Sometimes The Meek Won’t Inherit The Earth - Part 1

Profile and Demeanor In Practice; How Do Midwives View Themselves in the Workplace?

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Midwifery care is associated with the concepts of gentleness and patience. In fact, they are a hallmark of midwifery care. In corporate healthcare, these qualities are frequently undermined and disrespected. Providing midwifery care in corporate environments can be difficult. The needs of midwifery patients and corporate expectations, may not leave time or space for gentle birthing or, gentle-anything. But, most of the midwives I’ve known over decades have rarely failed to display calm, quiet competence in every setting, whether from the backseat of a car outside the ED, in the corner of an over-crowded emergency department, or assisting at crash c-sections. Midwives are educated to be calm, confident, and in control regardless of difficult circumstances. No one can argue that all hell does not break loose in certain settings of birth, but mostly I have felt pride for the control midwives demonstrate, the skilled work they do, and how they do it.

Preoccupying my thoughts, these days, is our profession’s long history of failure to establish a more respected and robust profile in local healthcare and around the world. Midwives are so clearly the perfect answer in many settings, not only for health inequities and disparities around the world, but in our own communities. Midwives are able to perform primary care for anyone, regardless of gender, in addition to women’s reproductive care. It has not been for lack of trying. Efforts have not taken hold.

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In various corporate settings, I have consistently witnessed unnecessary obstacles; bad attitudes and misconceptions of midwifery care. And now, we must experience the arrogant and witless destruction of healthcare infrastructure, all for the sake of distraction while more wealth is channeled into the greedy hands of men who neither deserve or require it.

In this developing environment, I fear for the integrity of our profession. Even in good times, asserting the benefits and wisdom of local and global midwifery care has not been received with a desired level of enthusiasm. Of course, midwifery is particularly vulnerable, representing predominantly women-centered and women-rendered care. With the daily purging of talented health care professionals and institutions, the path forward isn’t completely clear. I am proud of the dedicated stance by ACNM and its consistent support for women and reproductive care. We are threatened, now, and face obstacles that we cannot yet even fathom. As midwives, I will trust that our way forward becomes clearer as time and events unfold.

Primarily in the United States, UK, New Zealand, and Australia, midwives and student midwives have long experienced mistreatment and bullying from physicians, mentors, labor nurses and other colleagues. There are journal articles written on this subject everyday. Are midwives targeted because of the nature of their work or that the profession is predominantly female? Are the personalities most likely to enter midwifery more vulnerable or more passive?

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I can’t help but wonder if midwives, in general, are targets for mistreatment because they are naturally conciliatory and, possibly, accepting of intimidation? Is this a problem of lack of assertiveness or reluctance to engage with strong or aggressive personalities? Since midwives entered hospital practice, they have been abused and demeaned by colleagues from above and below. It seems that outdated healthcare hierarchies can crush midwives caught in the middle, particularly those with gentler personalities.

This is not a novel idea, but I am extremely supportive of mandatory assertiveness training as a potential solution to support midwives’ ability to stand up for themselves against stronger, confrontational personalities. Nurses, doctors, and administrators in hospitals have directed varying levels of abuse toward midwives for more than 50 years. Isn’t that enough? Perhaps more professionals and lay people could better appreciate what the profession has to offer if more midwives could stand firm from the outset of their training and employment, were less apologetic, and more, well . . .belligerent?

Assertiveness Refresher

Assertiveness is defined as an interpersonal behavior that promotes equity, with the proposition that all people are equally important. Midwives are caring for women and families every day. Especially in labor and delivery, midwives must facilitate interactions which require negotiation, skill and assertiveness. Seasoned midwives critically lacked assertiveness skills when first navigating hospitals as “providers”. Fending for yourselves in hostile environments was not taught or even suggested in early CNM programs. On the units, students were left to negotiate skirmishes as they arose.

Among doctors, nurses, and midwives, there were very few productive boundaries when it came to personal behavior. Early in CNM integration, midwives did not know how to deal with physician and labor and delivery nurse aggression and contempt. What happened? They used to be our friends. . .

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And being out-numbered didn’t help. When midwives requested assistance with the smallest of tasks for their patients, physicians and nurses could be hostile. It was not uncommon for OB nurses to refuse to take midwifery patients, fearing without basis that any involvement with midwifery care exposed them to legal liability. They got away with it, then, and really have not let up since.

I’d like to think that things are better now. In the midst of the worst cultures of care, nurses and doctors remain confident that they can be disrespectful. This must be dealt with early, if possible, or it will never resolve. Patients will suffer.

Assertiveness programs can assist when dealing with inappropriate L&D confrontations. Training will assist you with setting boundaries and how to guard them. To be assertive, you must express your needs (and those of your patients) in a way that is respectful to others.

Personal confidence and self esteem may require extensive professional training, in order to reinforce your beliefs, behaviors, and decision-making capabilities. It can be a grueling process. Some hospitals have to hire outside mediators, just to get labor and delivery nurses and midwives to sit together at the table. Mutual respect can be easier said than done, especially when dealing with stubborn, unhappy people.

Basically, your challenge is to remain polite and respectful, despite the typhoon of negative feelings and urges that are swirling around in your head. Remember that being an assertive communicator rarely comes naturally for most people. Although I recommend legitimate, formal assertiveness training, the following list may prove helpful, initially, to settle emotions and avoid the need for a security escort.

- know what you want to say; use “I” statements. But not, “I” want to throttle you

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- respect the opinions of others (even though you completely disagree)

- choose the right moment to assert yourself, and I don’t mean when the baby’s head is crowning

-be confident and not arrogant

-be firm but polite (yes, you may eventually need dental work from clenching your jaw and gritting your teeth)

-don’t be aggressive or raise your voice. A low growl may be effective.

-speak in a neutral tone, not 8 octaves above your normal vocal range

-actively listen to what people have to say. No rolling of eyes

-ask people to listen to what you have to say. Try not to react if they laugh. . .

-learn to understand your boundaries – wear an Oura ring or blood pressure watch.

-look for ways to compromise1 - we’re all just people.

1. Nurse & Midwife Support. https://nmsupport.org.au/students-and-graduates/assertive-communication

Relevance For Practice

Situation/Vulnerability:

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Practicing within a difficult culture of care creates vulnerability to mistakes and patient harm. Even without overt aggression toward you, lack of moral support and/or friendship can cause stress and depression. These care situations can divert your attention from your patient, leading to mistakes that result in patient harm.

Duty:

In overly stressful care environments, you cannot provide best care and your patient may sense this. You may not be able to perform as “a reasonable and prudent nurse-midwife would do in the same or similar circumstances”. You are responsible for reporting situations of abuse. The tendency to “power through” abusive treatment is not appropriate or in your patients’ best interests. Lack of mitigating your circumstances can provide critical causation evidence against you that will be difficult to defend.

Remedy/Protection:

Again, reporting and documenting abusive situations and the general state of the care environment. Engage in assertiveness training if it is available to you. If necessary, take an immediate leave of absence and seek therapy.

Warning: Once legal claims of negligence are filed against you, all circumstances surrounding an adverse event will be examined in detail via written interrogatories, depositions/examinations under oath. The process of legal fact-finding is lengthy; multiple individuals/co-workers will be deposed for their impressions or participation in events. Cross examination testimony in front of a jury will be one of the most difficult experiences you may ever endure as a professional care provider.