All this push for 'normal birth' - why I keep pushing.

Photo credit and copyright: Claire Riding. Midwife Lynda Drummond 

Photo credit and copyright: Claire Riding. Midwife Lynda Drummond 

Guest blog post by Australian student midwife @MegHitchick

“All this push for ‘normal birth’ – what’s the point? Women and babies used to die all the time in childbirth, so who cares if we have high rates of intervention? What does it matter which way we give birth, as long as the baby is healthy?”

As a consumer of the media, I see this - or some variation on this theme - so often. In a somewhat sinister twist, I occasionally see this one:

“Midwives endanger lives with their stubborn insistence on pushing for normal birth.”

I’m a third year student midwife, and a birth addict. In October last year, I attended the International Normal Labour and Birth Conference in Sydney, Australia. Seeing so many esteemed, brilliant and passionate people assemble to protect and promote normal birth was somewhat overwhelming, and possibly even more so was trying to keep up with it all on social media! Thousands upon thousands of tweets, Facebook posts and #normalbirth16 hashtags flooded the web, drawing many comments from people near and far. During one session, as I scrolled through my Twitter feed, one heartfelt comment stood out to me among the many. I won’t quote it directly, but in essence it said this:

“Great. Way to go making all us mums who had to have Caesarians or other help to give birth feel like crap. All this ‘normal birth’ stuff does is make a competition out of motherhood. I’m healthy, my baby is alive and that’s all that matters. So shut up with the ‘normal birth’ trumpet.”

In that moment, my heart broke. Not just a little bit, either - a big, frustrated ‘snap’.

It broke for this amazing, tough, proud mother who has come out the other side of birth feeling like a fighter, a survivor, and who hears the message of ‘failure’ in the normal birth movement.

It broke for all the women who feel that they are constantly judged for a choice that their bodies made for them.

It broke for mothers who did the best things for themselves and their babies - the best they could in the time and the place where they faced birth, and with the people and facilities that they were surrounded by - and who still feel that they need to justify themselves for it. They’re angry. And I’m angry for them. I’m angry alongside them.

Because the move to protect normal birth is not, and has never been, about trying to conscript women into accepting less intervention, less Caesarian section, less pain relief in birth. The purpose of such advocacy is never about blaming women for their choices and experiences. The point of the exercise is NOT to make mothers feel like failures if their birth did not meet the ‘optimum’ recommendations. Birth is not, and should never be, a competitive sport.

Advocating for normal birth is NOT about holding women accountable.

Advocating for normal birth IS about holding birth workers accountable.

The purpose of the movement towards more normal birth is to hold professionals, doctors, midwives and policy makers responsible for the way in which they provide care for women and their families through pregnancy and birth. It is to challenge systems that create the conditions under which so many women’s bodily processes and births are chosen for them.

And women should never, ever be given the ridiculous idea that in birthing, they were somehow not good enough, not strong enough, not natural enough. Instead, we must take great care to ensure that women hear the message right: it is up to us birth workers to be the best we can be, so that we don’t cause you harm or disrupt birth unnecessarily under the banner of ‘keeping you safe’.

It is entirely on the shoulders of midwives, doctors, policy makers and governments, to use the most recent evidence we have to give the best care: evidence that shows that continuous care by a known midwife improves outcomes (Sandall, et al, 2016) and increases maternal satisfaction (Forster, et al, 2016). Evidence that shows that continuous electronic monitoring in low-risk labour doesn't change how often we lose babies, but it changes how often we perform c-sections (Alfirevic, Devane & Gyte, 2006). Evidence that flies in the face of a whole lot of policy, procedure and propaganda.

So don’t be fooled - advocating normal birth is not some crazy, midwife-led agenda to keep obstetricians out of work and see women suffer through difficult labour without pain relief (although that’s what some outspoken critics might have you believe). It’s true that many of the most articulate advocates for normal birth are midwives, but are midwives really that vicious?

What possible motivation could a midwife have, for wanting to see less unnecessary intervention in birth? It's not like midwives are naive to the things that can go wrong - they see it often. They are trained to recognise impending problems, and to refer as necessary. Chances are, in a low risk pregnancy, it will be a midwife who first detects a possible pregnancy complication - and they DO recognise them. It would be a fair bet to say that a midwife has seen pregnancy, labour and birth unravel into disaster more often than the average person walking down the street. So by seeking to reduce interventions, can we infer that midwives harbour some secret desire to see these adverse events more often?!

Anyone who has stumbled upon a midwife shaking silently in the tea room over a near miss would know otherwise. Anyone who has seen a midwife arrive home from a shift where the unthinkable has happened, would know otherwise. Nobody wishes these things to happen - especially not midwives.

Midwives do not benefit financially from less intervention. Less use of 'technology' during labour creates more work for the midwife, not less. Midwives who provide the gold standard of midwifery care - continuous care with a known midwife throughout pregnancy, labour and birth - experience considerable disruption to their personal and social lives. So why should midwives care? There is nothing in it for them, not personally, anyway. The motivation is purely a deep conviction that pregnancy, birth and mothering are profound life events that can be source of incredible empowerment, when women are upheld in the centre of them. This conviction brings with it the determination to ensure that women do not only 'survive' their experience, they 'thrive' through it. 

That’s why I’m determined to continue to advocate for normal birth. Not because I think birth intervention is the sign of a ‘failed woman’. Not because I want women to feel ‘crap’ about the way in which they have given birth. But because I never want to see our systems of care undervalue and underrate the incredible intuition of a woman birthing in a supported, protected and empowered space. The process and power of normal, uninterrupted birth must be the focus of curiosity and deep respect for all birth workers. Only when this is true, can women be confident that their birth experiences represent the optimum for themselves and their babies. And then my heart won’t be broken anymore.

Meg Hitchick is an exceptionally talented student midwife at Western Sydney University. Meg has written a beautiful piece about eye contact and the importance of communication for The Practising Midwife, which is available here for you to read

I met Meg last year at the International Normal Labour and Birth Conference in Sydney. Meg wrote and performed an incredibly revealing 'skit' about the choices (or lack of) women have to negotiate during childbirth.  I recorded it LIVE via Facebook, and after making it publicly accessible, the video went viral. The performance has been replicated by others in England (with permission), and midwifery leaders are using it as part of a training tool. You can watch a recording of the skit below...please leave your comments.


Forster, D. A., McLachlan, H. L., Davey, M., Biro, M. A., Farrell, T., Gold, L., Flood, M., Shafiei, T. and Waldenstrom, U. (2016). Continuity of care by a primary midwife (caseload midwifery) increases womens satisfaction with antenatal, intrapartum and postpartum care: Results from the COSMOS randomised controlled trial. BMC Pregnancy and Childbirth, 16 doi:

Sandall J., Soltani H., Gates S., Shennan, A. & Devane, D. 2016. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2016, Issue 4. Art. No.: CD004667. DOI: 10.1002/14651858.CD004667.pub5

Alfirevic, Z., Devane, D. & Gyte, G. 2006. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane database of systematic reviews(3): CD006066.

A cultural glimpse into a pregnancy childbirth session in Mumbai

By Lina Duncan

It was a hot and muggy July monsoon day, minus the rain, and I was off to share a "preparation for birth" session with a new gathering of women. These women had never attended a pregnancy 'class' in their life. Some of them may have attended school to some level. The Foundation of Mother and Child Health (FMCH) started this project, had previously surveyed the area, focussing on the needs of the community, with an aim to improve the health and quality of life for children there. They looked at dietary issues and sharing cost effective methods of making food to benefit children that are anaemic and malnourished. Other interventions include child spacing, family planning, pregnancy and preparing the women for birth. A large proportion of the FMCH time is spent focusing on exclusive breastfeeding and healthy weaning. I admire the work of the close-knit team and always accept invitations to share my experiences and tips to any pregnant women who express interest in childbirth education.

So I jumped on the local train (with no doors, like in the film “Slumdog Millionaire) with my baby doll, pelvis, placenta, a knitted boob, all stuffed in my backpack. I also carried an illustrated large display book with diagrams of baby in the womb, baby’s growth through trimesters, and what the body does to prepare for birth. 


It was not easy to reach the little room where session was to be held, and I asked my guide how the women could even get out to the hospital in the middle of night, as the road went far inside to a dead end place and climbed uphill where it ended. Many families live on the hill in a jumbled puzzle of chaotically placed, simple homes. The bus from the station had been overflowing, we could not get on, and the rickshaws (like Thai tuk tuks) did not want to take us "such a short distance" - I was thinking it was about half an hour walk from the station.

Eventually a rikshaw driver agreed to take us to the start of the road and we walked into the slum. My mind was imagining young women in labour in the middle of the night and the hassle it would be to try to get anywhere near a hospital. These women need to travel to a government hospital in labour which would take a minimum of 20-30 minutes.

In recent years the government have been on a major push to lower maternal and neonatal mortality, institutional births are encouraged. You can read more about this here. An alternative would be to go and birth in the village with a traditional "dai", a midwife who has probably learned her trade from generations past, or from an interest in birth, maybe starting with helping goats, and moving on to humans.  

The small room was opened already, and some wide eyed and shy women were eagerly sitting on the floor. As we waited for the late-comers I introduced them to my baby girl doll and took every moment as an opportunity to bring positive truths to them. My doll being the first of these as she is black and unfortunately people prefer fair skin babies, all over Asia. So I affirmed her beauty and her female sex, and spoke to her as if she was my longed for, and loved baby of my own. There is a campaign called "Dark is Beautiful" in India that “seeks to draw attention to the unjust effects of skin colour bias and also celebrates the beauty and diversity of all skin tones”. One very special 7 year old I know washes her face and arms with toothpaste because her classmates tell her she is too dark. Kids pick up all these messages from the TV where skin lighteners are adverstised etc. Even the poorest communities have TVs. It saddens me to see this predjudice and preference for lighter skin colours.

With the last arrivals all squashed in to the small room, I moved on to female anatomy, womb, cord, placenta, amniotic fluid etc and we had fun learning and discussing the words in Hindi. Marathi is the local lingo in the area but I teach in Hindi because I can't speak Marathi and because Hindi is the national language. Women from all places come to settle in urban cities. The woman in charge translated into Marathi. Some mothers brought their daughters and sons, they were refused entry (for lack of space) but I managed to persuade the team that it's healthy and natural for them to be included, especially as they barely get any sex education in school. 

We talked about the signs of labour etc, and I could see these bright shiny eyes smiling back at me as they recognised and understood what had happened in their previous births, as I was putting a language to things they had experienced but no one had shared with them. We covered all the possible signs I could think of and then progressed to what happens on admission to hospital and what to expect. 

Now this is like walking a tightrope for me. Is it beneficial to know nothing and just float away into a discounted, “shut down zone” when experiencing pitocin for inducing or augmenting labour with no explanation?  With no pain relief offered, multiple vaginal exams by more than one care provider, with no explanations or consent? Also, with manual dilation of the cervix, fundal pressure, episiotomy and separation from baby? Probably not beneficial as far as the fear factor goes, whilst lying on a table, not allowed to be mobile, not allowed to eat or drink, and with IV fluids running.

 "Masala meds" may be introduced at any time to the iv cannula. "Masalas" in Indian food culture are different, delicious spices mixed together in preparation and whilst cooking, to create amazing food. Masala meds are usually Pitocin, to hurry along the baby, Drocin and Buscopan to relax the cervix and help it to dilate? They are “pushed” / infused in the IV fluids all together, hence the name “Masala Meds”.

I decided that information was better than ignorance, and not wanting to instil fear I passed on to these sweet women some relaxation and comfort tools, something to focus on when things get hard and to look forward to the end result. I also gently explained that they would most probably get an IV, that medicine would inevitably be added to it to speed things up, that they may feel scared and alone but to remember to keep their jaws relaxed and try to relax their bodies and minds inbetween the wave like contractions. I taught them Ina May Gaskin “horse lips”  and how to make low sounds quietly so they are not told to shut up. Women have to be brave to enter a government hospital to give birth, so I tried my best to make them into brave birthing warriors and not to fear the process, and I made them laugh a lot too. Laughter is always good.

