Call the Midwife?

The nostalgic BBC drama, Call the Midwife, set in London’s east end during the 1950-60’s, has consistently achieved high ratings since its launch in 2012. Midwives and nuns lived in and worked from Stepney’s ‘Nonnatus House’ and regularly dealt with the miracle and problems of childbirth. They used their skills and wisdom to support pregnant women, their families and communities whilst adapting to a rapidly changing world.

No doubt this focus on midwives has helped to positively influence how modern midwives are publicly perceived despite that they are worlds apart. But I doubt the public would be happy to learn how much their roles now incorporate a policing one, while their clinical ones seem secondary.

‘Tackling violence against women and girls’ which has recently become a Home Office (HO) priority is now partially theirs. NHS staff were advised in March that many women were coming forward to speak about their experiences of harassment, intimidation, assault and abuse which have increased during the COVID-19 pandemic. FGM is also considered violence against women and girls and there is speculation about an increase in incidence worldwide. The UN has predicted that there will be two million more cases over the next decade.

The HO new public awareness campaign #YouAreNotAlone encourages people to come forward for support and help if needed. The anti-FGM activist, Nimco Ali, has been appointed as an independent government adviser on Tackling Violence Against Women and Girls. A new strategy is due to be published soon.

I was reminded of a piece that I wrote twenty years ago when domestic abuse and violence was initially being pushed onto healthcare workers’ agendas, of midwives in particular, fully supported by their professional organisation, The Royal College of Midwives (RCM). I was concerned then about the undercover policing role they were expected to play, fearing this might undermine public trust in them and the privileged position they’d worked hard to earn.

Turns out I was right to be concerned. But from today’s perspective my concerns then seem trivial. Midwives now have so many agendas that monitoring the heath of the pregnant woman and her developing foetus no longer seems their priority.

In 2018 the RCM’s policy advisor said the duties of a midwife to their patients “should go beyond the clinical to include wider issues that may affect their pregnancy”. And actively supported initiatives which furthered them.

So screening in regard to domestic abuse/intimate partner violence has become a routine part of ante-natal booking appointments. Included also is what some perceive as judgemental questioning about lifestyle choices (diet, alcohol, drugs, smoking) and infant feeding where breast is deemed best, as well as mandatory questioning of ALL pregnant women about FGM. Having Social Workers in attendance at ante-natal appointments is viewed positively and even considered innovative by some.

Additional work that midwives are expected to do in regard to FGM such as data sharing (which breaches patient confidentiality) and mandatory reporting to the police of under 18’s who’ve reported/had it confirmed, are hugely concerning. This policing role has been sanctioned in law. And the damage being done to individuals, families and communities seems to be given little consideration or acknowledgement.

I doubt the Nonnatus House midwives would have approved.

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The Pregnancy Police

The notion that midwives should snoop for signs of domestic abuse is an abuse of their privileged position.

Giving birth is one of the most unrestrained experiences in a woman’s life. There is simply no way of retaining control. Women scream, curse, abuse the medical staff, their partners and the world in general. Midwives expect it – and women need it. Labour is scary and a woman needs to know she can trust her midwife absolutely. She needs to know that whatever nonsense she prattles when she’s out of her skull on pethidine, the midwife will never betray a confidence.

Midwives pride themselves on their special relationship with the women they deliver and many will be horrified – and rightly so – that their professional body, the Royal College of Midwives (RCM) is colluding with government in a project which cannot but undermine this relationship of trust.

The publication of the RCM position paper, ‘Domestic Abuse in Pregnancy’, in November 1997 was greeted with enthusiasm by the secretary of state for health. The Rt Hon Frank Dobson joined a photocall at the House of Commons to stress the government’s commitment to tackling domestic abuse. He was delighted that midwives were putting themselves forward to play a role in this, and midwifery leaders were thrilled that their value was being appreciated. Nobody pointed out that this initiative transforms the midwife from a health professional aiming to support a woman through pregnancy and labour, into an undercover cop.

The RCM says it is promoting this initiative because ‘domestic abuse may have a damaging, sometimes even life-threatening impact on the physical and mental well-being of a woman and her baby’. General Secretary Karlene Davis told the RCM journal that midwives are particularly well-placed to spot incidences of domestic abuse: ‘Midwives will at some point in their career attend women who are suffering physical abuse from their male partners and the move in the profession to more community-based midwifery services means that midwives increasingly see firsthand the signs of domestic violence.’ The position paper aims to guide RCM members to recognise abuse from physical, emotional and behaviourial signs, and provides specific guidance on what the midwife should do when she believes that abuse is taking place.

It is worth taking a look at some of the indicators of domestic abuse detailed in the paper which the midwife is encouraged to take note of. The College recognises that none of them is definitive proof of abuse, but recommends that if it is suspected the midwife ‘should ask further questions, carefully and tactfully’.

