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Festive news from Trisha Greenhalgh, p 1318
Encounter with a doula: is the NHS failing mothers? Personal View Abhijoy Chakladar
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nyone know what a doula is?” I asked in the coffee room. I was met with a roomful of blank faces. Earlier, during the morning obstetric meeting, a midwife told me that her patient had a doula. “A what?” I asked. “You know,” she said, “a birthing partner.” I didn’t know; anyway, isn’t that the job of the partner or the baby’s grandmother? The word doula derives from the ancient Greek for “woman of service.” Recently it has been used to describe experienced women who help mothers care for newborn infants; the role now extends to attending prenatal classes and the birth itself. On this occasion an epidural had been inserted as per the birth plan, and I was called to assess the patient’s analgesia, as she complained of discomfort. I found a missed segment and planned an epidural bolus with repositioning. The doula had been present since admission, as had the husband. Both the mother and father were confident and articulate, so I couldn’t help but wonder why they needed to pay for support. In my practice the mother is the principal focus, but I address the couple together, recognising their joint experience of bringing a new life into the world. I found myself disconcerted by the doula’s presence, as I was unfamiliar with her role. To whom should I direct my explanation? If I spoke to the doula and mother, would I marginalise the father? If I spoke to the couple would this be regarded as disrespectful to the doula? She was there, after all, at the express wish of the mother, her employer. I chose to speak directly to the mother—the patient. I gave the top-up and advised that she turn to lie on her side. At this point the doula interjected to say that the mother was comfortable as
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she was and asked if repositioning was necessary. I said it was for the top-up to be most effective. While documenting the procedure I was informed that the patient had decided not to move. I realised my mistake. If the mother had asked the same question, I would have qualified my answer with a description of how epidurals worked and the effects of positioning on the spread of a local anaesthetic. As the doula had asked, I had dismissed her question without explanation, compromising my care. Failure to offer sufficient justification to the doula seemingly gave sufficient justification to veto my request to reposition. In this clinical situation the presence of a doula swayed the decision making incorrectly. In retrospect, I should have confirmed everyone’s roles and established ground rules acceptable to all involved on entering the situation. Hired birthing partners are unregulated, not part of clinical obstetric teams, and therefore should not be involved in making clinical decisions. There is no nationally recognised certification for doulas, and it is possible to work without training. Courses are available for doula training; these claim to improve understanding of what parents expect from a premium service and options regarding birth plans; to reinforce the role of doulas; and to allow a brief experience of the childbirth process. The Nursing and Midwifery Council recognises doulas solely as emotional support for mothers and as unqualified persons who cannot substitute for registered midwives. Doula organisations often cite a meta-analysis published by the Cochrane Collaboration that found an association between continuous birth support and risk reductions in regional anaesthesia, instrumental delivery, and caesarean section. Most importantly, it showed a 27% relative risk reduction in mothers reporting negative ratings of childbirth experiences. Although these are positive findings, is this not what midwives are employed to do? About 1000 doulas work in the United Kingdom, offering packages that include antenatal, labour, and postnatal visits and on-call periods for a charge of between £400 (€440; $660) and £900. In the United States in 2005 there were an estimated 100 000 doula supported births. As the trend grows here, a cynic might ask whether the doula business is actually necessary or whether it is exploiting—for profit—unspoken fears about NHS perinatal care and the seemingly limitless market for birth related
products and services. The next evening I encountered another mother in advanced labour, with several children already in care, and birthing alone save for a midwife who was caring for two labouring women. Sadly it seems those who need emotional support most cannot afford doulas. I am disappointed by the real or perceived need for doulas. It is the medical and midwifery professions’ duty to support and advocate for mothers and families through a very special but potentially frightening experience. Traditionally, emotional support came from female relatives; more recently the modern father has stepped into this role. Partners, friends, and family—those who know the mother best—should provide this support. Sadly, this position cannot withstand chronic understaffing, shift work, midwifery care that is less than one to one, and European working time directives, making continuity of care impossible. Nor can it withstand single parenthood and increasingly detached nuclear families. The processes of child birth are new and anxiety provoking experiences, and what people fear most is the unknown. Combined with the often time pressured hospital environment and need for quick decisions, this takes control away from the individual. A lack of continuity in carers does not allow parents to develop trust in clinicians, as they find themselves having to start new relationships every 12 hours, diminishing the quality of communication. People seek some continuity in their support in stressful situations; perhaps doulas fill a gap in this market. Is this a passing fad, or is there really a need for doulas? Either way, clinicians need to be aware of doulas, so that care is not compromised by the presence of new people in clinical settings. This trend may be a sad reflection of failures in the delivery of medical and midwifery care, a sticking plaster concealing greater problems. Availability of this commercial service indicates that current social structures do not support pregnant couples adequately; healthcare professionals may not be able to support their patients as they would like to. Are we no longer able to make common sense decisions without asking a hired friend? Abhijoy Chakladar is anaesthetic trainee, department of anaesthesia, Worthing Hospital, West Sussex