It makes me sad that these young girls and women need to know about routine episiotomy and fundal pressure, but these practices are common place (and in the most expensive hospitals in town), and there is no such thing as a birth companion, an explanation or a consenting to a procedure. Tasks are performed and babies are extracted, I cannot really describe what I have seen, during birth. The new baby goes away, upside down for a minute, screaming, and comes back with it's genitals, not its face, to meet it’s mother. I showed them this as an example with my doll, and they all had a good laugh. I had tears in my heart and my throat. What a sad way to meet their special little one that grew inside. I have witnessed young girls eyes either light up or shut off according to what their in-laws are hoping for, mostly male babies, although this is slightly and slowly turning around. This makes my heart sing.

Class ended with my baby doll (with cord still attached) naked and covered with a blanket (and no hat) in skin to skin position. I explained the benefits of exclusive breastfeeding and skin to skin and explained that if they want a healthy and thriving baby, then that's what they can do, as much as possible. I talked about delayed cord clamping and the women who had birthed in the village with dais knew exactly what I was talking about. Dais respect the placenta as a life giving organ and even use it as a tool for resuscitation for “slow to get going babies”. They put the placenta into a bowl of warm water and massage it, and usually the baby soon takes it’s first breath, or breathing and colour imporves with this technique. Of course the babies get their own stem cells too which is most beneficial. I told them I am going to write to the priminister Modi so he may change the protocols, and therefore possibly turn around the huge problems of anemia in India.

A couple of them spoke up about their hospital births and one lady shared about her village homebirth. I smiled knowingly at her and she understood what I was conveying in my smile back to her - well done! 

I lent my doll to a little boy, for a few minutes whilst everyone ate a banana. He had come with his 7 month pregnant mother. She didn't look more than 4-5 months.

As I left and walked down the road to get back to the train station and my home, I day-dreamed of a small community birthing centre there, where women would be shown kindness, dignity and respect, and where babies would be welcomed in a way that honours new life and enhances bonding and nurturing. Maybe.....

One day.

Let's train an army of midwives for a land that has an astronomical amount of births per year. This land where women need an overdose of kindness and compassion whilst giving birth and beginning motherhood. 

Lina Duncan

Lina Duncan

Lina Duncan lived in Mumbai for 9 years, where she set up a private business providing midwifery services in collaboration with Indian doctors who acknowledged the midwife model of care. In her spare time she volunteered to facilitate local vulnerable women and families to access public health care for all things perinatal and offer support on their journeys. Lina loves to share information and especially enjoyed these classes, run by a local NGO. She is returning briefly to India to speak at the Human Rights in Childbirth conference in Mumbai from 2nd-5th February 2017 (see links below). Follow @HRiCIndia2017 on twitter for pre-conference updates and live tweets from the team.

Human Rights in Childbirth together with Birth India are hosting a conference in Mumbai this 2-5 February. To register click here   or here to find out more!


Speech to Rita: a midwife's experience of birth trauma

The birthday theatre group 

The birthday theatre group 


It was 2002. I'd begun my new position as consultant midwife, and part of my role involved listening to women and families in an attempt to influence and improve our maternity service. I did this through various channels, going out to meet parents in local communities, responding to complaints, and involving willing individuals in many aspects of service delivery (peer support) and improvement. This work fed into our MSLC, and I communicated activities via a newsletter. 

I also developed a service where I listened to women who were suffering from fear of childbirth, either as a result of a previous traumatic birth experience, or because of negative stories from others, either friends or family, or in the media. 

‘I was really scared when I was pregnant again, it was awful hanging over you, that this might happen again and it might be worse this time’ [Ann] (Thomson & Downe 2010). 

This fear was like I’d never known before, and I learnt so much about childbirth in the eight years I spent hearing such detailed accounts of consequential self-loathing, anguish, nightmares and horrific flashbacks, relationship breakdown, poor parent-infant attachement and distress. At this stage I had been a midwife for decades, so why had women not talked about these feelings to me before? In my world, birth trauma wasn’t reported in the same way as it is today. I remember speaking to one of my consultant obstetrician colleagues about how birth was affecting some women, and how I felt this was just the tip of the iceberg. He told me he hadn’t come across it, and maybe the women I was seeing were ‘unstable’ already. I was horrified, and saddened by his lack of understanding and compassion, but then I was reminded of the frustration I felt listening first hand in my small office, to personal accounts of horror. Supporting the women referred to me to overcome their fear and distress was my main focus, but it was going to be a challenge sharing the underpinning messages behind the stories of traumatised individuals and their families with those who worked in our maternity unit, and beyond.  There were many reasons why women felt damaged, and my findings reflect those of others. Interestingly, labour ‘pain’ didn’t feature heavily in the overall themes that emerged, as most women who I saw had had epidural anesthesia.  Overwhelmingly, women reported feeling powerless, and totally disconnected from the birth of their baby. Some felt violated. 

'Don't feel I gave birth and had a baby on that day, I just felt I went into a room and was just assaulted'.  [Claire] (Thomson & Downe 2008)

Women frequently described feeling that their baby had been ‘extracted’ not born, and that the process belonged to others, not them.  My increasingly apparent dilemma remained, for a time, unanswered - how could we improve the care we gave, to prevent this from recurring over and over again, when there was just me hearing about these experiences?

I worked closely with Professor Soo Downe at the University of Central Lancashire, and she suggested that we asked the women who had accessed my support, how we could improve services to prevent birth trauma. And so that's what we did. We invited those who had given permission for me to contact them, and invited them for coffee…

Seven women attended that first meeting, and after long chats the women present felt the most important thing was to offer authentic feedback to maternity workers, about their experiences.  One woman suggested using theatre to help them to do this, with themselves as the actresses! Some of the group felt worried about this – not being thespians – but after a couple more meetings they became totally engaged with the idea. So we asked a midwife lecturer who was also an actress, the wonderful Kirsten Baker, if she would help. At the time Kirsten was the owner of the Progress Theatre Group – a team of midwives, parents and maternity workers who use forum theatre to influence change.  Kirsten asked a playwright to transform the mothers' stories into a theatre piece, and 'Speech to Rita' was born.


The women who were keen to be involved needed support and reassurance, to be in a safe place to begin to work through the process of telling their stories. It was a long journey, with many tears shed.  Even though most of the group had had a 'redemptive birth' (Thomson & Downe 2008), reliving their personal experiences in front of others was harder than they had expected. We met in my kitchen, so the environment was non-threatening.  We ate cake, drank lots of tea, and laughed and cried together.  Kirsten did relaxation, breathing and vocal training to help with acting, and I tried to be the nurturer. Once the group felt strong enough, we rehearsed in our local village hall, acting out the 'Speech to Rita' script. The theatre session wasn't about criticising or blaming maternity care workers, but about highlighting the things that potentially cause upset or distress. In the busyness of maternity services, where organisational culture and staff shortages impact on time and emotions, midwives and doctors can become conditioned to just 'getting through' each day. And then there's the fear. Often unaware of the consequences of their actions or words, maternity workers do their best. Listening to feedback can help us to see that simple things like changing the language we use, and connecting compassionately, doesn't take more time but makes a difference. 

Early days in my kitchen

Early days in my kitchen

Rehearsals in the village hall

Rehearsals in the village hall

pre-performance rehearsal 

pre-performance rehearsal 

during the first performance normal birth conference, 2004

during the first performance normal birth conference, 2004

After years of touring, the group became more pressed for time, due to family and work commitments. Sadly, we needed to disband. But we felt proud that we tried to be the change, to make a difference, and according the this article - we had some impact (Byrom et al 2007).

I made a short film all those years ago, to say thank you to each courageous woman who stood tall, and tried to make a difference. We are still on that journey, trying to maximize potential for ALL women to have a positive birth experience, wherever or however she gives birth. It’s this that keeps me going.


I want to honour the women that taught me so much about childbirth, and my work as a midwife. Kirsten Baker, thank you for believing in and helping me. 

For Helen, Sarah, Maria, Debbie, Sue, Jeanette, Sarika, Nicky and Anna, you gave me, and the world of childbirth, more than you’ll ever know. 

Things you taught me…

  • More about the importance of birth experience than I ever learnt in a classroom, or during my years as a clinical midwife
  • That listening means more to you than me speaking
  • It’s the little things that matter, the language I use, and the compassion I show
  • Do ‘with you’, not ‘to you’
  • Pain isn’t necessarily an issue, it’s the feeling of powerlessness and lack of dignity that impacts on you the most
  • That antenatal education and preparation is important, but where you give birth, and who cares for you has the greatest influence on outcomes
  • Our continuity of care model made a positive difference to the birth you had
  • Developing respectful, authentic relationships with obstetricians, midwives and neonatologists is crucial when facilitating your choices, and maximising yours and your baby’s safety
  • Birth trauma is self diagnosed, and not dependant on mode of birth
  • That my actions hold the potential to influence your and your baby's future...
  • That I am so fortunate to have met you all, my wisest of teachers.


Byrom S, Baker K, Broome C, Hall J (2007) A Speech to Rita: giving birth to a voice. The Practising Midwife (10) 1 Pp 19-21 (Accessed here)

Thomson G, Downe S (2008) Widening the trauma discourse: the link between childbirth and experiences of abuse.  Journal of Psychosomatic Obstetrics & Gynecology 29(4): 268–273

Thomson G, Downe S (2010) Changing the future to change the past: women's experiences of a positive birth following a traumatic birth experience Journal of Reproductive and Infant Psychology 28 (1): 102 -112

Screen Shot 2016-12-26 at 09.13.31.png



A hero’s tale of childbirth

Birth trauma is a poorly acknowledged phenomena, but one that is gaining momentum within social media channels.  As I reflect on my work from over a decade ago with women who experienced devastating birth trauma, it is important to highlight Gill's work. I was fortunate enough to meet Dr. Gill Thomson in 2005, when she began her PhD studies at the University of Central Lancashire. Gill has written extensively on the topic of women's experience of childbirth, and has kindly provided key insights from her PhD for my blog. I hope this helps to raise more awareness of the effects of childbirth on women and their families, and society as a whole. Thank you Gill.

dr Gill thomson 

dr Gill thomson 

My PhD study, completed in 2008 focused on how women who had experienced diverse birth events.  It aimed to explore how women experience and internalise a subjectively determined traumatic birth event, as well as how they were able to develop the strength and resilience to achieve a subsequent positive birth and the impact of this experience on maternal wellbeing.  I used a philosophically informed theoretical and methodological framework, drawing on the work of Martin Heidegger and Hans Georg Gadamer.  Through purposive sampling methods, a total of fourteen women were engaged over two recruitment phases.  In phase one an interview was held with ten women who had already experienced a self-defined traumatic and positive birth.  In phase two, four women were recruited on a longitudinal basis; interviews were held after a traumatic (interview 1) and subsequent birth (interview 2).  In addition, all women (across both phases) were also involved in a final interpretation meeting.  Thirty-two interviews were held in total. 

I present women’s childbearing journey of tragedy and joy through seven interpretive themes and used a theoretical framework to re-conceptualise the women’s birth narratives as a hero’s tale.  A heroic journey of adversity, trials, courage, determination and triumph.  A traumatic birth was a growth-restricting life event; an abusive, deeply distressing experience characterised by a lack of control, isolation, poor care practices and an embodied sense of loss.  The aftermath of trauma held wide scale negative implications for poor maternal health and functioning; women described how it had negatively impacted on their sense of self, they often struggled to form positive relationships with their infants and blamed themselves (and often their partners) for what had occurred.  These women had held what they considered to be realistic expectations of labour and birth, they actively prepared for the birth during pregnancy, and to become a parent was often a long awaited for, and positively anticipated life event. However, the reality left women feeling broken and unable to experience love for their infant.  A trauma birth was imbued with an inherent sense of secrecy as women felt unable or unwilling to discuss their experiences for fear of being perceived as not coping – ‘a bad mother’.  A healthy baby was the only outcome of consideration, and women’s birth experience rendered as a means to an end.  

