a policy that says women who've got risk factors are allowed to have intermittent auscultation.
Kirsten:
[1:00:00] That's not going to, you know, it's not going to go the way that I think it's, I would want it, I mean, it's going to go the way I think it's going to happen, which is that they're going to go, no, and they're either going to give me a really hard time, or I'll end up having my name attached with something that I don't believe in. And, you know, neither of those are an option for me at this point in my career. But, you know, if you're picking something that's, you know, changing one brand of antibiotics to the next and it's non-controversial and there's clear evidence, or if it's about improving the guidelines so it says that women actually have choices, then definitely I would encourage you to participate in that process.
Mel:
[1:00:44] And it highlights too that policies can be just reflective of the culture of that workplace and of that profession. And we know for a long time we've talked about a lot of hospital based care being culture-based where basically, oh, that's just how we've always done it. And interestingly, the RANSCOG guidelines and policies are often, when they talk about the level of evidence that they used, they'll sometimes just say that they decided that by consensus. So if everybody sitting around the table went, yep, that sounds good, they'll put it down in the policy and they'll list that this decision was made by consensus. And that talks to the practice of using cultural-based care because they've all just gone, yep, that's how I do it, yep, that's how I do it and then they all just around the table agree that that's how they do it and so they go, well, that's how we're all going to keep doing it. So that's a factor as well in policies that we might have overlooked.
Kirsten:
[1:01:44] Yes. And the RANSCOG policies are all available on their website so you can go and download them and have a look for those levels of evidence. They do, in the fetal monitoring one, they do cheat slightly because they've got a high, they've got level one, which means, you know, it's really sound evidence, next to their recommendation that women with risk factors should have CTG monitoring, when in fact that's not what the evidence says at all. So there's a little bit of activity in some of them, but you're correct. Most of the rest of it, if it is just we think this is a really good idea, then it's specifically listed as consensus-based, which doesn't mean that, It's just, you know, you can just ignore it because, like, you know, there's never been a randomised control trial that shows that jumping out of a plane with a parachute on is better than jumping out of a plane without a parachute on. The recommendation that if you're going to exit a plane at altitude, you should really wear a parachute and know how to use it is based on consensus-based guidelines. So, you know, all of these things require some critical thought rather than just, you know, rules-based thinking about, oh, well, if it says consensus-based, I can ignore that because it's probably nonsense. It's not necessarily nonsense.
Mel:
[1:03:09] Yeah and and i mean and to summarize what we've done today is basically the place of policy is to help organize hospital institutions and organize clinicians and give some baseline and standard of care that's expected of people working in these places but as you can see we've kind of highlighted some of the good parts of that that sometimes they can be helpful because they've got good direction and they'll help maybe a less experienced clinician know exactly what to do within a system and they can work amazingly in emergencies where everybody knows exactly where they've got to be and what to do. The flip side is that they are written within the interest for professional organization and institutional organization and don't always consider the experience of the woman and so now that you have this information you're able to work within that and understand the structures that you might be coming up against and come up with some strategies to be able to navigate that. Beautiful. All right. Well, that has been this week's episode of the Great Birth Rebellion. We talked all about the place of policy, and we do hope that it helps you get the best birth possible. What was your line? It's doing creative.
Kirsten:
[1:04:28] Rule breaking in order to improve outcomes.
Mel:
[1:04:32] So, yes, that's the advice for clinicians, isn't it? Creative. I keep losing it.
Kirsten:
[1:04:41] Creative rule-breaking to improve the outcomes.
Mel:
[1:04:45] Creative rule-breaking to improve the outcomes. That's the idea. In order to do that, you do need to know the research and I do think you need to be a little bit more, have a more level of expertise. All right. On that note, that's been today's episode of the Great Birth Rebellion. Beautiful. To get access to the resources for each podcast episode, join the mailing list at melaniethemidwife.com. And to support the work of this podcast, wear The Rebellion in the form of clothing and other merch at thegreatbirthrebellion.com. Follow me, Mel, @MelanietheMidwife on socials and the show @TheGreatBirthRebellion. All the details are in the show notes.
This transcript was produced by ai technology and may contain errors.
©2025 Melanie The Midwife