[email protected] Patient consent obtained. Cite this as: BMJ 2009;339:b5112 BMJ | 5 DECEMBER 2009 | Volume 339
VIEWS & REVIEWS
The forgotten poet laureate The only doctor who diately afterwards of BETWEEN was ever poet laureate the first world war. THE LINES was Robert Bridges The society’s pro(1844-1930). He is spectus stated that Theodore Dalrymple now almost forgotten, “literary education and unless I am much in England does not mistaken I think one inspire writers with a could move quite due sense of responfar in literary circles sibility towards their before meeting anynative speech.” On one who could quote the other hand, a single line of his. “The promoters Yet he was once of this association very popular. My are of course well copy of his last poem, aware of the danger the 200 page long Tesof affectation, which tament of Beauty, is of constitutes the chief the 12th impression objection to any Bridges gave up within the first year of conscious reform of medicine in 1882 because its publication, 1929. I language.” In other have reasons for thinkwords, Lord make of lung disease (though, ing, however, that me pure but not yet. as he lived another 48 it was more bought Another medical years, it cannot have been than read. Indeed in founding member of very serious except as a this respect it was the the society, incidenpretext to retire to literary Brief History of Time of tally, was Sir Ronald pursuits) its day. Ross, failed poet and The bookseller I successful discoverer obtained it from, whom I have known of the mosquito vector of malaria. for 40 years, gave me the book rather Bridges gave up the practice of medithan sold it me. “I have many other cine in 1882 because of his own lung copies,” he said, as if I were doing him disease (though, as he lived another 48 a favour. “But this is in beautiful condiyears, it cannot have been very serious tion,” I said. “It tends to be in beautiful except as a pretext to retire to literary condition,” he replied. pursuits, one of which was the sucEarly editions of popular books tend cessful promotion of the work of a far not to be in beautiful condition; the greater poet than he, Gerard Manley conclusion, therefore, is such that even Hopkins). For 14 years, however, Dr Watson should have been able to Bridges was a devoted doctor at Great draw. And it is not difficult to see why Ormond Street, where he worked in many readers might not have reached the outpatient department. His experithe end, quite apart from the Latin and ence is all too evident in his poem On a Greek phrases interspersed in the text. Dead Child: “Perfect little body, without Here are the first lines: “Mortal Prufault or stain on thee, / With promise of dence, handmaid of divine Providence, strength and manhood full and fair! / / hath inscrutable reckoning with Fate Though cold and stark and bare, / The and Fortune.” To struggle through thoubloom and the charm of life doth awhile sands of lines of this would require real remain on thee. / Thy hand clasps, as dedication. ’twas wont, my finger and holds it: / Moreover, Bridges used a somewhat But the grasp is the clasp of Death, quirky, not to say cranky, orthography heartbreaking and stiff; / Yet feels to and vocabulary, of which the following my hand as if / ’Twas still thy will, thy is but one instance: “a fair-order’d huspleasure and trust that enfolds it.” bandry of thatt nativ pleasaunce.” I think Bridges should have remained Bridges founded the Society for in medicine. Pure English, whose activities were Theodore Dalrymple is a writer and retired doctor postponed, alas, by the advent immeCite this as: BMJ 2009;339:b5182 BMJ | 5 december 2009 | Volume 339
Medical Classics Human Guinea Pigs: Experimentation on Man By M H Pappworth Published 1967 The 19th century physician in England was a comfortable gentleman, educated in the classics and well versed in medical practices unchallenged since Greek and Roman times. In the early 20th century a few talented doctors saw the need for science in effective clinical practice. This knowledge was to be obtained by experiments on human subjects. They were full of zeal; and because of their intellect and prowess and the sheer excitement of their findings they were in turn unchallenged. Until, that is, Maurice Pappworth in London and Henry Beecher of Harvard University looked at their experimental methods. Pappworth trained in Liverpool and modelled his clinical and teaching practice on that of Henry Cohen. In 1939 he applied for a consultant post but was, surprisingly, unsuccessful. He did not further pursue a hospital post but instead worked in private practice, also coaching candidates for the membership of the Royal College of Physicians (MRCP) examination. He was the scourge of the London examination board, by dint of his coaching skills and also, allegedly, from the intelligence concerning the way the examination was run that he gained from candidates leaving the clinical examinations. He learnt of the dismay expressed by many young doctors at the exploits of their seniors, who experimented on patients unaware that their involvement could be dangerous. Despite these deficiencies these same physician scientists were establishing the basis of modern medicine. So Pappworth wrote his Human Guinea Pigs: Experimentation on Man, which had its intended effect. He catalogued a list of published accounts in reputable journals of experiments on children, pregnant women, people with learning difficulties, dying people, elderly people, and volunteers—healthy as well as patients with