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Views & Reviews Review of the week

Labour pains

BMJ 2007; 335 doi: (Published 26 July 2007) Cite this as: BMJ 2007;335:209
  1. Duncan Double, consultant psychiatrist, Norfolk Mental Health Care NHS Trust
  1. dbdouble{at}

    Wendy Savage, champion of women's rights in childbirth, is back with a polemical look at who controls birth and who controls doctors, writes Duncan Double

    In 1985 Wendy Savage made medical headlines when she was suspended from practice over charges of incompetence in managing five obstetric cases. The charges centred on births where she was accused of having delayed performing caesarean sections.

    After an inquiry conducted in the full blaze of publicity Savage was finally reinstated as senior lecturer in obstetrics and gynaecology at the London Hospital Medical College and honorary consultant at The London Hospital. A Savage Enquiry was her gripping account of these events. In it she wrote, “I and many of my supporters saw my suspension as part of the continuing struggle about who controls childbirth.”

    In this new book Savage describes for the first time what happened to her when she returned to work. The book focuses on the problems that arise when doctors disagree among themselves. Interpersonal difficulties in her department persisted, despite the recommendations of various reports that working relationships should be improved. Ten years from the last day of her inquiry she was told of an anonymous complaint about her management of a further five cases. This time she resisted external assessment, and the matter fizzled out, though leaving her exhausted. She went on sabbatical before retiring a few years later, having also earlier become honorary professor at Middlesex University.

    This book, which includes contributions from other authors, also returns to the themes identified in the first book—for example, asking what services women want and who decides what they get—and considers what still needs to be done.

    Savage describes the damage that gossiping causes to the reputation of doctors who are wrongfully suspended. Her experience leads her to conclude that such doctors are seen as “different” or “difficult,” often because they are more conscientious than others or act as whistleblowers. John Hendy, who was Savage's barrister for the inquiry and who has continued to gain considerable experience in medical disciplinary cases at Old Square Chambers, which specialises in such cases, observes that personal malice or professional jealousy may in some cases play a role in trumping up charges, but these factors are almost inevitably impossible to prove.

    The book indicates how suspension from work can be devastating. One woman surgeon, not yet in a position to divulge the full details of her case, writes anonymously about her experience. She is not unusual in having felt suicidal about her situation.

    The book also highlights the importance of academic freedom, so that unorthodox or new opinions can be furthered. This is essential if we are to train doctors to think.

    Medicine is not an exact science. Attitudes and approaches vary on a spectrum from doctor centred to patient centred. A doctor centred bias can be reinforced by an overemphasis on physical abnormalities at the expense of dealing with difficult personal issues. Inevitably, with any one doctor there is an interaction between the degree of patient and doctor centredness. But Savage realises that most doctors achieve the right balance.

    Of course, there are a few rogue doctors. Good clinical governance depends, however, on supporting the vast majority of sound clinicians. It actually makes health organisations less safe for patients if this is not the case. As the chapter by Michael Goodyear, an academic oncologist from Canada, says, “Cultures of excellence not only value their workforce but let them know they are valued.”

    Wendy Savage was accused of being non-interventionist. This was primarily because she was prepared to give women choice about a trial of labour in circumstances in which other obstetricians might have moved more directly to caesarean section. It is still a requirement of the General Medical Council's Good Medical Practice to respect colleagues and not allow personal views to affect professional relationships adversely. In particular, malicious and unfounded criticisms should not be made that may undermine patients' trust in the care or treatment they receive or in the judgment of those treating them.

    One of the contributors, Marsden Wagner, writes from the international perspective of having been director of women's and child health at the World Health Organization. He suggests that the real function of tribunals such as the Savage inquiry is to punish deviant professional behaviour that could threaten the income, style of practice, prestige, and power of mainstream doctors. Is medicine really in such a vulnerable state? Medicine is hardly a total cultural deceit—but those who point out the respects in which it is deficient may be perceived as being outside the acceptable range of medical practice.

    Savage describes the damage that gossiping causes to the reputation of doctors who are wrongfully suspended


    • Birth and Power: A Savage Enquiry Revisited

    • Wendy Savage and contributors

    • Middlesex University Press, £25, pp 420

      ISBN 978 1 904750 58 1

    • Rating: ***