Why Do Bad Maternity Systems happen to Good People?

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The truth is that just because there is a better way doesn’t mean that’s the way it’s done.  I had an “aha” moment about why crappy care prevails in health care—-in particular, why women are still being abused and traumatized when they come to hospital to give birth— when I listened to this podcast  on the “religious” CBC radio programme Tapestry.  In the podcast, Mary Hynes interviews Gretta Vosper, an ordained minister of the United Church of Canada. Gretta tells the story of a particularly bitter conflict which had emerged within her church community and the pain that conflict had caused her.  She questioned why it is that in so many church settings, the meanest voices seem to own the podium.  What is peculiar to our humanity that this happens so often?

The reason, Gretta said,  why the bullies often win is that they exploit a loophole in our human nature.  Most of us want to get along and not be confrontational, so even in a place like a church where you would think people are mandated—commanded even— to get along and have empathy with each other, the bullies are set up to win.  Even in a place like church.  One bad apple can and does spoil the whole bunch.   A cursory look elsewhere in human history confirms this.  Why don’t we speak up? Why don’t we call evil out wherever it happens?

If churches can at times be hotbeds of hatred, is it really a surprise that health care workplaces are so often such unhealthy places for both the sick and the people who care for them?  Is it really so strange that hospitals are the institution where vulnerable people go to be healed but all too often come out further wounded?  That working in health care feels like being cast into both roles of an abusive relationship?  We are perpetrators, and sometimes victims.  We should perhaps be more often surprised under the circumstances when we get things right.

Since health care workers are the workforce of hospitals as well as being  members of the caring profession you would be forgiven for assuming that hospitals should automatically be workplaces filled with kindness and empathy. Indeed, kind people are attracted to the health care field but kind behaviours are often suppressed.  Horizontal and vertical violence are rife.  There is a combustible mix of people with the “disease to please” and one or two power brokers ready to exploit that: taking advantage of the softer nature of others as increasingly a certain management model and style has set in.  Staff are overworked and underpaid as managers are rewarded and in some cases paid bonuses for balancing the budget on their backs.  We are told that the patient comes first, and we have to do more with less, we understand that—-and people are being stretched beyond their capacity.  If we don’t look after our staff at a very basic level, they can’t look after anyone.

Once, I was finishing a caesarean section late at night.  My house officer assistant and I were both very tired. When we went to apply steristrips before putting the final dressing on the wound, we were clumsy with fatigue, accidently pulling off the steristrips we were trying to put on, making them stick to each other, having to redo some, and dropping swabs and equipment on the floor.  We were moving in slow motion, and screwing up out of sheer exhaustion.  The scrub nurse was watching us, and suddenly, she got so frustrated and angry that she lost it. She snarled at us to get out of her way, slammed on the dressing, and proceeded to very roughly take down the sterile drapes.

When that nurse ripped off those drapes, the drain I had put in the woman’s abdomen pulled out partway and I had to take down the whole dressing in the recovery room and remove it. It wasn’t a big deal, but maybe it could have been.  There might have been some sort of consequence for the woman, the newly minted mother at the end of the drain.   Infection, a missed haemorrhage. Certainly it was unkind.  And it is a million little unkindnessnesses that stack up together and make us all victims of the bad maternity system: the patient, the nurse and me.  I was too exhausted and too afraid to tell this nurse that her bitchy behaviour had caused a problem for the patient, because, in one part, the confrontation was just going take too much energy for me to muster up.  The next time I’d see that nurse she might make trouble for me.  In another part it was also because this small seemingly insignificant example of crappy care is a lot more common than you’d think.

Maternity care in too many parts of the world is an assembly line of impersonal care, provided by wounded healers working in a broken system.  We must do something different than we are doing now.

PS. I wrote this after reading this excellent post of Sheena Byrom’s here (where you can also download her awesome presentation about maternity care in the UK).  In it she asks why we aren’t following the evidence and changing the maternity system for the better.  And it got me thinking.

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19 thoughts on “Why Do Bad Maternity Systems happen to Good People?

  1. Thank you for this honest and articulate post Alison. Your explanation that bullies win because they exploit “the loophole in human nature” is exactly right. That exploitation does undermine the health system is so many ways, of which you provide excellent examples of here in your post. We, in our Bachelor of Midwifery degree at SCU, are working on ways of teaching and developing teamwork skills for our students, with the vision of closing that loophole. Your comment that addressing the issue may mean that the nurse may make trouble for you in the future is a perfect example of the response that an overwhelming majority of health care workers experience when being bullied – from students fearing that they won’t get a job, to experienced practitioners like yourself fearing that the nurse may find some way to payback (as they can so easily do!) with the potential for compromising safety for both the woman/patient and the health care practitioner in terms of mental health and wellbeing – do you have suggestions about how that problem can be solved?

