Me, Accountable?
The peer review process after a midwife presides over a complicated birth is a disturbing procedure. Midwives rarely ask hard questions, such as whether this mother truly was a low-risk candidate, whether or not the midwife was monitoring the baby carefully, and why she decided not to call for help sooner. Most peer review processes are characterized instead by soothing platitudes, an atmosphere of comfort and understanding toward the midwife, and reassuring all participants that they are indeed wonderful, special people.
I will never forget the first truly horrifying hemorrhage I presided over. She was a gorgeous young mother, the very picture of health itself. Her husband was devoted and loving. They were both so eager to have their first baby together at home. The baby came out without much fuss after a couple hours of pushing, but almost as soon as the birth took place, this young mom started bleeding in such copious amounts that it gushingly overcame several of the very large pads we had spread out on her floor. It was a terrifying day that ended with her safe in the hospital, and I was haunted by the memory for months to come.
It was a couple weeks before I had an opportunity to discuss the case at my very first official peer review. A new midwife at the time, I was very eager to hear my fellow midwives’ opinions on what I could do differently next time to avoid ever seeing a hemorrhage like that again. I got an answer I was not really looking for: “We know you didn’t do anything wrong. We know you. We know you’re a good midwife. Sometimes things just happen.” At the time, it felt flattering, but insincere: they didn’t actually know me. They had never attended a birth with me and had spent precious little time with me. They claimed to know me, but what they really knew was what they would want to hear if they were in the hot seat. Peer review was more like an enabling therapeutic back-patting than any form of accountability.
I learned how to play this game, even though it never felt right. You failed to risk someone out? Well, the birth went well anyway, so your intuition must have been right-on! You didn’t call the second midwife in time for the birth, ten times in a row? Your mamas sure go fast! Your client ended up in the hospital needing a blood transfusion? These things happen in hospitals all the time! Sometimes I would forget my place and offer a piece of harsh criticism; I was never the most diplomatic person, after all. But this was met with resounding censure: we are here to be supportive. I would apologize and get back in line. I felt I had too much to lose to stop playing their game.
These women simply do not understand the purpose of peer review. If you can’t admit you made a mistake, how can you ever get better?
When I was in school, we had a class that we would be able to discuss a difficult birth in and get feedback from our instructor (a nurse or another midwife). During my tenure there, that class changed and birth reviews were disallowed because we weren’t allowed to “talk badly” about or say we though a midwife “didn’t do something right” in front of others. That was the end of birth review in class. Difficult births just weren’t talked about anymore.