For a number of the women in my study it took them years before they could consider having another child. They had not originally intended to have large age gaps between their children. However, the impact of a traumatic birth meant this was inevitable, and to a large extent robbed them of their family ideals.  However, becoming pregnant again, and the reality of having a potentially similar birth operated as a catalyst to receive support as women ‘broke down’ during antenatal appointments.  The power and determination to have control and to achieve the birth that they wanted was evident in their narratives.  A number of different strategies and methods were adopted in planning for a subsequent birth.  These included discussing the birth with a midwifery professional, and how this afforded them the opportunity to understand what happened and why it happened.  This was described as highly beneficial in terms of relinquishing self-blame as well as offering reassurance and hope for their forthcoming birth.  Other strategies involved re-visiting the delivery suite, attending further antenatal classes and using homeopathic medicines. A further salutary strategy involved creating multiple birth plans for different birth eventualities – a preparatory approach that helped the women to develop their capacities to respond to the uncertain and erratic nature of childbirth. 

A subsequent positive birth was experienced as a euphoric, joyful, healing life event - an occasion to be celebrated and embraced.  Women experienced person-centred ‘care’ from professionals who they trusted, and who understood what they wanted to achieve. They felt in control over what occurred during the birth and felt they were actively involved in decision-making.  Women felt that they had given birth, irrespective of how the birth had occurred; for example, a woman who had a second caesarean felt that she had given birth due to feeling so involved and connected to the birth process.  In my study, I describe a subsequent positive birth as a ‘redemptive’ experience; a cathartic and self-validating experience that confirmed how bad their former experience had been and enabled women to release and relinquish self-internalisations of blame and guilt.  The transformational nature of redemption was evident through women describing themselves as ‘whole’ and ‘complete’ and able to find ‘the parts of me that were missing’ following a healing, positive birth.  To experience such a different birth on occasion induced anger and discord through women through feeling ‘robbed’ or ‘cheated’ of not achieving this ideal the first time.  However, women spoke of how their subsequent redemptive birth had provided ‘a perfect happy ending’; an occasion that enabled them to hold positive and happy memories of childbirth, rather than ones encroached by trauma and dysphoria.  Similar to insights from wider trauma literature, all of the women referred to how they had, or wanted to engage in altruistic behaviours by sharing their birth experiences to protect, help and inform others. 

A number of practice implications were generated from this study including: proactive opportunities for women to reflect and discuss their birth experience; to encourage the use of expressive writing for women to detail the often ‘unspeakable’ nature of trauma; further research to identify suitable interventions/approaches to help ameliorate the impact of a traumatic birth; for antenatal preparation to be more reflective of the realities of childbirth, and to encourage co-creation of multiple birth plans to prepare women for different birth trajectories; and for appropriate training to be provided to health care providers to enable them to be cognizant of how women experience and internalise trauma, and care practices that promote a positive, fulfilling childbirth event. 

I want to conclude on what I consider to be one of the key revelations from this study.  When I embarked on this project, I had had three experiences of childbirth, one that was highly medicalised (i.e. induction, epidural, episiotomy and forceps) and two that would meet definitions of normality.  I considered, similar to wider literature, that a positive birth was fundamentally related to a ‘normal’ birth that was drug/intervention free, and involved a natural, vaginal delivery.   This is not what was revealed in these women’s accounts.  A number of the negative/traumatic births were straight forward vaginal deliveries, whereas some of the positive births involved a cascade of interventions, operative births and postnatal morbidities (third degree tears, haemorrhages).  These insights highlight that it is not what happens during the birth, but rather how it happens that is crucial.  To a large extent, the current discourses of childbirth serve to dichotomise and polarise women’s experiences; with fulfilment and renewed life meaning achieved through normality - and complexity, complications and interventions associated with adversity.  This study offers a new perspective, of how a birth that is managed with care and sensitivity and for woman’s views and beliefs to be central and considered in all decision-making is one that needs to be strived for.  To provide a model of care based on humanistic values of respect, trust, genuineness, honesty and empathy to enable women, irrespective of how they give birth to achieve an ‘ordinary miracle’ of childbirth.

Please get in touch for further information:

Publications from PhD study:

Thomson, G. & Downe, S. (2013).  A hero’s tale of childbirth.  Midwifery 29(7):765-71.

Thomson, G. and Downe, S.   (2010).  Changing the future to change the past:  Women’s experiences of a positive birth following a traumatic birth experience.  Journal of Reproductive and Infant Psychology, 28(1), 102-112.

Thomson, G. & Downe, S.  (2008) Widening the trauma discourse:  the link between childbirth and experiences of abuse.  Journal of Psychosomatic Obstetrics & Gynaecology, 29(4), 268-273.

Thomson, G.  (2011).  Abandonment of Being in Childbirth.  In:  Thomson, G., Dykes, F.,  Downe, S.  (eds). Qualitative Research in Midwifery and Childbirth:  Phenomenological Approaches.  Routledge:  London.

Thomson , G.  (2009). Birth as a Peak Experience.  In Walsh, D. and Downe, S.  (Eds)  Intrapartum Care (Essential Midwifery Practice), Wiley Blackwell Publishers:  Oxford.

Thomson, G. and Kirk, J.  Tales of Healing.  In Walsh, D. and Byrom, S. (Eds) ‘Birth Stories for the Soul: Tales from Women, Families and Childbirth Professionals’.  Quay Publishers:  London.








It's Time For Rhyme!

Birth Campaigner, Doula and Spoken Word Artist

Kati Edwards

gives the lowdown on why she gave birth on TV!

Kati with husband Dave and children Matilda and Seraphina 

Kati with husband Dave and children Matilda and Seraphina 


Having your birth filmed isn’t everyone’s cup of tea.

Airing that birth on mainsteam TV in front of an audience of 1.5 million on BBC1 isn’t either!

So why did I do it?

Well partly it’s because I’m probably a bit bonkers.

But mostly it’s because it’s really important women see undisturbed births.

Most, I think, don’t know it’s possible or what the advantages are.

Seraphina Skye’s birth featured on the BBC1 documentary “Childbirth – All or Nothing”. It aired in February 2015. Here’s a mini clip of it 

I got tremendous feedback after the show aired. To this day people still contact me to say that show inspired them to have a home birth.

Landmark Films who made the show for the BBC did a great job.

My Fear of Childbirth

Pregnant the first time, I thought I had tokophobia, a fear of childbirth but I didn’t.

I had a fear of the medicalisation of childbirth, something there is currently no word for!

My mum told me from a young age birth was the worst thing ever.

She said it was so bad she couldn’t believe women have more than one child!

She hadn’t prepared to feel any pain.

Her very charismatic Gynaecologist told her he would take care of everything.

And when she did feel pain, she was scared.

She had no inner tools to deal with it.

There had been no practice of breathing or visualisations, nothing.

She woke up after the epidural and thought her legs were paralysed.

Then she got an infection and stayed in hospital for two weeks.

Not the best start either for her or me.

But it was catalyst for me to do everything I could not to repeat this experience.

In fact, it was the midwife at my first antenatal appointment in 2011 who suggested I should watch ‘One Born Every Minute’ as it was ‘very realistic’.

And yes, feel free to reel in horror!

I came home and diligently watched the show for the first time. I was petrified!

The women I saw didn’t seem in control. They looked really scared.

Somehow, it just didn’t look right to me. Too much panic and too many distractions.

‘Why can animals birth, almost always, effectively and yet somehow humans are deficient? Surely birth doesn’t need to be like that! What is going on?’ I thought.

 Learning To Relax

And so I started to research. I was working at the time for the NHS in the Psychological Medicines service in Physical Health.

So my interest has always been how the mind affects the body and the body affects the mind.

I wanted to know what I could do to prepare for birth.

I discovered the Association of Radical Midwives, self hypnosis for birth and Ina May Gaskin.

I discovered techniques to calm the mind and affect the body.

I learnt how providing an environment that’s conducive to the birth is so crucial.

And my partner found out how he could be a better birth partner and how his role of keeping me calm was so important.

I feel lucky to have experienced continuity of care from a fabulous midwife and I had a doula too.

The things I learnt were not available in my NHS classes which seemed to be more focused on the various ways of surviving childbirth and how the system worked. There was a great emphasis on the vast array of pain medications available but little about the side effects.

I wanted to know how I could actually support myself to have a better birth experience.

 The Birth You In Love Project

After the show aired, I felt I had more to say. So much was lost in the edit.

I had the idea to create my own series of bitesize films and my friend, Cathy Brewster of Greater Manchester Homebirth Support Group suggested I crowdfund the money to make them.

So I set up the crowdfunding platform and was overwhelmed by the support from friends, family and so many people I didn’t know. Amazing!!!

And so, ‘The Birth You In Love Project’ was born; a series of mini-vids to help empower parents to be.

While they’ve been being being created, I’ve been using spoken word to speak at birth conferences, events, festivals and midwifery study days all over the UK.

Among them, I’ve spoken at the Manchester Home Birth Conference, The MAMA Conference in Scotland, I’ve been on Sprogcast (twice), been on the line up with Ina May Gaskin (twice) and I even got a gig in Norway at a conference called Women’s Right’s In Childbirth: Take Back Control in October 2016

Ina May, Kati and Sara 

Ina May, Kati and Sara 

After this gig, I changed my twitter profile to Kati Edwards: International Birth Warrior!

No really, I did!

Giving birth in front of 1 ½ million people on mainstream TV gave me a new focus. I left my NHS job and I’m now a doula, a hypnobirthing teacher and I speak and write about the changes I’d like to see in maternity services.

The Birth You In Love Project EMPOWER series will be a FREE video resource to recommend to women wanting to know how they can support themselves through birth.

You can contact me by email, Facebook, Twitter or at

The Emperor’s new clothes: the politics of birth research


In Hans Christian Andersen’s tale of the Emperor’s new clothes no one dares to say they don’t see a suit of clothes on him for fear they will be seen as stupid and incompetent. It takes the cry from a small child, “but he isn’t wearing anything at all”, to identifying the farce being carried out.

Sometimes research papers are put out with misleading media releases and political agendas that go unquestioned by a media hungry for controversy and the next sensational headline. In this blog we will identify the naked Emperor in the form of the recent New Zealand paper (NZ) published by Wernham et al. (2016), titled A Comparison of Midwife-Led and Medical-Led Models of Care and Their Relationship to Adverse Fetal and Neonatal Outcomes: A Retrospective Cohort Study in New Zealand.  The Wernham paper caused consternation around the globe with doctors waving it in triumph pretending the Emperor had a magnificent outfit on while midwives scrambled to understand what was happening, crying amidst the crowd, “but he isn’t wearing anything at all.”  

How did something that was fairly low level scientific evidence get more attention, and lead to such public questioning of the safety of midwifery care, than 15 randomised controlled trials and a Cochrane Systematic Review (CSR) on this issue?

Just a reminder about the Level 1 evidence of continuity of midwifery from over 17,000 women randomised in 15 separate RCTs:

“This review suggests that women who received midwife-led continuity models of care were less likely to experience intervention and more likely to be satisfied with their care with at least comparable adverse outcomes for women or their infants than women who received other models of care. Further research is needed to explore findings of fewer preterm births and fewer fetal deaths less than 24 weeks, and all fetal loss/neonatal death associated with midwife-led continuity models of care.”

 How did we ever think the Emperor had new clothes?

The first alert in this recent saga is the media release that came out from the first author’s university, strictly embargoed beforehand to excite the ‘crowd’ awaiting the emperors arrival. The media release revealed the first bias in the authors’ agenda and was the ultimate hook for the media:

“Mothers using autonomously practising midwives throughout their pregnancy and childbirth are more likely to have adverse outcomes for their newborns than those who use obstetricians, according to a retrospective study of nearly a quarter million babies born in New Zealand published in PLOS Medicine by Ellie Wernham of University of Otago, New Zealand, and colleagues.”

Firstly, this study was never about midwifery care during childbirth, or pregnancy for that matter. Midwives also look after women cared for by private obstetricians so this care is never just about medical care just as it is never just about midwifery care. Secondly, there was no statistical difference in perinatal mortality. You would have hardly known this from the media reports. Thirdly, the authors were clearly data dredging when they combined Intrauterine hypoxia, birth related asphyxia and neonatal encephalopathy in order to get a highly significant outcome. Rare adverse events and small numbers were sensationalised in the media release (“55 percent lower odds of birth related asphyxia, 39 percent lower odds of neonatal encephalopathy, and 48 percent lower odds of a low Apgar score at five minute after delivery”). Neonatal encephalopathy occurs 1-2 in 1000 births and is a rare event. Presented this way makes it sound so dramatic and it takes only one or two cases to change the outcome.

