Birth (and midwives) in the media

by Laura Godfrey-Isaacs: Midwife, artist and feminist academic & activist

Twitter: @godfrey_isaacs

We will all experience a ´media-informed´ birth wrote Fleming et al in 2014, with information that is ´fragmented, weakly linked and poorly referenced´ - how pertinent this seems of the journalism displayed in major UK newspapers in August 2017, and how it highlights the responsibility journalists have to portray birth in a balanced way, as most women will not witness birth before they are in labour.

In 2016, I undertook an extensive literature search examining birth in the media since the 1980s. I identified the same themes. They are very much in evidence as you trawl through the articles. These themes have been seen to reinforce certain dominant ideologies and narratives of birth, as well as around motherhood and gender.

For example, the first and perhaps most pervasive idea is that birth as an event predominantly about ´fear, speed, pain and danger´ explored by Elson (2009) in her study ´Mass Media vs the real thing´:  here we see birth depicted in countless films and TV shows as an emergency event with ´women as powerless, physicians in control and technology as the saving grace for women´s imperfect bodies´ as observed by Morris & McInerney (2010) in their analysis of reality TV shows in the US.  This idea has been perpetuated, ironically by the contention in recent articles that midwives’ pursuit of ´normal birth´ (something that is written into their international definition of scope of practice by the International Confederation of Midwives) is the cause of stillbirths in the UK (which are higher  in relation to some other European countries). The contention is astonishing  when the evidence, such as the Birthplace Cohort Study (Brocklehurst et al 2011) concluded that births in midwifery-led settings in the UK are safe, including those at home and midwifery-led units (which are attended by midwives only) with fewer unnecessary interventions than in obstetric settings.

Secondly, as with this current rash of articles, we see an emphasis on medicalised birth as the norm,  satirised by Monty Python in ´The Miracle of Birth´ way back in the 1980´s with their parody of a CS and the machine that goes ´ping´: this as  Sheila Kitzinger (2001), the famous birth anthropologist, suggested,  normalises the medical narrative and encourages women to´submit´ to the potential scenario. So if women only see medicalised birth, it tends to suggest that anything other than this is outside of the norm, and only practised by women who are hostile to the status quo, and by extension builds mistrust of midwives who seem to be ´peddling´ this kind of birth choice.

Thirdly, we see women´s autonomy and agency in birth diminished, dismissed or ridiculed, with media texts tending to promote dominant social constructs around femininity with ´the good woman´ and by extension the ´good obstetric patient´, identified by Williams & Fahy (2014) being highly valued. The implication, therefore is that women should ´do as they are told´ within the medical paradigm, and not question or have their own choices taken into consideration. In addition, partners (nearly always men) are often cast as the hapless and comedic figure, who similarly should remain unquestioning and compliant.

Finally we come to the depiction of midwifery – often absent from the representations of birth, unless as an historical, harmless, bicycle-riding nostalgic figure such as in ´Call the Midwife´ or as we have seen this week as the bad guy´, in distinct contrast to the heroic medical figure. In an analysis of newspaper reporting of adverse birth outcomes Professor Bick (2010) describes how ‘experts´ are used to analyse negative outcomes in a highly selective way, are rarely midwives and seldom proffer a balanced view. Furthermore, vilification of midwives and their singling out selectively from reports is common-place, as this headline from the Daily Mail (2011) exposes: ´Íf you don´t hurry up I will cut you-what one woman was told at NHS Trust where five died´.

Therefore, the depiction of birth as a dangerous event which should not be left in the hands of midwives, and the vilification of midwives for their support of ´normal birth´ could be seen to be part of a long-standing media narrative, which seems to have reached a height recently. The question now is why, and why now?