The first section on the woman’s obstetric history is the most worrying because within it are listed some not uncommon problems which some women may experience during their fertile years. Midwives are encouraged to consider the possibility of abuse if a woman’s history reveals any of the following:

• A high incidence of miscarriage

• A high incidence of termination of pregnancies

• Stillbirth

• Pre-term labour/delivery

• Unplanned pregnancies

• Unwanted pregnancies

• Smoking, alcohol and drug abuse

This is probably broad enough to include most women a midwife sees. Unplanned pregnancy is so common (half are unintended) that most midwives would regard it as normal. There might be a whole host of reasons why a woman has a history of repeat abortions, miscarriages or stillbirth. To identify smoking as a marker for domestic abuse – given the number of women smokers – is bizarre.

‘Common injuries in pregnancy and postnatally’ are listed to be given similar consideration by the midwife. Included are problems such as frequent vaginal and urinary tract infections, and frequent visits with vague complaints such as reduced fetal movements or abdominal pain. None of these of course is an injury or even proof of injury, and they are not uncommon in pregnant women. Thrush and cystitis are particularly common in pregnancy.

Some of the following are cited within a long list of behaviourial signs of possible abuse:

• ‘Missed appointments or non compliance with treatment regimes, lack of independent transportation, access to finances and ability to communicate by telephone.’ (In other words if a woman is poor – suspect abuse.)

• ‘The partner accompanying the woman, insisting on staying too close and answering all questions directed to her.’ (In other words if a woman has a dominant partner – suspect abuse.)

• ‘Denial or minimisation of violence by the woman (or her partner) with an exaggerated sense of personal responsibility for the relationship.’ (In other words if a woman says she hasn’t been abused – suspect abuse.)

If abuse is detected the midwife is encouraged to challenge it with a ‘multi-disciplinary approach, in which professionals work in partnership with the woman herself, and which includes support for both the abused woman and the midwife’.

In some of the examples listed it might be reasonable to assume that abuse may be actually occurring and the midwife’s alarm may be justified. These include rape, sexual assault and injury to the genitals, repeat or chronic injuries or even removal of perineal sutures post-delivery.

It is nevertheless worth asking if, even then, it is appropriate for the midwife to use her privileged position to carry out what I would call a snooping exercise and initiate a multi-disciplinary approach. I find it problematic for two reasons.

Firstly the RCM is encouraging midwives to act as though every woman on their case load is a potential victim of domestic abuse, and every male partner is a potential abuser. Real life is not like that. Most couples do not have abusive relationships and would find it insulting to imagine that a midwife was effectively using medical consultations to ‘screen’ their relationship.

Secondly, there is the issue of who defines ‘abuse’. It should not matter a jot whether a midwife approves or disapproves of the way a couple relate to each other. What she perceives to be abusive may be acceptable to those involved in a particular relationship. No couple should face the humiliation of a health professional trying to tease out details of private behaviour – unless, of course, one of them wants action taken. A midwife may genuinely want to help a woman she sees as vulnerable. But her perspective is not the same as the woman’s and they should not be conflated or confused. The woman may not want her ‘help’ or that of other agencies. The woman’s wishes should be respected.

The midwife has been accepted and even welcomed into the lives of pregnant women at a very special time for them. She is accepted not only as a professional healthcare worker, but also as a confidant, a problem solver, somebody who is trusted and from whom confidentiality is expected. Is it not an abuse of that trust and a betrayal of the confidence women have in the midwife if her agenda is now seen to include probing their personal lives?

This new role for midwives could even be detrimental to the health of the pregnant woman and her baby. If women feel that their every word, symptom, or bruise is being screened by the midwife for evidence of domestic abuse the barriers are likely to go up.

How many times have I heard pregnant women or women in labour say to their partners ‘I hate you, you bastard, I never want to see you again’, sometimes even physically lashing out at him? Was I supposed to have taken that as evidence of retaliation for abuse perpetrated on her by him, or as a release of pent-up emotion in a sympathetic environment? If midwives jump in and act on confessions, false or otherwise, pregnant women are likely to clam up, become reticent about confiding in them or may even absent themselves from antenatal care. The relationship between the midwife and the woman, which is based on the provision of healthcare, could be seriously undermined by the extension of the midwife’s role to include suspicious prying.

The RCM seems to be making an assumption that pregnant women might unknowingly be waiting for midwives to help them sort out abusive relationships and would consequently welcome intervention. Most healthcare workers could cite examples of women they have come across in the course of their professional lives who are stuck in domestic situations they may not be entirely happy with and would wish to be free of. Many also know of instances where women have managed, without their help or that of social workers or the police, to extricate themselves from unpleasant situations and make new lives. Women need our help with pregnancy and labour, they are quite capable of living the rest of their lives for themselves.

Policing pregnant women is not part of a midwife’s brief. They should stick to the job they are trained to do and for which we have fought long and hard to gain acceptance – that of delivering a professional and supportive health- care service. It would also be a shame if the perceived gains of pregnancy care, exemplified by the ‘Changing Childbirth Report’ in 1993 which seeks to provide women-centred care, are lost in the course of midwives inadvertently acting as an extension of the police and sticking their noses where they are not wanted.

This was first published 16 May 2001

Bríd Hehir is a health visitor and former midwife.