Why the Emperor is actually naked

The authors were unable to look at actual care during childbirth because they don’t appear to have this data, so they took model of care at booking and then misled the media and public that this was an indication of care at birth, when it was not. The problem with this is while all women who book with private obstetricians will remain under the care of private obstetricians from booking to birth, between 30-35% of women under midwifery care will be referred during pregnancy to a doctor. Despite this fact all outcomes (only adverse perinatal ones) in the paper are reported as due to midwifery care, when they are clearly not.

One could argue that the randomised controlled trials (RCTs) of continuity of midwifery care reported in the Cochrane Systematic Review use a similar method - that is model of care on booking and intention to treat analysis. However, the difference is randomisation reduces selection bias and the study groups should be as similar as possible at the outset so the researchers can isolate and quantify the effect of the intervention they are studying (in this case midwife or medical care). In a RCT you can see what care women got and you would also know the mode of birth and maternal outcomes, which are not reported in this study. RCT’s can be used to change practice but lower level evidence should not; yet that has not stopped groups such as the Australian Medical Association calling for this in Australia.

The NZ study had several concerning limitations that were not adequately considered in the unfolding debate:

1.     One of the most significant findings of the CSR of continuity of midwifery care was the 24% reduction in preterm birth under midwifery care. There was also a significant reduction in perinatal mortality. Only women over 37 weeks were included in the recent NZ study, so there was no chance to see whether this important effect was seen in this study.

2.     Not only are Apgar scores a poor clinical predictor of long term outcomes but there were a large number of missing Apgar scores and this was greater for women who booked with obstetricians.

3.     The inclusion of women more than 42 weeks, which were seen in larger numbers in the midwife booked group and are more likely to have stillbirths associated with prolonged pregnancies, is concerning. If the authors took 37 weeks gestation as a cut-off to exclude preterm birth (higher risk), why not take 41+6 to exclude the higher risk post-term pregnancies. It would have been very interesting to know how many adverse events were seen in the post-term group. Women choosing midwifery care are more likely to not want to be induced and to go over 42 weeks, as is seen in this study.

4.     The inability to separate antepartum stillbirth from intrapartum stillbirth is critical in trying to assess the impact of birth provider on outcomes and this could not be done, despite the study protocol suggesting it would be.

5.     In the study protocol published with the paper neonatal nursery admissions were examined but not reported. When we look at the author’s Master’s thesis where this information is available, more neonatal admissions are reported for babies born to women who booked with private obstetricians. This was not reported in this paper. One has to ask, why?

6.     In the first author’s Master’s thesis (where this study originally came from), substantially lower rates of caesarean section (22% vs 32.9%) and instrumental birth rates (9% vs 12.3%) are reported for women who booked with midwives, leading to significantly less maternal morbidity. Again this was not reported, giving a very one-sided view considering the authors are virtually questioning the entire NZ maternity system.

7.     There appears to be quite a bit of missing data in this study and it is unclear how this was dealt with in the analysis.

8.     Many socio demographic variables are not accounted for (e.g. alcohol and drug use), and others such as smoking are notoriously underreported. Midwives tend to look after women with greater socio demographic disadvantage and mental health issues. None of this is adjusted for.

9.     Other medical complications that arise following booking, such as gestational diabetes, pre-eclampsia, etc are not accounted for and may be increased in women who book with midwives due to ethnicity factors, life style etc.

10.  Rurality and birth place were not taken into consideration, limiting the usefulness of this study to help make targeted changes rather than slamming the entire N Z maternity system.

11.  There is no difference in PMR between Australia and NZ despite the fact that 30% of care in Australia is by private obstetricians whilst in NZ around 90% of women have a midwife as a lead care provider.

12.  A previous NZ paper that also hit the media headlines in recent times, purporting to show the risk of perinatal death was higher when midwives were in their first year following graduation, has recently been questioned by the NZ Ministry of Health who have been unable to replicate the study. This is worrying.

13.  When we carefully matched the population of low risk women in NSW who had a birth in a private hospital under private obstetric care with low risk women who had a birth in a public hospital with midwife/medical care we found greater morbidity for women giving birth in a private obstetric model of care.

The one highlight in this whole saga has been the united support of the midwives in NZ by the NZ Ministry of Health, The NZ committee of RANZCOG, senior obstetric academics, consumers and midwifery professional bodies around the world.

The political fallout from this paper has been extraordinary, for it actually tells us very little. No practice changes could ever be made based on this study. The Emperor may have no clothes, but the delusion has been maintained by a misleading media release, politically motivated reporting of findings by the authors, a hungry unquestioning media sensing blood in the water and wanting sensational headlines, and obstetricians determined to drag the advances made by the profession of midwifery back to the ‘good old days’ when they were compliant handmaidens. 





Midwife Diaries and more - an interview with Ellie!

        Midwifery support giver - Ellie Durant 

        Midwifery support giver - Ellie Durant 

I was absolutely thrilled when Ellie Durant said YES to writing a guest post for my blog. Read on...and you'll see why! 

Sheena, it’s a huge honour to be asked to write for your blog. You’ve asked me some things about myself and my midwifery support business, and I’ve also included a little something extra for your readers that I hope they’ll enjoy and find useful…

This is what Midwife Diaries is all about!

Hi Ellie, I’ve heard you speak at a conference, and seen your positive presence on social media, but I would love to know more about you…

To cut a long and meandering journey short, I started my website Midwife Diaries when I moved to New Zealand to practise as a midwife. It was a way of recording that journey, fulfilling my passion for writing and keeping friends and family in the loop about what I was up to 12,000 miles from home.

Midwife Diaries is now my full-time business that works to support aspiring, student and newly qualified midwives in particular, though we have many experienced midwives who are part of the community too.

On a personal note I love cycling and running – these are what have kept me passionate (and sane!) both as a midwife and in my own business.

I think many midwives are devoted to their one true calling and I have huge respect for this. I also know my own nature is to ‘cross-pollinate’ and entrepreneurial drive for helping midwives and my passion for writing are the things that fuel me.

 What made you want to become a midwife, Ellie?

My story is that I got obsessed with midwifery when I was a teenager, trained in Leicester, worked in Peterborough for 18 months and then went to New Zealand.

I wanted to become a midwife for the reasons most aspiring midwives have: women and their lives fascinate me.

I also wanted to do something useful and meaningful. Now that energy goes into Midwife Diaries.

I’ve seen that you’ve published a book, and that your focus is on supporting student midwives and newly qualified midwives - tell us more!

My book Becoming a Student Midwife: The Survival Guide For Passionate Applicants is about the process of getting into midwifery.

It’s a bit of a ‘Trojan horse’ - most people expect Becoming a Student Midwife to simply help them into the profession by the way of personal statement advice and interview technique. But, though that is a large part of it, the reality is that admissions tutors are rather astute and perceptive individuals, and to truly have the best chance of winning a place an aspiring student midwife has to become the best candidate. So, Becoming a Student Midwife actually teaches aspiring students the fundamental ideas, philosophy and research behind modern midwifery. Important things like why we use words such as 'women' and 'client' rather than 'patient', and the fundamental differences between holistic midwifery care for healthy 'normal' women and other medical professions that are geared towards treating the unwell.

My intent was that Becoming a Student Midwife would be enlightening and thought-provoking for people new to the ideas within midwifery and its unique style of care, whilst also giving them the practical tools and techniques to demonstrate their knowledge and qualities at the application level.

I believe the strengths needed for a good application are the same strengths needed throughout your midwifery career.

These are high-level communication skills, self-belief and huge amounts of compassion both for yourself and everyone around you.

There’s a new version of Becoming a Student Midwife in the works which covers recent politics and everything I’ve learnt from successful student midwives.

There’s even a chapter by Virginia Howes, independent midwife, which suggests career pathways into independent practice, something that sits in line with the continuity models suggested by The National Maternity Review.

Ellie, I love your website - and just wish I had had this kind of resource when I was a midwife wannabe, or student. What kind of feedback do you receive?

That means the world to me, Sheena. The best feedback is always along the lines of ‘your blog posts make me feel normal’.

Feeling you are in the company of others who know and respect what you’re going through is a much more significant thing than it first appears. Especially when you hit the dark patches.

I also get some great feedback from student and newly qualified midwives who like the summary pieces, for instance on The National Maternity Review, or MBRRACE.

Midwife Diaries content is supposed to be inspirational and very easy to read, particularly where the subject matter is complex.

This is because midwives are so busy and often just need the facts presented in a way that’s going to stick.

 Do you find social media helps your goals?

Very much so, I run ‘The Secret Community For Midwives In The Making’ which is a Facebook group. We’re now 2 years old and have nearly 12,000 members. Movers and shakers in the birth world do Q&As (thanks Sheena!).

We also have various members of the multidisciplinary team come and chat to us – last night an expert Family Worker who specialises in supporting women experiencing domestic violence was a guest: see the bottom of this post for the ten most significant things we learnt from her!

Members can contact myself and the other moderators and we can post anonymised questions for them so they can have the benefit of the Community without risking confidentiality.

The level of support is brilliant and we have a phenomenal volunteer moderator team.

Can you tell us what your plans are for the future?

Just to confuse everyone further, I’m writing a novel about a student midwife called Chloe. It covers controversial subjects, like abortion and drug abuse, but it’s actually quite upbeat!

A major dream of mine is to one day start a 24 hour, free support line for midwives to be able to debrief, completely confidentially. I have plenty more ideas for Midwife Diaries, perhaps more than I can actually pull off, but I'll keep them under my hat for now.

Right, enough about me!

The Ten Most Crucial Things We Learnt About Domestic Violence and Midwifery from Our Family Worker Q&A:

1.    A major problem with a professional’s role in domestic abuse intervention is that the perpetrators tend to be convincing, manipulative and charming. It’s a very hard job!

2.    Follow safeguarding procedures at your Trust – at some point during pregnancy all women are supposed to be asked about domestic violence, while they are alone. Studies show that women not experiencing domestic violence don’t mind being asked and, those that are, need to be asked.

3. Perpetrators of domestic violence target women when they are at their most vulnerable, so well-known signs/situations include women who:

Have experienced domestic abuse in a previous relationship

Have learning difficulties

Have grown up in care

A surprising number have lost their mother or ex-partner within the last 6 months

A significant age gap between partners, 9 years, or less if the woman is younger

4.    Words to avoid when talking to sufferers include ‘victim’ because it suggests someone who is powerless and women will already be feeling that way because of the perpetrator. Don’t shy away from the correct terms ‘rape’ and 'abuse’ though, if this is what’s happening. This gets easier with practice.

4. If you have a woman who doesn’t speak English it’s best not to get a relative, male or female, to translate, as they could be a perpetrator of abuse too.

5. Discussing domestic violence with men on a global scale is important. It’s not a ‘women’s issue’, it’s an ‘everybody's issue’.

6. The best way to protect a woman is a safety plan. Women’s Aid trained domestic violence and abuse professionals will make these mainly. Safety plans include knowing which areas of the house to avoid arguments in (bathroom and kitchen as there are sharp objects) and what to do if he comes home in a bad mood. Also having someone to contact for help, and advising to call the police early.

7.    It may be that women will not disclose abuse or ask for help. However, offering the National Domestic Violence Helpline and talking about the issue could help ‘loosen the jar’ for the next professional who comes along, who can then ‘pop the lid’.

8.    Don’t ever give out leaflets about domestic violence as it’s not safe. Numbers should be written on a plain piece of paper or women can save the numbers on their phone under a different name.

9.    These women often have isolated lives. Calling just to see how they are will demonstrate you are there to help. That small act of kindness can make all the difference. Calling when you say you’re going to call definitely helps.

Huge thanks to the lovely and accomplished Rosa Sampson Geroski, a Family Worker from Cambridge, with an experienced background in intervention for domestic abuse.

I hope you found this helpful. I’d love to see you over on Midwife Diaries, or in The Secret Community!