Birth does not fit easily into the medical paradigm, it is not a ´procedure´, there is no ´cure´ and women are generally not sick - comparisons with dentistry or colonoscopy therefore (suggested this week by some columnists) is not useful. We do not even know yet what triggers labour - but what we do know is that birth is a process that involves a subtle and complex interaction between hormones from the baby and the mother, which start it, and it is a physiological process vulnerable to interruption, be that from fear (adrenaline) or medical interventions. Midwives who are ´with woman´ and go through the whole  experience with women are acutely aware of the fragility of the process, which can be heavily influenced by the environment, birth setting and people involved - and the dangers of interference with this process.

 Birth is also not just a process but a major life event for the woman, the baby, the family and by extension has implications for the whole of society - how we are born has a major effect on our mental and physical health, due to the cocktail of hormones, interactions and experiences we have at the time, and how we give birth as women, has major implications on our health, subsequent pregnancies, and on how we mother and parent. Midwives have a public health role and therefore are aware of the long term implications of certain birth practices, and have a responsibility towards the health and wellbeing of the whole family throughout the birth continuum - therefore the outcomes of birth are far reaching, with safety (physical and psychological) a complex consideration.

Birth is also a place of contested ideologies and ownership - historically a space controlled by women, and relatively recently a place shared with a medical profession and politicians. And, at some times and in some places medical interests and politics have tried to squeeze out women´s traditional place and knowledge of birth. Turf wars continue to run and the polarisation of birth can be a cause of conflict between  professionals, women and in society - over who should really control birth; the doctor, the midwife, politicians or the woman - but of course the best scenario is when all those actors work together to facilitate a woman´s birth, where she feels in control, respected and has the best outcome possible, whatever her preferences or needs. This history and these questions point to wider societal struggles over women´s sexual, reproductive and bodily integrity and control - and is a symptom of a dominant patriarchal culture within which birth is framed.

Midwives are caught harshly in these debates as they traditionally represent women´s power and knowledge in birth, distinct from medical institutions (despite their professionalisation). They are generally women themselves and are therefore subject to a partriarchal system of control (their response to some media reporting recently called ´hysterical´ by a columinst - an insult that implies they cannot think rationally as their wombs are moving around), or identified as´cultish´ and ´radicalised´. And, we all are subject and bound by a pervasive move towards media opinion rather than facts in our post-truth era, which results in the discrediting of research and experts in any field, compared with those with media or political power.

What can we do in the face of this onslaught of media ´stories´ and opinion, for the sake of the midwifery profession and the women we care for, so that a more balanced view of birth and midwives is promoted. What we can do is unpack the dynamic, look at our own place within in, and become aware of some of the misogynistic constructs in the media around how a woman gives birth or mothers her children. We can speak up, and not be silenced. We can carry on with our practice and treat women as individuals, providing them with the best evidence around birth, and keep asserting the research, which is that midwifery is a safe practice, that is highly regulated and controlled, and that there is no guidance that pushes for normal birth ‘at any cost´. We can work with our obstetric colleagues and other medical professionals in the maternity team by putting women at the centre of care, and ultimately we need to stress that, as stated by the Lancet Series on Midwifery, the WHO and many other global health and development organisations, the world needs more midwives not less.

 

NORMAL BIRTH - evidence and facts

"Yellow journalism is is a type of journalism that presents little or no legitimate well-researched news and instead uses eye-catching headlines to sell more newspapers'' 

I would usually add screen grabs of the offending news articles HERE, but I am not. They are sickeningly inaccurate and offensive. 

But this post is referring to recent ludicrous press claims in several newspapers, of a non-existant 'cult of normal birth' by midwives, and that mothers and babies are suffering because of it. These stories are fear-mongering untruths, aimed at damaging a profession, and limiting women's autonomy and choice. And, they are adding to the fear amongst pregnant women, that already prevails. 

Shame on you all.

Professor Soo Downe OBE, midwife and internationally recognised expert in the field of childbirth, presents the

EVIDENCE AND FACTS

1.       There is no evidence whatsoever that a ‘cult of normal birth’ exists: indeed, less than half of women in the UK who could have a normal birth do so (40% as opposed to 80%), and nearly  double the World Health Orgnaisation (WHO) recommended rate of 15% of Caesarean section (CS) are being done (over 26%) at a time when the whole world accepts that CS rates are too high, and that high rates risk harm to mothers and babies.