cardiac, hepatic, and renal illnesses. On occasion the doctors used themselves as subjects. No one was spared. The common theme was that informed consent was not needed. The book’s final section identified the need for ethical principles. Pappworth mourned the loss of the physician friend. He reminded the reader of the experiments of certain German doctors under Hitler and questioned where the line was to be drawn between such experiments and the more recent experiments described in his book. He laboured the point that an experiment is ethical or not at its inception: it does not become ethical post hoc, and the ends do not justify the means. The book was a great success, and he reinforced his points by doing tours of the country speaking at local medical societies, adding spice by describing what local physicians were doing in the field of experimentation. His reward was the universal development of research ethics committees. Some 57 years after he passed the MRCP examination he was awarded his fellowship. Martin Eastwood retired consultant gastroenterologist, North Queensferry, Fife
[email protected] Cite this as: BMJ 2009;339:b5113
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VIEWS & REVIEWS
Science friction FROM THE FRONTLINE Des Spence
I finished my methadone clinic, grabbed a taxi, was herded onto an Easyjet flight to Luton, and then disappeared into anonymous London. The next day I headed to a meeting of the parliamentary health select committee, just a grunt in a suit, to give evidence of the disproportionate and distorting influence of the drug industry in medicine, of the rampant hospitality culture that they sponsor but deny. I believe the situation to be counter to the interests of the patient and the profession. My outspokenness has not always been easy, because “big pharma” truly is big: big money, big friends, and big teams of lawyers. Peter Wilmshurst, a consultant cardiologist from Shrewsbury, also gave evidence against the industry. Peter is being pursued for libel by a medical appliance company called NMT Medical after publicly criticising their research (BMJ 2009;339:b3659). His name has been added to a growing list of doctors who have found themselves the subject of libel suits by companies and organisations over criticism of research “evidence.” Regrettably, the legal process often demands a certainty when none exists, and courts’ interpretation of clinical research seems no more rational than
that of the tabloid press. The truth is that even the best medical research is a type of elaborate science fiction—a leap of faith. And whether the assertions of maverick doctors are correct is not the point: they should have an absolute freedom to express them. For in this age of evidence based tyranny the profession’s need for outspoken dissent has never been greater. Turning to the courts serves only to put a boot to the throat of legitimate dissent. It promotes a climate of intimidation, making doctors wary of voicing controversial ideas. But ideas are our precious metal and the catalyst of change. Science has no feelings to hurt, so libel should be reserved for politicians and racing car moguls, and the business of scientific intercourse reserved for the pages of journals not the courts. Sponsored research needs to be opened up, and companies should be forced to give full disclosure of trial data, so that proper open debate might be had—mere trial registration is not enough. We need to defend academic free speech vigorously, for all of today’s “nobodies” with tomorrow’s big ideas. Des Spence is a general practitioner, Glasgow
[email protected] Cite this as: BMJ 2009;339:b5176
Round robin OUTSIDE THE BOX Trisha Greenhalgh
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Dear all Once again you’ll have to forgive me for not sending a personal greeting for the festive season. My feet don’t seem to touch the ground these days! Here’s a summary of our news. Sophie has passed grade 1 on the recorder, and her painting was singled out by the mayor when he visited her school. Dominic remains ahead of all developmental milestones and is out of nappies except at night. The nanny loves her new ensuite, and we also—finally—got the patio resurfaced. Martin completed 20 years’ service for the IT company and got an engraved silver tankard. And, after nearly six years off, I’ve gone back to work four mornings a week. I was nervous, of course, even with the re-entry course and peer mentoring. We’re now a “polyclinic” instead of
a GP surgery, and my boss is Mrs Foggett (yes, the same one, but now she manages me!). I’d better not make any comment on that. The first thing she made me do was produce all sorts of documentation to confirm I hadn’t engaged in any criminal activity since going on maternity leave. Apparently they need an audit trail. It’s lovely to be back seeing patients. Some of you may recall the retired postmistress who sent the hand knitted baby blankets. She was my first patient on my first day back, of course, and explained it all to me from the patient’s perspective. Apparently, she now sees the HCA* for her blood pressure (three monthly), ERP** for her bad knees (four monthly), GON*** to check her ring pessary (biannually), and VSAC**** to complain about how infrequently her children write to her (as required).
I must have hesitated, because she then said, “I suppose you’re wondering what your job is now, doctor.” She explained that she’d just completed digital inclusion training (an in-house initiative to hit our silver surfer target) and then leant over the keyboard and clicked me through to the end of life planning algorithm. “Now, doctor,” she said. “Can you see that first pull-down menu? When my time comes, I’d like to die at home.” All the best to everyone Mandy PS: Here’s a section from the glossary Mrs Foggett gave me: * healthcare assistant; ** extended role physiotherapist; *** gynaecology outreach nurse; **** voluntary sector attached counsellor. Trisha Greenhalgh is professor of primary health care, University College London
[email protected] Cite this as: BMJ 2009;339:b5191 BMJ | 5 DECEMBER 2009 | Volume 339