You can find me: (subscribe for free to weekly blog posts)

In The Secret Community For Midwives In The Making

Ellie x

A Passion for Birth: passing on the baton

                    My family - 5 girls

                    My family - 5 girls

I recently read Sheila Kitzinger’s biography – A Passion for Birth. The first thing that struck me was the synergy between Sheila’s life and mine. It was quite a revelation.  Poles apart in terms of heritage and social standing, Sheila and I not only have similar names, but Sheila was born to a strong rebellious mother as I was, she was mother to five girls, and I am the youngest of five girls.  Like Sheila, there is no division in my life between work and home – it all blends into one, and childbirth and women’s human rights thread through the core.

Until I read her biography, I wasn’t aware of these aspects of Sheila’s life. The book reveals facts about this legendary woman, who set the scene for radical change in childbirth practice in the UK and around the world, and challenged us to think about the experience of childbirth as a potentially exciting, exhilarating, and fundamentally important event.  Sheila's work and passion epitomizes the ROAR of childbirth activism.

During the first part of my career, in the early 1980s, birth activists were mystical beings that I never saw – and inspirational texts were far less accessible.  Individuals like Ina May Gaskin and Sheila Kitzinger influenced my thinking, my practice, but their physical presence was far from my life.  These inspirational women provided me with ideas for ‘another way’, when I was immersed in a culture where ‘doing to’ women was the norm, and permission was not sought for routine unnecessary medical intervention.

Having been brought up in a family of only girls, gender inequality hadn’t occurred to me, even though my wonderful mother, like most women, did the ‘double shift’ of paid work and unpaid housework and motherhood.  Until I read Sheila’s work I didn’t understand the enormity of women’s rights, and how childbirth was fundamental to the struggle.  During my early career childbearing women were compliant, and any woman revealing that she’d attended NCT classes was labeled ‘difficult’ even before the next sentence. Midwives conformed to hierarchies too, and bullying was accepted. I remember a time when I was reprimanded by my colleagues for ‘allowing’ a woman to have a bath shortly after giving birth. The midwives were horrified, as it was the usual routine for a woman to have a bed bath shortly before being transferred to the postnatal area. I couldn’t believe it. I’d worked in the GP maternity unit (that was part of the same organisation) for years prior to this, and there it was normal practice for women to soak in a bath immediately after birth. My superiors told me I was practising dangerously. I challenged the directive, and there began my first move to try to influence maternity care, and I contacted other units in search for evidence. I was never confident even though my belief was strong.  I was considered rebellious (for such a simple thing) and ‘alternative’.  It was around this time that I read Sheila’s book, Pregnancy and Childbirth (1980) – it was a revelation.  My instinct to question unnecessary rituals was founded, and looking back, it was then I began to ROAR.  With a few like-minded midwives, mostly fellow members of the Association of Radical Midwives we searched for evidence to support change. I was fortunate to work with an enlightened head of midwifery, Pauline Quinn, who listened to feedback about our maternity service from women who had their babies with us, via a local NCT tutor. Clare Harding was a highly educated individual, and a member of the Maternity Services Liaison Committee.  Slowly, things began to change. The separation of mothers and babies, binding engorged breasts, giving milk supplements to breast-fed babies, and enemas, pubic shaving, routine episiotomy gradually became activities of the past. But it wasn’t easy, and if it wasn’t for the injection of information and assurance via articles and books from people such as Sheila, I would have been more reticent.  The compassion within me that lead me to choose midwifery as a profession, that helped me to try to be courageous, was often tested. Like others, I was often fearful….

Today we have evidence, and greater access to midwifery and obstetric leaders who continue to push boundaries to promote and support women centred care. We can even chat to them via social media channels. Social media also enables us to learn about innovative practice, and can link us with like-minded individuals then we can join together to enable a greater, unified message.  However, we also have the increasing fear of recrimination, of litigation and doing the ‘wrong thing’, that is leading to defensive practice and vicious circles of despair and distress. This isn’t resulting in a safer service, quite the opposite.  Because of this, and due to our extensive networks, Soo Downe and I decided to bring together a global voice to speak out and identify the need for another way, and to highlight practice where positive change has been made.  We wanted to convey the notion of a link between compassion and love as a antidote to fear, and to try to encourage practitioners to acknowledge the difference between real fear that protects us, and manufactured fear that potentially leads us to practice defensively, and adds to an already stressful situation (Dahlen 2010),.   

And through the years leading up to the birth of The ROAR Behind the Silence, Sheila’s philosophy has underpinned my actions, my search for courage, and my attempt to spread compassion.

Sheila Kitzinger certainly handed me the baton, and I am always willing to pass it on.




Dahlen H (2010) Undone by fear? Deluded by trust?  Midwifery 26, 156-162


A glimpse of childbirth in Bulgaria: time to ROAR

Dr. Tracey Cooper is a consultant midwife, who works in Lancashire, England. Tracey is probably the most courageous midwife I have ever met, her strength and courage fuelled by compassion.  

Tracey won a COST research grant from the European Union with Bulgarian midwife Yoanna Stancheva, at the Zebra Midwifery Practice (ZMP) in Bulgaria. The project involved Tracey's travel to Bulgaria to work with the practice for 10 days, to help improve the midwives' decision-making and confidence in providing quality antenatal care within the current legal framework. This research project represents a first attempt to describe and optimise midwifery competencies, as well as to define a strategy for moving towards midwifery-led care in the future. It is a component of a long-term commitment, which members of international midwifery alliances have made in order to improve the organisation of care in the country.

Tracey said: 'My observations are that Bulgarian midwives have very restricted competencies in comparison to other midwives in the EU, and that maternal and neonatal outcomes ranked Bulgaria low compared to the rest of the EU.  By observing the prenatal consultations taking place at the Zebra Midwives practice, I could assess their level of comfort when using essential midwifery skills, such as abdominal palpation, fetal auscultation with a Pinnard and a Doppler, blood and urine test reading, diet recommendations, etc. The midwives at the Zebra Midwifery practice had difficulties recognising these skills as solid clinical evidence for the woman and baby’s wellbeing. These results were congruent with the restrictive legislation and medicalised culture of birth prevalent in the country'.

Photo: Midwife Iona Nashkova learning new skills, with Tracey 

Photo: Midwife Iona Nashkova learning new skills, with Tracey 

The Zebra Midwifery Practice is the only registered midwifery practice in the country. It is a surprising fact that although midwives have been legally allowed to open midwifery practices since 2011, it took five years before the newly graduated midwives from Zebra were able to take advantage of this opportunity.

Midwives are not interested in opening their own practices because they are not allowed legally to provide the full spectrum of midwifery services required for basic antenatal care, such as prescribing tests and making clinical decisions. These elements of antenatal care are only within the obstetricians’ capacities even in physiological pregnancy and birth.

The ZMP provides severely restricted midwifery care by UK standards. Moreover, midwives cannot get contracts with the national insurance company, and women have to pay for this restricted version of midwifery care.

The number of registered midwives in Bulgaria is 5897. The majority of midwives are at a retirement age, average age of midwives is 52 years. A  large number leave the country for other places where they can practise autonomously and have opportunities for professional growth. The vast majority work in 2 places, having at least 2 jobs.

This is midwifery crisis as midwives are leaving, and many will come to a retirement age within the next 10 years. Because of this, action needs to be taken to make the profession attractive for midwives, so they want to stay and work in Bulgaria, and for midwives from other countries to want to work in Bulgaria, too. 

In the photograph below, Tracey attempts to influence decision making about the issues surrounding maternity care in Bulgaria, with the WHO, the British Embassy, the union and midwifery leaders, birth activists, women and their families at a Round Table meeting. The obstetricians union and the Department of Health were also invited, but did not attend. 

Tracey found during her short visit the following issues:

  • Pregnancy and birth viewed by current care providers as risky and a medical event for all women and not a normal life event.
  • Reliance on technology and not on midwifery care and relationship based skills - many interventions performed unnecessarily for no clinical reason:

 - during pregnancy - medication, scanning
 - during birth - enema, shave, fundal pressure, routine use of oxytocin and episiotomy.

Babies are separated from their mothers, and kept in a nursery. The mother only has access to her baby twice a day, for two 30 minute periods.  There are no guidelines for rooming in, and a three day stay following a normal birth is compulsory.

Photo: Nadezhda Chipeva

Photo: Nadezhda Chipeva

Tracey told me: 'Many women only have one child, and some I spoke to said this was because they felt they could not go through the childbirth experience again. Others were considering freebirthing at home alone, as they were too scared to go back to the hospital for birth.  Care is not based on evidence but routine, outdated practices'.

In Bulgaria, there are no unified, nationally applicable guidelines for quality midwifery care.

During antenatal care, midwives are not allowed to:
- prescribe routine urine and blood tests. This is basic care for pregnant women and midwives cannot prescribe the tests even though they are trained to do so and it is part of their competencies
- perform vaginal examinations or recognise onset and progress of labour using behavioural cues. By national law, midwives are not trained and allowed to perform vaginal examinations, which is a breach of the EU directives on midwives’ competencies;
- assess CTG monitoring;
- work outside hospitals and without supervision of obstetricians;
- make contracts with the Bulgarian national healthcare service which puts them at a disadvantaged position.

During birth, midwives are not allowed to:
- Make clinical decisions for physiological birth;
- Make vaginal exams to assess dilation in labour;
- Repair vaginal tears and episiotomy.

Although directive 1 of the national law describing the midwifery scope of practice allows midwives to assist birth with a cephalic presentation, the midwives’ role during birth is limited to supporting the perineum which is a completely technical detail at the end of birth and does not reflect the meaning of the phrase “assisting birth”.

Midwifery care during the postpartum period was practised until 20 years ago. Nowadays, postnatal care is not part of state sponsored maternity services. Even in Bulgaria, postpartum care has always been an essential element of midwifery work, but at the moment there is a troubling gap in the care for mothers and newborns. Midwives need to be able to offer breastfeeding support, to assess the mother’s physical and emotional recovery, as well as the newborn’s health. The national insurance company does not consider it an element of basic maternity care.

Women have to attend the hospital on their own when they are in labour, with no support persons. Babies are taken away from them following birth. The baby is kept in the nursery, the woman only has access twice a day for two 30 minute periods. This increases the potential for mental health issues, problems with breastfeeding and emotional attachment issues for woman and baby.

Tracey found the situation very disturbing. 'Women were extremely anxious, as told everything that can go wrong, with no reassurance during consultations with obstetricians. The intervention and the obstetrician being the lead care provider has not reduced intervention or helped mortality rates. The caesarean section rate is 42%, Perinatal mortality11/1000, compared to EU mean average 7.14/1000, Stillbirth 8%, compared to EU mean average 5.27%, Neonatal mortality 4.5%, compared to EU mean average 2.74%'.

A delivery in Bulgaria. Photo: Nadezhda Chipeva 

A delivery in Bulgaria. Photo: Nadezhda Chipeva 

Tracey asked you to think about this: 

'Can you imagine being in labour, with no birth partner,  in a room full of people? You are in lithotomy and a midwife is lying across you, pushing on your fundus (abdomen) with all her weight, while a routine episiotomy is performed. Then, when your baby's head is born, an obstetrician pulls out the baby without a contraction. Your baby is taken away, and you can’t see him or her for at least two hours? This goes on all day every day! It has to stop!

We have to find some way of supporting our midwifery colleagues in Bulgaria to end this inhumane practice'.

I asked Tracey what we could do to help: 

'Be aware of the suffering both women and midwives endure in Bulgaria, and keep this highlighted on social media. We must try to persuade the government in Bulgaria to remove their law that birth is a medical emergency, and to recognise the value of midwifery led care to improve quality and therefore the future wellbeing of Bulgarian women and their families, and also reduce unnecessary costs'.

Yoana Stancheva and colleague IIona Neshkova are dynamic midwifery leaders, who are working hard to influence maternity care in their country.

