Hierarchies of Care Affecting Professional Midwifery
Abuse of power within hierarchical structures is nothing new. We see it in our news feeds every day. Hospital corporate entities are structured around the traditional medical hierarchy, particularly regarding hiring, supervision, advancement, and the responsibilities of advanced practice professionals.
Hospitals have long been a hotbed of liability, reliably manufacturing fresh evidence for medical malpractice claims. One solitary hospital malpractice case can produce individual, vicarious, and corporate liability, all rolled into one. Trial lawyers are familiar with the many malpractice nightmares involving for-profit hospital corporations. They depend on hospital negligence to provide brisk law firm business. Lawyers will never starve as long as the financial interests of hospital corporations take precedence over provider support and quality of care.
Nurse-midwives in hospital practice are particularly vulnerable to unhealthy and hostile work environments where disrespectful behaviors interfere with communication, collaboration, and morale. An unhealthy hospital culture that condones disrespect may cause midwives to abandon their profession, ultimately harming the patients who seek their care. Disrespectful behavior toward midwives in hospital systems is shamefully commonplace. Recipients of this behavior can experience fear, anger, isolation, and depression with a host of other ailments, such as insomnia, fatigue, and poor health. 1
Cultures of Disrespect
Disrespectful behavior is also at the root of problems in developing modern team-based approaches to improving patient care. The antiquated hierarchical structure of healthcare, with its sense of privilege and status, can lead those at the top to treat those lower down with varying degrees of contempt.2 This is particularly apparent in doctor-nurse interactions. Nurse-midwives are in the unfortunate position of absorbing disrespect from the top and bottom of a care structure. It has been described by some midwives as being the ham in a hostility sandwich. Hospital corporations have allowed the problem of mistreatment to persist by ignoring it, thereby tacitly accepting it.3
Encouraged by hospital corporate entities, physicians have historically viewed nurse-midwives as legal liabilities, which is entirely without any basis in fact. Yet, this attitude is perpetuated in many unenlightened hospital settings. Some physicians disdain advanced practice nurses or physician assistants. Although hospitals will hire them as less expensive labor, they cannot be trusted to stand behind these hires in the face of litigation and will find ways to subordinate APRNs and PAs as “mid-levels” whenever possible.
Blurred Roles
Hospital administrative departments often blur the roles of labor and delivery nurses and nurse-midwives, as if the midwifery scope of practice, capabilities, and education were identical to nursing practice. While certified nurse-midwives have a background in nursing, they have advanced beyond that role and possess a distinct philosophy of patient care, scope of practice, and education. Nurse-midwives will initially regard pregnant women as normal, expecting to support a normal process. Nursing will regard pregnant women as “patients”, in need of care for a pathological process. Two very distinct professions and scopes of practice with, unfortunately, similar titles. “Nurse” in nurse-midwife is not helpful in distinguishing the profession or avoiding confusion.
Nursing vs. Midwifery Administration
Hospitals employing nurse-midwives may appoint a midwife “lead” or coordinator for a midwifery group practice. Typically, this appointment confers nothing but a fictional title and a willing figurehead with minimal-to-absent authority. The traditional hospital administrative entity for nurse-midwives is the OB department nursing administrator, further demonstrating that midwives and L&D nurses are considered equivalent.
Exceptionally thoughtless institutions may have nurse-midwives and labor and delivery nurses sharing patient care duties in obstetrical triage. In these scenarios, the midwives are called upon to perform RN tasks such as placing the patient on the monitor, taking vital signs, offering water, and tucking them in. Although these tasks are not strictly part of the midwifery scope of practice, providing this care can enhance midwifery assessment of the patient.
But midwives performing in a nursing role can confuse triage patients, understandably leading them to believe that they are just receiving nursing care. Patients may not appreciate the difference, further perpetuating the societal impression that midwives function as “nurses” rather than advanced practice providers. But as long as nursing and hospital administration fail to appreciate a difference, why would anyone else, including the patient?
Role confusion regarding nursing and midwifery allows the development of “liability landmines, where midwives are considered nurses with an annoying avocation for delivering babies or just “mid-level” creations of the American health system. When hospital corporations disrespect and downgrade midwives, so does society, which will disrespect them by extension. In the world of litigation, it may be easy for a trial lawyer to convince an average jury that a “midwife” has no business being an independent primary obstetrical health provider. Clumsy and inaccurate definitions of the certified nurse-midwifery role can be expected from misinformed attorneys. During litigation, poor legal representation can result in nurse-midwives being represented less competently and disciplined more harshly by misinformed juries.
Unethical Hospital Advertising
Hospital entities mining patient business have made unfortunate mistakes in advertising, comparing “safe” hospital care with dangerous “midwifery care” in homes, where catastrophe awaits unsuspecting women and their unborn babies. It is very similar to hyperbolic lawyer advertising. Unsuspecting hospitals that insert advertising into web accounts of catastrophic birth injuries occurring at home have found themselves in legal difficulty. Many State Consumer Protection Acts consider this type of advertising as unethical and against the law.
1. Disrespectful Behavior in Healthcare. Its Impact, Why it Arises and Persists, and How to Address It – Part 2. Matthew Grissenger, RPh, FASCP. P&T February 2017. Vol. 42 No.2. pg. 74
2. Ibid. p. 74
3. Ibid. pg 75