2.       The Morecambe Bay Report seems to be the sole source for all this reporting. This described the situation in one hospital (not a midwife led unit) in one Trust in one part of the country some years ago. Dr Kirkup, who  authored  the report,  has reiterated that there were five areas of failure found – the issue of normal birth was only one of them. He has emphasised that all five areas were equally important in their potential contribution to adverse outcomes. While the report was very important in highlighting the range of problems that were occurring at Morecambe Bay at the time, and that could have been occurring elsewhere in the country,  extrapolating from this that a 'cult of normal birth' exists, and that it is the sole and direct factor responsible for the death/morbidity of thousands of babies across the country, is scandalously bad journalism

3.       There is no evidence that there is an increase in incidences of perinatal asphyxia in the UK.

4.       There is no evidence that normal birth per se (any more than any other mode of birth)  is associated with baby deaths or damage.

5.       The evidence we do have, from reviews of good quality  randomised controlled trials, is that, if women have continuity of midwife led care, they are less likely to lose their babies (from early pregnancy to the early postnatal period, including birth), 24% less likely to have babies born prematurely, AND more likely to have a normal birth. WHO and many other responsible agencies around the world accept this evidence. 

6.       Indeed, WHO is currently working on a guideline to reduce unnecessary CS

7.       The current press coverage in the UK seriously risks damaging mothers and babies in the future if, as consequence, normal births fall and CS  or instrumental vaginal birth climb

8.       In the United States of America, which has one of the highest rates of intervention and one of the most expensive maternity systems in the world, maternal and infant mortality are one of the highest among the group of the worlds richest countries

 

9.       It is also unacceptable that our Secretary of State for Health, who is supposed to be concerned with reducing baby loss, has not challenged these deeply flawed claims, on the basis of the harm it may do to future mothers and their babies.

Given all this evidence, it is astonishing that the press are reporting the complete opposite. They should seriously consider if they are breaking their own press code of ethics, that states that they must adhere to the following:

Seek truth and report it

Minimise harm

Act independently

Be accountable and transparent

All of these ethical principles seem to have been violated in the elements of the recent reporting that link normal birth as a systemic problem, and as the (only) factor in adverse outcomes in mothers and babies.

It is clear that there are still some areas of poor practice which need to be addressed, but the outputs of recent quality assessments show that the majority of maternity care is excellent, including good collegiate relationships between midwives supporting women to have normal births, and obstetricians providing technical interventions where these are needed . Addressing poor quality care should not be at the cost of reducing this excellence.

Professor Soo Downe OBE

DON'T JUDGE ME: I was a victim.

Image:  www.slate.com

Image:  www.slate.com

Dear midwife, do you understand the power of your words?

We met last week, you said that the woman with a controlling husband was stupid for staying with him: I hope that this piece makes you stop and think, and learn and change.

Firstly, who are you, defender of women’s rights and autonomy, advocate, care giver, change maker, worker, midwife, to pass judgement and to call a woman stupid? As I sat across from you, did you think that I was stupid too? I am a third-year student midwife and I presented the paper I had just had published in a journal to a group of qualified midwives: did I not fit the profile of victim of domestic abuse?

I am not stupid

I am not stupid: I am bold, fearless, courageous, loving, loyal, fiercely intelligent. I fled from a controlling and manipulative husband, packing my life and my children into my battered car in less than an hour. After years of unhappiness, months of convincing myself to just hold out a little longer, of ‘safe words’ I knew to use if I had to call my dad and get him to race the 8 miles from his house to mine, it all came down to one abusive phone call too many. It was a choice that was not taken lightly. Do you understand that you made me feel judged, spineless, cowardly, ridiculous, weak, for staying so long?