Here is Yoana, speaking up at the Young Midwife Symposium at Women Deliver Global Conference, Copenhagen 2016

Yoana feels Tracey's visit to Bulgaria has been invaluable: 

'Tracey's visit provided the most comprehensive review of the state of midwifery in Bulgaria that an independent observer has ever done. What's more, Tracey was immensely involved in understanding the motives behind the system of maternity care that we have deemed "working" for us. These motives are difficult to comprehend for people who don't belong to the general culture of institutional responsibilities and personal involvement of caregivers with the concept of care. Tracey was committed to grasp it all, with patience and compassion which the system of abuse does not deserve. Her observations were like a large, inspiring breath of fresh air that promised hope for a hopeless situation.'

You can find Tracey Cooper on Twitter , IIona Neshkova on Twitter  and Yoana Stancheva on Facebook



Midwives! Your future is being consulted on – please read and respond before 17th June

Last week the NMC sent an email to registered midwives informing us that the UK Department of Health has launched a consultation seeking views on the proposed changes for midwifery legislation. 

You can respond online here

 Please also read the Draft Statutory Instruments

The Royal College of Midwives are encouraging midwives to commentWe are seriously concerned, and urge you and your colleagues to respond

Here is a summary - for your attention and action: 

The Midwives Rules are being completely deleted.

 - There will be no more statutory supervision, which means that there will be no independent professional support for midwives who are working outside of Trust guidelines (but within professional midwifery competencies and obligations, for example, in supporting a woman who is making a good and safe choice for her and her baby, but which the Trust does not support for cost or standardisation reasons).

 - While the employer may choose to provide and pay for supervision, it is very unlikely that this will be set up as anything other than an extra means of discipline, rather than as an independent professional support system.

 - The loss of the supervisory function, that usually results in supervised or supportive practice if a midwife is not practising at an adequate level, will mean that ALL such cases will need to be refereed to either employer disciplinary procedures, or directly to the NMC fitness to practice system (apparently these cases are already mounting up).

 - The NMC Midwifery Committee is being disbanded. This will mean, as we understand it, that there will only be one midwife representing the whole midwifery profession at the national NMC level.

These are very serious changes. They are being introduced with no evidence that they will increase the safety of women and babies, or the professional capacity, status, and credibility of midwives, and, based on logical deduction, a very strong likelihood that they will do the opposite.

Please all consider these issues, and, if you feel strongly enough about them, spread the word among your networks, and let the RCM/your MP  know!

Professor Soo Downe OBE, Sheena Byrom OBE, Neesha Ridley

Click here for how to contact your MP, and here to contact the Royal College of Midwives

When midwives are broken - what can we do?


It’s always a great pleasure to visit universities and meet enthusiastic student midwives. I also have the priviledge of speaking to scores of midwives at conferences and events. Social media is another way I connect with maternity workers, and I read blogs written by midwives about their work both in and out of the NHS. There are many heart soaring moments when I read about innovation, kindness, compassion and women centredness. But I am always alert to messages of distress, and when I hear accounts such as the one below, my heart well and truly sinks. I have written about the overwhelming and increasing pressures of being an NHS midwife, and midwifery manager, before.

I have chosen to share this midwife’s plight for many reasons. Firstly because she asked me to, and because her words represent the feelings of all the others who write to me almost on a weekly basis. And of course I want to add to the lobbying for much needed change in maternity services; how can midwives care and nurture others when they feel stressed, burnt out, and unable to do their work?  The situation is intolerable, and needs action. By using a pseudonym below, I am protecting a midwife’s identity. But many midwives speak out reveal their names, when they don’t feel able to continue. Others reach out to tabloids annonymously to highlight their distress, and recently the mother of a midwife contacted the press. In 2015, the RCM revealed that 50% of midwives in England were stressed

Julie is a newly qualified midwife, and like so many others, the NHS is in danger of loosing her.

It's with much sadness and desperation, that at only four months into my midwifery career, I am going off sick for the first time with stress/burnout. Working conditions, despite generally very good support from colleagues and amazing support from my SOM, are untenable. I am completely heartbroken at my inability to give the kind of quality care women deserve due to staffing issues and chronic overworking. And this is despite my unit having some of the highest levels of positive feedback in the country. The price to be paid for this appears to be the health and wellbeing of all staff (particularly midwives and registrars). I'm sharing this with you as you have all been so supportive of my transition to life as a newly qualified midwife. And I believe it is an outrage that four months of work as a midwife is enough to break me, someone who has sought every strategy possible to engage in maintaining resilience (yoga, meditation, peer support, Twitter, reflecting, conferences, self-care, etc), whose passion and love for midwifery is so strong and who has made it their life's work to reach the point of qualification. I have thought about leaving midwifery. In fact, I have thought it almost daily for the past three months. I had no idea working clinically as a midwife would be so distressing. The most profound problem is that there is no time. No time to create meaningful relationships, to properly support people in their journeys, to hold space, to be tender. I have done my very best every shift and believe I have given everything I could have to the families I have been with but that is not the same as it being as good as they deserve.

On the advice of my supervisor of midwives I'm going to my GP tomorrow to get signed off for two weeks. In this time I will be reviewing my finances to see how I can reduce my clinical hours as a midwife. As someone with a disability who already works 34.5 hours I don't know how I will survive financially. I may look for another part time job to make up the shortfall. My (retired) mother has spoken of giving me a monthly allowance. All this to enable me to practice midwifery. I am angry. I am angry for myself but I am angrier for the people we serve, that working conditions for midwives are so far from adequate and sustainable that they are unable to provide the care they deserve.

If you have any ideas as to how to come back to the vocation I truly love and an identity that shapes who I am, in a way that is healthy and productive then I would be so grateful. And if you can, in any way, publicly share what I have told you (anonymously, as I fear being open may negatively impact me) then I beg of you to please do so. Tell everybody what is happening. That conditions are now so bad they are beyond normal newly qualified midwife transition. That we are experiencing burnout in months. My unit is struggling to retain even the most committed staff. We are demoralised. Not by the wonderful women and families, not by our colleagues, but by the inability to provide truly compassionate, individualised, safe, holistic care and support. The 'workload' is relentless and the only thing left to give is ourselves. And I am broken.

Please share my story if you can.

In response to my supportive email to her, Julie later wrote:

It's reassuring to know I'm not the only one struggling! I really feel that the public deserve to know the real state of affairs. There seems to be an expectation for midwives to be virtuous and perfect (a mother-type complex?), able to carry all burdens without complaint, ever grateful for the 'privilege' and 'joy' of the job. That is not to say midwifery work is without these elements but I do not feel 'privileged' on most shifts! The stress is too great to even appreciate the beauty and wonder that exist. I live with a fellow (non-disabled) NQM, who is on the verge of breakdown too and she has had two two-week long absences from work from physical illnesses she attributes to internalised stress. Again, this is within a four month period of working clinically. I just wanted to let you know as it does affect my ability to earn extra income by managing the potential work-load of another part-time job in order to facilitate reduced clinical hours as a midwife and thus it makes me intensely financially vulnerable (I am 30, live independently with a housemate and all the associated costs). This on top of the stress of working in a busy, high risk obstetric unit with chronic understaffing, demoralised midwives and unmanageable workloads is just horrible. However, to temper this I would like to add that the labour ward co-ordinators, my incredible SOM and colleagues are doing their very best on a daily basis to support me and everyone else, however there is nothing they can do about the staffing and workload issues which underpin everything.

Thank you for taking time out to listen to me. I feel heard and understood which is so lovely in these trying times.

‘...if I'd known the realities I think I would have pursued doula-ing. It's a shame as midwifery is such a beautiful paradigm in its own right but enacting it authentically in the UK, particularly in a hospital setting, seems almost impossible’

If you have any ideas as to how to come back to the vocation I truly love and an identity that shapes who I am, in a way that is healthy and productive then I would be so grateful. And if you can, in any way, publicly share what I have told you (anonymously, as I fear being open may negatively impact me) then I beg of you to please do so. Tell everybody what is happening. That conditions are now so bad they are beyond normal NQM transition. That we are experiencing burnout in months. My unit is struggling to retain even the most committed staff. We are demoralised. Not by the wonderful women and families, not by our colleagues, but by the inability to provide truly compassionate, individualised, safe, holistic care and support. The 'workload' is relentless and the only thing left to give is ourselves. And I am broken. Please share my story if you can.

So what’s the solution? I offer some suggestions. Please comment below and add yours


  • WE ARE SHORT OF MIDWIVES, especially in England. The RCM’s calculation is that England needs 2,600 more midwives.
  • The proposed NHS savings of £22bn by 2020 isn’t going to happen unless we work in different ways, and become more innovative and dexterous.
  • The Better Births report tells us this too, and provides some solutions to improving the working lives of maternity care workers, by supporting the development of new models of care, increasing choice of place of birth, and proposing the exploration of no fault compensation.


Heads of midwifery, consultant midwives and leaders do you:

  • Meet regularly with your staff, seek opinion on pressures within your services, then lobby for change using quantitative and qualitative data, and benchmarking tools such as BirthRate Plus?
  • Establish schedule of meeting with student midwives and newly qualified midwives? Their views will reflect the culture of your services.
  • Know if your service offers women the full choice offer of place of birth, which gives midwives the opportunity to experience and use their full range of midwifery skills?
  • Monitor your services’ continuity of midwifery care (r) levels, which evidence tells us improves outcomes and experience for mothers, and increases midwives job satisfaction? 
  • Carry in-depth analysis of sickness episodes/levels?
  • Obtain regular feedback from service users via MSLCs or other forums, and frequent audit of views?
  • Work closely with RCM and other union reps to seek opinion on working conditions and job satisfaction, and to share knowledge of your service?

Rewarding staff and showing appreciation, such as organising a celebration event where staff nominate peers is a great way of lifting morale, and increasing motivation.


  • Look after yourself. You are your greatest asset, and listening to your body and mind then acting on signs of stress are crucial.
  • Talk to someone you admire and trust, and ask for their guidance. This may be your supervisor of midwives, or a member of your team.
  • Stay close to your positive role models.  
  • Exercise regularly, and eat well. Use relaxation aid such as Elly Copp’s The Relaxed Midwife - A meditation aid to pause, rest and recharge and Maggie Howell's Midwives Companion
  • Join the Royal College of Midwives, and meet with your local representative
  • Network with wider groups, such as closed Facebook groups, and seek positive support from others via social media sites such as Twitter. 
  • Read this Hannah Dahlen paper which highlights the importance of identifying real and manufactured fear.
  • Read Chapter 17 in The Roar Behind the Silence entitled Caring for Ourselves: the key to resilience by Hunter and Warren.

The Roar Behind the Silence: why kindness, compassion and respect matter in maternity care – has many examples and ideas for change in maternity care, for all levels.

It doesn’t have to be like this. Carmel McCalmont is an Associate Director of Nursing and Midwifery, and co-wrote a chapter for ROAR, about supporting student midwives in practice. She said:

We try to carry on the work we do with our student midwives into the NQM phase. I personally visit each clinical area every morning and talk to all staff. It is important to learn the names of new  before they start working, to say ‘Hello’ and call them by name from day one. I speak to them during preceptorship at their formal programme, and advise them that I have an open door as do the matrons. It is vital to check their well being to empower and support them.

If we have an incident involving a NQM we try to wrap our arms around them to support, reassure and guide because we really can't afford to loose these amazing midwives who are the future of midwifery.

Carmel's contact details:

Twitter: @UHCW_Midwife

'There is nothing higher value to society than improving the way we are born'

An interview with Dr Neel Shah MD, MPP, Assistant Professor, Harvard Medical School 


Hello Dr Shah, what an absolute pleasure it is for me to have the opportunity to interview you for my blog. Thank you so much for your time!   I first became aware of your work via social media, and I was instantly intrigued by your interests, and approach to maternity care. The article below drew my attention (click on image).


For those who don’t know you, could you tell me a little more about yourself, your background, and your current position?

Sure! I wear a few professional hats, but first I am an Obstetrician/Gynaecologist, which means I get to care for patients at critical life moments that range from surgery to primary care to childbirth. I’m also a scientist that focuses on designing, testing, and spreading health systems innovations that can measurably improve patient care.

 What made you choose the field of obstetrics and gynaecology? 

