A story of scrutiny and fear: Australian midwives' experiences of an external review of obstetric services, being involved with litigation and the impact on clinical practice.

OBJECTIVES: to describe Australian midwives' experiences of an external review of obstetric services, involvement in legal proceedings and the impact on midwives' clinical practice and personal wellbeing.

BACKGROUND: the external review process (commonly referred to as the 'Douglas Inquiry') was initiated by a state government and was in response to hospital staff and consumer complaints that focused on anomalies in client care and a significantly high rate of adverse outcomes and clinical errors. It took place within the context of a number of legal proceedings against medical practitioners. As a result, some midwives employed by the hospital were called to give evidence at a variety of legal forums.

DESIGN: a qualitative study using an explorative descriptive design. Snowball sampling was used to invite 16 Australian midwives to participate in a tape-recorded interview. Thematic analysis and the techniques associated with constant comparison were used to analyse the data.

SETTING: Australian maternity tertiary referral centre.

FINDINGS: the analysis identified two overarching themes, 'A story of scrutiny' and 'A story of fear', each with a number of subthemes. 'A story of scrutiny' consists of three subthemes. 'A cloak and dagger affair' reflects the midwives' sense of being and feeling 'exposed' and 'vulnerable' whilst simultaneously being 'kept in the dark' and uninformed during the review process. The subtheme 'Being thrown to the wolves' describes the midwives' experiences of being involved, as witnesses, in medico-legal proceedings. The third subtheme, 'The Inquiry followed them home' outlines the effect on midwives' emotional wellbeing and personal relationships. The second major theme, 'A story of fear' again consists of a number of subthemes. 'Feeling unsafe at work: a culture of fear' describes the midwives' experiences of working within an environment they perceive as driven by the fear of litigation. In order to protect themselves and maintain a sense of control, the midwives adopted a number of strategies to 'feel safe' including defensive decision making and moving towards a medical philosophy of care. These concepts are captured within the subtheme 'Covering your back: setting boundaries'. The impact on relationships between midwives, women and medical practitioners is described within the subtheme 'Professional relationship: coloured by fear'. The effect on midwives' confidence and the resultant negative emotions elicited make up the subtheme 'Between a rock and a hard place: the midwives' distressing dilemma'. Finally the subtheme, 'Opting out: the changing nature of professional work practices' describes the specific professional decisions and work strategies that midwives made about their ability to continue working in an environment that they perceived as threatening.

CONCLUSION: the findings suggest that the midwife participants in this small study were totally unprepared and ill equipped, both personally and professionally, to deal with the consequences of working within an environment that was the centre of a number of high profile legal proceedings and an extensive external review of obstetric services. The midwives were naïve about legal processes and unprepared for the legal 'game playing' and media attention that often accompanies court proceedings. Despite the fact that no midwife faced litigation, the participants described their work environment as becoming increasingly stressful and permeated by a culture of fear. In turn, this situation has reinforced the need for some midwives to adopt an 'institution' ideology which reinforces birth as an abnormal event that needs to be medically managed. This has led to changes in professional and personal work practices. The findings also have implications for the midwifery workforce and retention. Although the findings are context specific, this study provides valuable insight into the phenomena of fear of litigation and its impact on midwifery practice. Given the similarities concerning obstetric litigation in some other Western nations, the findings have relevance in the international midwifery arena.