‘Stupid’ suggests that she knows what he’s like and that she has a choice. That I knew, that I had a choice. Theoretically there is a choice: stay or go. In reality, is there somewhere to go, money, support, safety?

Photo: Pinterest 

Photo: Pinterest 

Do you know what it’s like to live with someone who controls you? Apparently, it isn’t normal for your husband to make all the decisions, to shout at you as soon as he gets home from work, to drink every night, to ignore you, to use sex as a weapon, to check your messages, to track your phone, to scour your phone bill, to follow you, to go through your handbag, to set all your passwords to his name, to read every single reflection you’ve ever written and every scrap of paper you put in the bin. Who knew it wasn’t normal for the man you love to drive you halfway to a family celebration and then refuse to go any further and turn around and go home, to accompany you to your best friend’s wedding and force you to leave after the speeches for no other reason than he didn’t want to stay.

Who was I to say that it wasn’t acceptable to live with a man who told me that my family hated me, that the only reason my dad offered to pay for my wedding was because he wanted to make up for the fact that he had never loved me. I must be stupid for not realising that he was calling my parents behind my back and telling them I was mental. It wasn’t OK for him to hurl abuse at me until I’d end up curled in a ball on the floor sobbing, at which point he would change completely, insisting he hadn’t meant to upset me and that he loved me. It wasn’t OK for him to spend months threatening to tell people that I was an unfit mother if I left him, for me to stand in a supermarket and beg him to love me when I was pregnant with our children. None of it was OK, and none of it was my fault. I understand that, my head knows that he was the one to blame, but he’s conniving and clever and cowardly. He’s inside my head, and has eroded my sense of self-worth. I’ve been left wondering why I would deserve to be loved, and those thoughts spill over into all my relationships: colleagues, friends, women I care for, why would I be good enough?

You have not walked a mile in my shoes

You do not know me, you have not walked a mile in my shoes, you did not barricade yourself in the home office and sleep with a knife under your pillow because you were scared of the man who vowed to love you and protect you. At least I hope that you do not know how it feels, and I hope you don’t have children or friends who will know the loneliness and pain of living in an abusive relationship. I hope you don’t have a son or daughter who will turn up on your doorstep unannounced one day because he or she is scared. I also hope that if that happens, you listen and hear. I hope you don’t tell your child to suck it up because they made their bed, and that you don’t tell them that they’ll never cope without him.

To be honest, I was not stupid, I was afraid. I was afraid of being alone, of coping with my children, of losing my children. He convinced me I was useless, redundant, insane. I felt as though I had lost my mind, and I wanted to die. By the end of our relationship, after nearly a decade of him, I thought the only way out was if I died. I had hit rock bottom and had lost control of my life, and he kept making it worse.

Image: South China Morning Post http://www.scmp.com/news/hong-kong/article/2049285/hong-kong-losing-battle-against-domestic-violence

Image: South China Morning Post http://www.scmp.com/news/hong-kong/article/2049285/hong-kong-losing-battle-against-domestic-violence

To anybody who has cared for and will care for women in abusive relationships, you cannot imagine the damage that occurs. He never hit me, but he demoralised me and took great pleasure in telling me how awful I was. On our wedding day, which is four years ago tomorrow, he looked me up and down and sneered ‘that dress is very you’, swiftly followed by ‘I thought you’d have worn more make up’. Not surprisingly, he got insanely drunk and did not utter one word to me after we said our vows. I knew. I knew I shouldn’t be marrying him, but I loved him so much and I wanted to prove that I was good enough for him, that I deserved his love. I was also in over my head and couldn’t think of how to get out.

I’m not sure I can do justice to how that relationship made me feel. I have come out of my marriage bearing battle scars that run deep, and I doubt that I will ever trust anyone again, at least not for a very long time. I will not invite people into my life unless I am sure they don’t just want to hate me and punish me: friends and family are kept at bay because I don’t want pity or misunderstanding, or to get hurt. Some of the friends that I thought were my friends have broken my heart, others who I tried to keep out have called my bluff, got through the armour and are here to stay.