The clinical breadth was compelling—because we provide primary care we need to consider how patients are accessing the healthcare system; because we perform surgery, we need to consider how we deploy expensive technologies equitably. But most of all, I just loved delivering babies. Even when you are exhausted and it’s the middle of the night, there is no existential crisis when you are assisting a birth. It’s awesome every time. Never gets old.

 What do you think are the main barriers to improving maternity care and outcomes in the USA?

It is not knowledge. There is a tremendous gap between what we know and what we actually do. Closing this gap feels imminently possible to me. Improving care requires science and measurement and value propositions. But it also requires effective advocacy—building coalitions with aligned interests and establishing consensus.


I understand as well as working was a clinical doctor, you are the founder and executive director of  Can you tell us a little bit about this organisation, and why you set it up? 

My profession provides the most expensive services that any patient (or society) will spend money on in their lifetimes, but at the point of service we rarely know what anything costs. In medical school this drove me crazy. It also occurred to me that although nobody goes to medical school to treat the GGP (Gross Domestic Product - healthcare in the U.S. is nearly 18%GDP which means about 1 in 5 dollars is spent of healthcare), my colleagues often had important insights into the opportunities to make care more affordable. I formed Costs of Care six years ago to ensure that these insights percolate into the public discourse.

It is obvious you are passionate about making childbirth safer, and less expensive, and you are undertaking research in this area. What does the research entail, and why do you think this is important?

Most of health services research is about diagnosing problems – we detect variation in the quality of care but fall short of doing anything about it. Instead, intervention is left to administrators, policymakers, and other “implementers.” By contrast, my research (based at a place called Ariadne Labs in Boston) is predicated on the idea that we have a role to play in intervention too – in designing solutions that have potential for scale, and then fielding, monitoring, evaluating, and many cases spreading these solutions far and wide.

We are becoming increasingly aware of the iatrogenic damage caused by unnecessary interventions in childbirth, and the potential consequences. You have been recognised for your work New York Timesin this area, can you elaborate?

Media attention is helpful because ultimately, women have to be the driving force behind changes and improvements to our system. There are two ways that we inadvertently harm patients. The first is by doing too little – there is a broad and intuitive understanding of this. The second way is by doing too much – this has been much more challenging to explain. I agree with you that there is increasing awareness and awareness is a necessary first step. The next step, the hard work in front of all of us, is to then do something about it.

I was thrilled to see that you are listed amongst the 40 smartest people in health care - WOW! What an accolade! How did you feel about that?

Superlatives are always great! You have to be suspicious of any list that aims to plausibly put me next to Barack Obama, but flattering nonetheless. Hopefully this type of attention will help elevate the visibility of the issues we are aiming to fix in maternal health.

If you had 3 wishes granted which you feel would improve outcomes for childbearing women and their babies, what would they be?

There is nothing higher value to society than improving the way we are born. And there is a lot to improve. In the United States right now, 80% of government spending on healthcare goes to the last month of life. With a fraction of that investment, we could do a lot to ensure women and babies are getting better care.

 Lastly….who are your inspirations, and why?

I’m so fortunate to be surrounded by people who inspire me. My dad taught me to be curious. My mom taught me to be resilient. My brother taught me to take the road less traveled.

Professionally, I work with one of the people I admire most - Atul Gawande. He’s inspiring because he is a tremendously gifted writer, researcher, and surgeon, but there is more to it than that. He is also one of the most generous mentors and leaders I have worked with, and has this unflappable sense of purpose and focus on doing work that will have impact.

Dr Shah, I am forever grateful to you for highlighting and taking action on matters that affect us all, wherever we live, or are born. And also, for connecting with me when I invited you to, and for responding to me so generously. I hope to meet you one day!

Dr Neel Shah can be found on Twitter @Neel_Shah

Voicing the silence: Elizabeth's story

Dr Elsa Montgomery is the Head of the Department of Midwifery at King’s College, London. I met her recently and she told me about her research into the experience of childbirth for women who had been sexually abused in childhood.

I was impressed by the way Elsa has used her findings to create an accessible and innovative way to enable silent voices to be heard, and shared widely.  When I saw the animation - Elizabeth's story (see below), I felt uncomfortable, just as I had done in the 1970s, when I was first exposed to a scene like this in real time. I remember the horror that I felt as a young woman, seeing another so vulnerable and helpless. I also remember looking round the room and seeing no emotion in my colleagues' faces, just composed stares, intent on the job in hand. I had to try hard to get used to it. Conditioning. Becoming de-sensitised. It is, after all, part of our education.

Or is it? 


On the 1st October 2015 Sheena posted a blog entitled ‘Silenced and shamed – speak and reclaim – the journey of a midwife’. In it the author told of how her journey into midwifery triggered memories of her childhood sexual abuse.

Silence was a key theme in my research into the maternity care experiences of women who were sexually abused in childhood and many of my findings were reflected in the experiences the midwife shared. Since I completed my study I have worked on ‘Voicing the Silence’ in order to raise awareness of this hidden issue through the powerful words of the women who spoke to me and who deserve to be heard. This blog explores the experiences of one of those women.

This week has seen the publication of two important reports: the MBRRACE-UK Maternal Report 2015 and the Annual Report of the Chief Medical Officer, 2014 which focuses on women’s health. Both include case studies of women who experienced abuse in childhood. However, despite the magnitude of the problem – approximately 20% of women have experienced some form of childhood sexual abuse – it remains a hidden issue and those affected are frequently silent due to fear, shame and guilt. These women are encountered in the everyday situations of midwifery practice and many of those situations will be reminiscent of their abuse – even if the care they receive is sensitive (Montgomery et al 2015). Lack of disclosure means that their trauma is likely to go unrecognised.

Like nearly a quarter of the women who died between six weeks and one year after pregnancy, Elizabeth (a pseudonym chosen by the woman) experienced significant mental health problems in pregnancy and even made an attempt on her life:

'I just felt overwhelmed with everything and I just thought I would be better off dead, I’d be – this baby would be better off without a mother like me and I would be better off dead.'

None of those caring for Elizabeth in her first pregnancy knew of her history of childhood sexual abuse. Not even the Perinatal Mental Health team to whom she was referred by her GP after she tried to take her life:

'I suppose then people caught glimpses of how bad things were but - I couldn’t, I still really couldn’t tell anybody.  I couldn’t, I couldn’t tell anybody about the abuse – and that was really where it all stemmed from'.

Before she became pregnant, Elizabeth had believed that she had left her childhood history in the past, yet, like many other survivors, she discovered that childhood sexual abuse casts a long shadow (Children’s Commissioner 2015).

CLICK ON THIS link  to read more about the animation below created by a film production company, JMotion, as a result of a Collaborative Innovation Award from King’s Cultural Institute. It is hard-hitting and portrays Elizabeth’s experience in labour with her first child. She had been so bemused by the number of people in the room that she had asked her husband: ‘Are they selling tickets outside?’

This scene is played out in maternity units across the country every day. The word cloud below was created from the evaluations of the first group of students to see the animation.

They found it disturbing because it is so familiar to those who work in high risk maternity settings and they feared they may have been ‘colluders’ in trauma for women. Elizabeth’s experience is an indictment of what can happen in our maternity care system – especially when control is taken from women and they are not heard. Elizabeth’s story has happy ending even though the journey was a difficult one. Like some of the women mentioned in the midwife’s blog, Elizabeth planned a home birth for her second baby. Although that did not work out, the midwife listened and she had the birth she hoped for. Looking back over her experiences, she was able to say: 

And that made me feel so much better about myself, um – that my body could be actually used for some good and, and could make this beautiful baby ….

Although continuity of care is likely to make disclosure of sensitive issues easier for women, Elizabeth’s experience shows that it isn’t essential. Dignity, respect and compassion can and should be available to all women.


Children’s Commissioner (2015) Protecting Children from Harm: a critical assessment of child sexual abuse in the family network in England and priorities for action. London:

Davies SC (2015) Annual Report of the Chief Medical Officer, 2104, The health of the 51%: women. London: Department of Health.

Knight M, Tuffnell D, Kenyon S, Shakespeare J, Gray R, Kurinczuk JJ (Eds.) (2015) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care - Surveillance of maternal deaths in the UK 2011-13 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-13. Oxford: National Perinatal Epidemiology Unit, University of Oxford.

Montgomery, E., Pope, C., Rogers, J. (2015) The re-enactment of childhood sexual abuse in maternity care. BMC Pregnancy and Childbirth 15:194
DOI: 10.1186/s12884-015-0626-9  

Further papers from my study:

Montgomery, E., Pope, C., Rogers, J. (2015) A feminist narrative study of the maternity care experiences of women who were sexually abused in childhood. Midwifery, Vol. 31, No. 1 pp 54-60

Montgomery, E. (2013) Feeling safe: a metasynthesis of the maternity care needs of women who were sexually abused in childhood.  Birth, Vol. 40, No. 2 pp 88-95

Thank you so much Elsa for sharing your important research in such an accessible and innovative way, to maximise the potential for health care workers to understand the importance of dignity, kindness and respect.  



Elsa can be contacted via Email:      Twitter @elsamwm

The pressure must stop - a young midwife's first ROAR

Yesterday a man came to me livid with frustration 'this is not good enough' he told me 'my daughter has been waiting hours to be seen' He went on to tell me 'it isn't you. It isn't the other midwives, the care has been impeccable but the situation just isn't good enough.

I know. I agree. I have shed too many tears over a career I could not love more because there is nothing I can do. What he didn't know was that heartbreakingly this is a daily occurrence in my life as a midwife. What he didn't know was that actually yesterday was a rare Saturday off for me yet I had come into work so that my amazing colleagues could have a break from their 13 hour shift. A break they won't be paid for whether they take it or not, but that they physically need as human beings. I had come into the unit so that women like his daughter could be seen. So that our unit could be open to women who needed our skills as midwives, doctors, health care professionals. Women who were in labour. Women who's babies weren't moving much. Women who were concerned about their own wellbeing. 

5 maternity units in the North West of England have been closed over the weekend. These women need our care. We are literally being worked to the ground. I am watching amazing midwives leave a profession they love because the workload and stress is too high. 

Today is a rare Sunday off for me. But I will be spending it supporting our rights as workers. The NHS is run on good will. But there is only so much we can take. We joke at work that midwives don't need to eat. To rehydrate. To empty our bladders. To sleep. Let us look after ourselves so that we can look after our women. Our future generation of children. 

Earlier this year, our country voted for a government that said no to more midwives. The Conservative party have demonstrated five years of austerity, falling living standards, pay freezes and huge cuts to public services. They have threatened to make cuts to our night shift and weekend enhancements. Over the past 4 years I have missed Christmas days. New Years days. Family's birthdays. Countless nights out. I had a good education and did very well at school. I am 22. I have held the hands of women through the most emotional times of their lives. I have dressed angels we have had to say goodbye too. I have supported women to make decisions that empower them. I have been scared myself. Tired, stressed, emotional every day. Yet I am not and will not be paid well like my friends who have chosen business careers. I am not offered pay rises for my efforts or successes. I don't care because I get something more valuable than that from what I do. I love what I do. I'm passionate about what I do that's why I do it. But I do care that we are the ones who are being threatened with further cuts. Further strain.

So today I stand with doctors, midwives, nurses, teachers, firemen and many other amazing people to spread awareness of a situation that has gone too far. To share information that the general public are oblivious to because as midwives, we will not let these women be failed. I am regularly met by stunned responses from women and their partners to the situation they watch me working under. But today I say no. Enough is enough. 

I have shed too many tears over a career I love. Missed too many meal breaks. Not physically been able to care for too many women the way I wanted to. Spent too many days off in work. Lost too much sleep over the stress I am under. Watched more of my colleagues than I could count (myself included) be signed off work with stress in the early years of their career. Watched too many good midwives leave careers they love. This is not humane. Please let's end this. Protect your NHS. Your children's future. You're education system. The core foundations of Great Britain. 

I have recently learned the world is a selfish place. But I have also learned that there are a lot of very good people in it. The NHS is run on good will and because of this we have been pushed too far. 


Let's change this.