    • There are no easy solutions to this Carolyn but I think people behave better when their work is valued. One of the big problems with women’s health is that it involves women. And in our current society, what women do is still not valued enough. I will definitely have more to say on the solutions end of things though….watch this space.

  2. Kathleen Fahy

    Hi Alison, I couldn’t agree more about how bullies exploit others desire to get along well and not cause conflict. There is one way, however, that an individual can make a contribution to improving the culture in maternity care and that is by giving feedback; both positive (often) and negative (much less often). We all need to practise this so that eventually it becomes skilled and expected.

      • That’s really interesting: I’ve found it much easier to point out improvements when I’ve spent time giving feedback. I think it is the idea that it becomes expected & normal to have a reflection on the care we provide, rather than only when it goes wrong

      • Another very important point you have made Gourmetpenguin. Many maternity systems function by running from crisis to crisis, answering complaints and health and disablity inquires. In some places teams have started doing “time out” before and a debrief session after every operation they do. This gives an opportunity to provide specific feedback, and addresses your point of normalizing reflection.

  3. Fiona Hermann

    Alison, you make great points. I think the other benefit of the debriefing in theatre approach is the places that use it ( or so I hear) also expect and encourage all members of the team to speak up and point out any issues or potential errors. There is no hierarchy. Health care systems still value senority over kindness or common sense, in many cases.

  4. Jane Aubin

    Some great points Alison & valuable comments too. Why does this continue to happen? And what is the solution? I think reflective practice helps, but does it improve the system & makes way for change? I’m not entirely sure- after a difficult & very busy shift last night I’m feeling deflated & cross at the system. Compassion & caring are important traits when in this profession, however seeing less of it lately makes me wonder why some people are even part of this profession? How do they continue to get away with it?
    However, on a positive- I do see many caring & compassionate midwives & nurses with their hearts still in it who continue to fight for what they believe in, lets hope they don’t give up.

    • Thank you Jane for your comment. I share your views. I do work with some kindred spirits at times. I couldn’t keep on without them. I feel I am also seeing less compassion lately. I can’t help but think that the generalized distress of society and the increase in inequalities is having an impact. Everywhere–not just in our little world—people are suffering. That’s why, more than ever, we need kindness. I hope that you and I can hang in there.

  5. Rachel Hilliard

    I have really enjoyed your blog posts, they speak to my own birth experiences. I also work in a pretty uncaring organisation (university) with its share of bullies. To thoughts occur to me. I think a mindfulness practice has great potential to support people in reconnecting with their compassion. And I also think Robert Sutton’s work developing the No Asshole Rule shows how you can create a culture where bullies are not able to flourish.

      • There’s a few little gems in it. One is a story about rafting in Satan’s Cesspool. This is a real river in California. If you fall out of your raft, the strategy is to not fight it, and just keep your legs out straight in front of you, use your life jacket to float, and your legs to push off all the boulders and crap that comes your way. If you work in a shitty place, or say, you live in the patriarchy, this could definitely apply to you. Sadly, we have to live here in the midst of all the shit (because there is no parallel universe). This is definitely a possible strategy many of us could employ I think. We don’t have to lower ourselves to catching and flinging back the venom the jerks fling at us. Instead we can remain calm. Focus on small ways to gain control. Help fellow victims cope by being kind and supporting each other, and by teaching them the strategy.

  6. HI Alison, I met you at hospital the other day. I am a new social worker in the Women’s hospital . Reading your blog nearly made me cry. I have spoken with a number of women in the time I have been there who’s stories about their deliveries have sounded truely frightening, painful, traumatising. To be honest I have not known what to do with what I have heard, I have struggled myself in the environment. I would love to meet you if that was possible and talk about what you have written here. And thank you for writing this. Rebecca

  7. Another astonishingly honest post Alison.

    Many years ago as an anaesthetics junior, I was called to help a senior consultant put a central line in a sick patient on the ward. It was 2 in the morning and I knew this consultant had been working all that day. He looked dog tired. When the line was in, he asked me if I would check the X-ray and sort out the paperwork. I responded “Sure. You must want to get home, you must be exhausted.”

    He became furious. “Th-that’s just irrelevant!” he roared. “This woman needs my care!” This was not the response I was expecting!

    But he was wrong. Fatigue isn’t irrelevant. As well as making us irritable (as he had clearly become), it makes us more likely to make procedural mistakes, and errors of judgment.

    He is not the only senior doctor who has unsuccessfully attempted to demonstrate that they are immune to exhaustion, to hunger, to fear, to grief, and to the other frailties which make us human. Why does this culture exist that doctors must be superhuman? (The same one which insists doctors don’t make mistakes?)

    It took him five years, but that consultant eventually apologised for his outburst, and we laughed about it.

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