It's not over...

The thing is, it’s not over. We have two glorious children together, I am civil to him for their sake, I can pretend to be friends with him so that the little people in my life do not have to suffer any more. He still controls me. I am going to have to fight to get any money out of our joint-owned property, he chops and changes his mind, he decides when he is working so he can control me. He attempts to manipulate the children, telling them to be brave and count down the days until they are next together. The truth is that they make a fuss when he drops them off because he is making a fuss, they are small and do not deserve to be caught in the crossfire of his games. He wants to be in charge and does not understand why this can’t happen all the time. He isn’t sad that he’s lost my love, he’s sad that I made the decision to stop loving him because that meant he lost a bit of his control over me. I nearly drove myself off the road one day and hoped that people would think it was an accident. Enough was enough. I heard a specialist midwife talk about domestic abuse in a lecture at university and realised that she was describing my life, my marriage. That sowed the seed of doubt, and realisation soon followed. One of my children looked at me one day and said “I don’t want you to die mummy”, and I would have done it, I would have left my kids to get myself out, I nearly walked away and left them. “I don’t want you to die mummy” made me realise that I am important to them, that I matter. I matter!

I had moved all my important documents to a friend’s house weeks before I decided to go, mainly because I was afraid that he would take my children away from me. When I left, I packed everything I could carry and squeezed it into my car, I lived out of bin bags at my dad’s house for a month. I was grateful to him, but I felt in the way and lost, although the relief of not having to yield to my husband was immense. I chose things for a new flat without asking permission or feeling bad, or being made to feel bad. My children and I spent the summer exploring our new home and the surrounding beaches, we spent a week on holiday in Cornwall and we barely stopped laughing. We walked and laughed and cried and adjusted. I was strong and brave and courageous for my children, the hardest part seems to be now. My wedding anniversary, mother’s day, his birthday, my birthday all fall within a ten day period, and it has been tough, although I do not know why. This year I had no expectations of him and therefore was not disappointed. I didn’t cry this year, on any of those days. Last year I cried on each of those days. Progress.

I need to thank the women who picked me up

I have written this anonymously, but I need to thank the women who picked me up and stuck me back together again. The one who emailed me late at night to check that I had returned safely from the marriage counsellor I had been forced to attend, the ones who had the courage to say I couldn’t go home as they didn’t think I was safe, the ones who scooped me up, the ones who kept me going, the ones who treated me as though nothing had happened so I could feel normal, even if only for one shift, the one who invited me into her home and cooked for me, the ones who called my bluff on my standard response of ‘I’m fine’, those who continue to challenge and push me, who realise that an abusive relationship doesn’t define me. To the woman who asked whether my children were clean, dressed, fed and loved, and if they were then that was enough for today. To the friend who insinuated herself into my life without me even realising it, thank you for persevering with me, I couldn’t imagine my life without you in it. To the women who have met my glorious girls, and have smiled at them, given them a word of kindness, to the women who inspire me each and every day with their strength, courage, kindness, laughter, and love.

To my lecturers and mentors, there are literally not enough words to express the depth of my gratitude to you. Thank you for your kindness, support, honesty, compassion and understanding, thank you for giving me the tools to save myself, thank you for having the courage to ask difficult questions. Thank you to the group of feisty and fearless midwives and student midwives who stand shoulder to shoulder with me, who share my successes and hug me when I break. Thank you for sticking me back together piece by piece and for making me feel as though I matter.

To the midwife who prompted this reflection, thank you for your crass comment as it made me stop and think. I hope you have glimpsed inside my life, but you can never know the reality, as I can never know the reality of yours or anybody else’s life. Please think before you offer an opinion next time, please show some compassion, for your colleagues as well as the people you care for. Domestic abuse isn’t always evidenced by a black eye or bodily bruises, you don’t know who is going home to an unhappy relationship, who is being controlled, bullied, raped, beaten, degraded, humiliated, downtrodden. You don’t know who isn’t safe just by looking at them, you don’t know which woman, colleague, student, needs you to ask that question about what their life is like when they step in through the front door. You don’t know whose home has become a prison, and whose partner their jailor. Always ask the difficult questions, and never judge. Please be kind, because here is the thing about being in an abusive relationship, it is just so secretive and lonely.