This post was written on Facebook, by midwife Hayley Huntoon. We need to make change happen to enable young midwives to ensure mothers and babies are safe #ENOUGH


Have we got lots to learn from the Dutch? Natalie's reflection


Sheena asked me to write a little bit about my experience of my midwifery elective placement in The Hague, the Netherlands. This was a very exciting however, I have never written for a blog before and hope it is interesting enough to read! So here we go:


My name is Natalie Buschman, and I have recently finished my midwifery degree at King’s College London.  At the end of our third year we are given the opportunity to work in a different place or country for 2 weeks, and I arranged to go to the Netherlands. I am actually Dutch, but have lived in the UK for the last 17 years, and had my own two children here in the UK. I therefore have never experienced the Dutch maternity system and only know what the majority of birth workers know: the Netherlands is the envy of the world keeping birth physiological without unnecessary medical interventions. The Netherlands is well known for their high home birth rate and while this has steadily declined from 35% in 2000 to 16% in 2013 (Brouwers, Bruinse, Dijs-Elsinga et al., 2014) for a variety of reasons, it is still high in comparison with meagre 2.3% in the UK(Birth Choice UK, 2011), and certainly a desirable statistic to have!  Furthermore a rather unique feature of Dutch maternity care is the “kraamverzorgster” who can be described as a maternity nurse or postnatal doula supporting families after they have a baby. A kraamverzorgster is available to all women and their families, regardless of income. They will assist the midwife during homebirth or in the hospital (midwife-led) during labour and are available for undivided postnatal care for the first week. All in all, my elective was a great opportunity to go home and have a taste of this highly acclaimed maternity care system.

Ellie the kraamverzorgster with traditional ‘beschuit met muisjes’ or crispbake with mice (aniseed with a sugar coating)

Ellie the kraamverzorgster with traditional ‘beschuit met muisjes’ or crispbake with mice (aniseed with a sugar coating)

The first thing I quickly need to explain is the concept ‘first line’ and ‘second line’ midwifery care. In the Netherlands, like in the UK, you can self-refer to a midwife. Women will contact their midwife/midwifery practise of choice directly for low risk care; this is considered the first line. Only if there are any underlying medical conditions and/or any complications arise during the pregnancy, will the midwife refer the women through to the second line or obstetric care. As such there is a definite divide between first and second line care. As a newly qualified midwife in the Netherlands you are a first line midwife, unless you choose to work in the hospital under obstetric supervision as a second line midwife. Overall, as a second line midwife, you look after women who are already under obstetric care in their pregnancy or who become higher risk for any reason during their labour and birth OR for maternal request for pharmaceutical pain relief such as an epidural. As a first line midwife you look after all women without any specified risks. There is also third line care, which are the big academic specialist hospitals for which women need a referral from the second line or general hospitals.


Midwives Chantal, Anke, Peggy, Carola and Rachelle, their main interim midwife, from midwifery group practice “Anno” in the Hague welcomed me for two weeks this past August and indulged my curiosity.  Anno is an established practice with, on average, between 30 and 35 women on their books each month.

Light airy clinical room at Anno’s home base in the Tree and Flower quarter

Light airy clinical room at Anno’s home base in the Tree and Flower quarter

It is usual for a midwifery practice to have a ‘shop front’ in the Netherlands, and Anno’s is warm and inviting with a nice airy waiting area and two welcoming clinical rooms located in the tree and flower quarter of The Hague. They offer preconception, antenatal and six week follow up appointments (if desired as most women do not do this) at Anno’s home base as well as an antenatal clinic at two different GP’s. The midwives will do home births or hospital births, whatever the women desire. Their homebirth rate of approximately 6.5% (about 2 births per month) and is much lower than the latest national average of 16%, which the midwives felt, is due to a ‘city’ thing as well as the population they serve. Additionally, Anno offers dating and growth scans. First line midwives, and hospitals, earn their income from the woman’s health insurance; therefore due to the high percentage of Dutch midwives working independently, competition is fierce.  The idea that you can have your first scan done with your midwife is an appealing one. Perhaps this makes the difference in the amount of women who will go for their nuchal scan and combination test whether there are any chromosomal abnormalities, with the most commonly known being Down’s syndrome, in their pregnancy.  Roughly 50% of the women booked at Anno will go for this test after being counselled by one of the midwives, while in my experience at the Trust where I trained, the vast majority of women will have this test done. It felt like there was a more conscious decision on what they would do with the information rather than going ‘along’: an opt-in instead of an opt-out.


Before I started, the midwives had requested a little ‘bio’ from me and a photograph so the women they cared for could read about me before meeting me. I thought this was a nice touch, and on several occasions the women’s reaction to me was “I was just reading about you - how fun you are from London!” The next comment was mostly how good my Dutch was!  While it is my mother tongue, I have to admit that I mostly eat, sleep and dream English so switching back did cause some initial giggles all round with some literal translations and weird sentence constructions on my part! Luckily, the Dutch side of my brain kicked in fairly quickly and it even managed to get to grips with the Dutch midwifery dialect (i.e. jargon!).  In order to get the most rounded experience in my very short time, I spent time in the antenatal clinic at Anno’s home base as well as at the GP surgery which serves a very large immigrant population, predominately Turkish and Moroccan women, scanning clinic, postnatal visits and being on call for anything and everything. I was also privileged to be at two births and while they were not at home, it was still a great opportunity to see the midwives in action and how it worked being in a hospital without working for that hospital!


So what are my thoughts after this whirlwind of Dutch maternity care? I can only really share my thoughts on the first line midwifery care, as this is what I observed. There were some practical things like how amazing it would be to have kraamverzorgsters, who take care of most of the clinical postnatal issues such as checking stitches, whether the uterus is well contracted, mum’s pulse etc. They also support the family in how to take care of the baby and of course give invaluable breastfeeding support. A midwife visits every other day for at least 8 days, checks with the kraamverzorgster if there are any concerns and there is actually an opportunity to ask the woman how she is! Don’t get me wrong, there was not necessarily time for a cuppa but it definitely felt less rushed then what I have experienced in the UK. Something that did stand out for me was the amount of women that were expressing breast milk. I just did not understand why they expressed rather than put the baby on the breast? What I did forget is that though the Netherlands has an excellent maternity care package, it is very short! Women in the Netherlands are entitled to 16 weeks paid leave (at 100% pay), and are expected to start their maternity leave at minimum 4 weeks before their baby is due. They are then entitled to 10 weeks after the baby is born, even if the baby is born later then the expected date. Maybe this explains the frantic expressing? Funnily enough, midwives recommend you don’t go outside with the baby for at least one week. How old fashioned was my first thought, but upon reflection, how wonderful! There are so many pressures upon new mothers these days: to bounce back into shape, and ideally into those size 8 jeans you never fitted into in the first place, tidy home with of course Mary Berry style cakes for all visitors, and to be out and about with a perfect baby in the perfect pram! Although Dutch mothers are expected to go back to work after only 10 weeks and likely have some of the same pressures, that first week is really protected with being told that the baby should not go outside (which means mothers can stay in too). Furthermore, there is a kraamverzorgster helping several hours each day, and a midwife that comes round at least 4 times! I wonder if the care received in the first week has any impact on issues such as breastfeeding rates, bonding and postnatal depression, it would be interesting to even compare the UK with the Netherlands. PhD anyone?


Furthermore, there were other things that really struck a cord with me like continuity of care and the confidence of the midwives. The midwives are in a position to give great continuity of care, even in a small group practice, from beginning to end and make sure every midwife has seen the women so there is always a familiar face. Even I, in the short amount of time there met the same women and their families on several occasions, which was hugely satisfying all around! And yes we know that true continuity of care has better outcomes for women and their babies (Sandall et al., 2013) and is mentioned as a factor for work satisfaction for the midwives (Warmelink et al, 2015). However, for a lot of midwives in the UK to work this way would be utopia with the ever increasing work load and amount of women to see… it was so satisfying to see continuity of care as normal practise, not some dream… Of course the ability to work this way is also due to the clear separation of first and second line care as outlined by the Dutch Obstetric Indication List (aka the VIL). This list describes what is physiological and what should be considered a pathological pregnancy, labour and birth and decisions on whom to refer to second line and who to keep in first line care should be based on the VIL. Nevertheless, there is change happening in the Netherlands and midwives are fearful what this could mean for their autonomous independent practice serving pregnant women…


What is happening? Surprisingly and also controversially, findings from the Euro-Peristat (2008; 2013) showed the Netherlands to have one of the highest perinatal mortality rates in Europe in 1999 as well as in 2004. Unfortunately, the media seized this opportunity for scaremongering the general public that home births and midwives cause babies to die, and many unwarranted assumptions were made including that the separation of first and second line care is at fault (de Vries et al, 2013). It turned out that preterm births were included in these statistics and a reanalysis showed that the perinatal rate in the Netherlands is lower or not any different to other European countries, where first line care and high rates of homebirths are uncommon (de Jonge et al. 2013). Of course, these corrected findings were never reported in the media and the damage has been done. In view of the Euro-Peristat findings, the Dutch government is trying to ‘improve’ maternity care, depending what way you look at it, by creating more integrated care rather than a more specified divided first and second line care. This is how we work in the UK and there is a lot to be said to be able to provide care as a midwife for all women, no matter the perceived risks their pregnancy potentially carries.


In my short time spent with Chantal, Anke, Peggy, Carola and Rachelle I felt they were very certain of their care and decision-making. Listening to phone conversations with clients made me realise that they truly believed in the normality of pregnancy, labour and birth. Perhaps this sound funny but having spent the vast majority of my intrapartum training on an obstetric labour ward, I can vouch for how hard it is to keep hold of that belief and trust in a woman’s body! Regrettably with the current system in the UK, I think there are a lot of midwives have lost this belief and trust…. Notwithstanding the various years of experience of the Anno midwives, in my chats with them there was a positive self-assurance, even in the brand new midwife (she qualified only that week) whom I met when she came to help out one day, something I have not always felt chatting with (NHS) midwives in the UK. Absolutely, UK midwives also have self-confidence but it felt different … It could just be a cultural difference, with the Dutch being more extrovert by nature, or maybe it is because in the in the NHS, doctors are always in the background to keep a watchful eye out just in case resulting in midwives feeling and acting more cautious?


While a large proportion of midwives think integrated care can be a positive thing, there are many others who fear this change. Professor Raymond de Vries and his colleagues describe this glass half full or half empty standpoint poignantly in his article in Midwifery (2013). It gives the reader not only some ideas as to why the Dutch maternity care is changing but it also highlights the scary truth that scientific evidence is not enough to convince the greater public of the benefits of midwifery care, people also need to be convinced also on social and cultural levels (de Vries et al., 2013).  I feel this is true not only for the Netherlands but also the UK and any other Western country where midwifery offers a safe and viable alternate option to obstetric care. Whatever direction integrated care will go in the Netherlands, I hope the Dutch people will keep their faith in their midwives and wish that the midwives I met and all their colleagues will keep believing in women, their bodies and stay positively self assured and confident in the care they provide! The Hague and the rest of the Netherlands are lucky to have them!

The Hague coastline

The Hague coastline


Brouwers HA, Bruinse W, Dijs-Elsinga J, et al. (2014) Netherlands Perinatal Registry. Perinatal Care in the Netherlands 2013. Utrecht: Netherlands Perinatal Registry, 2014.

Birth Choice UK (2011). National Statistics. Available at

De Vries, R., Nieuwenhuijze, M., Buitendijk,  S., E. (2013). What does it take to have a strong and independent profession of midwifery? Lessons from the Netherlands. Midwifery, 29 (10),  1122-1128.

De Jonge, A,. Baron R., Westerneng, M., Twist, J,. Horton EK (2013) Perinatal mortality rate in the Netherlands compared to other European countries: a secondary analysis of Euro-PERISTAT data. Midwifery, 29 (8), 1011-1018.

Europeristat (2008,2013). Available at Last accessed 23 September 2015. 

Sandall J., Soltani H., Gates S., Shennan A., Devane D. (2013) Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, Issue 8. Art. No.: CD004667. DOI: 10.1002/14651858.CD004667.pub3.

Warmelink, C.,J., Hoijtink, K., Noppers, M., Wiegers, T., A., de Cock, P., Klomp, T., Hutton, E.,K. (2015). An explorative study of factors contributing to the job statisfaction of primary care midwives. Midwifery, 31 (4), 482-488.