We need a rethink - maternity services in England

It’s the last day of July 2017, and I’m sat reflecting on a month of highs, and of lows.

The week before last, I was surrounded by more that 300 future midwives, at three different events across England, over three days.

What a privilege it is to be invited to be amongst this phenomenal group of people. When I’m with them I feel inspired, hopeful for the future of maternity services, and my children’s children.  They are intelligent, compassionate, eager, aspirational, and full of enthusiasm. Some of them told me they’d had other successful careers prior to starting midwifery; I met a student midwife who was previously a stockbroker, one who owned her own business, and one who managed a marketing company. Their personal ambitions however, link them together. They all want to work with childbearing women, to facilitate positive childbirth outcomes, where mothers and babies are both physically and emotionally well. I watched delegates soaking up the information and inspiration delivered by each speaker, at all the events….and I jotted down some of my thoughts…

‘..not a movement in the room, eyes wide...’ ‘questioning comments showing so much insight’

so much desire to improve maternity services…

Brighton student midwife conference - july 21st 

Brighton student midwife conference - july 21st 

Many of the speakers at each of the three events directly and indirectly talked about the importance of positive birth, of promoting physiological, normal birth when possible, and of the midwife’s role in supporting this.

One question from a future midwife stuck me. ‘Do you think that midwives, by encouraging and supporting ‘normal birth’, make women feel disappointed if they need an operative birth?’

Just before the session where this question was asked, one of the midwifery lecturers told me she was worried that the student midwives she taught had limited exposure to normal, physiological childbirth during their clinical placements. In general, the women they cared for had limited choice in place of birth, and were frequently exposed to potentially unnecessary medical interventions.

I feel some despair that student midwives question the fundamental role of the midwife in promotion normal birth, instead of challenging maternity service provision, lack of resources, lack of continuity of carer, increasing fear and political pressure.

'The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures'. 

At the same time, on social media, the polarization of birth continues, in it’s fiercest form.  Hans Dietz, a clinician from Australia, wrote a damming ill-informed opinion piece about England’s Better Births report, entitled: 

'Women and babies need protection from the dangers of normal birth ideology'

Thankfully, Prof Lesley Page gave a counterbalance to the article, providing factual evidence that quashed any authenticity to Dietz’s opinions.

In England, the word ‘normal’ in relation to birth is being increasingly demonized. This is in spite of the fact that it is a globally recognised term, and there is an international movement, backed with robust evidence, to support normal birth processes, whilst striking a balance between over and under use of medial interventions.  Indeed, Scotland’s maternity policy document published this year said ‘Services are redesigned using the best available evidence, to ensure optimal outcomes and sustainability, and maximise the opportunity to support normal birth processes and avoid unnecessary interventions’.

In England, the Royal College of Obstetricians and Gynaecologists Every Baby Counts campaign clearly highlights that staff must be vigilant for early warnings of any 'departure from normality'. Absolutely, this is a fundamental midwifery skill.  But how is this possible if midwives are seeing normal physiology less and less, and being advised not to use the terminolgy?

 

Every international authority in the world is now promoting normal birth where this is possible (for the vast majority of women and babies). Most, including the Lancet, WHO and the new UN Director General, explicitly state that midwifery (i.e. the active support and promotion of normal physiological birth, as well as the recognition and action on emerging pathologies) is THE solution to the world wide need to reduce maternal and neonatal mortality and morbidity’ (Downe, 2017)

Yet midwives tell me they feel afraid to support women’s choices, and admit the press, the fear of litigation, being named as a ‘maverick’ makes them more likely to practice defensively ‘just in case’.

Also, in the midst of being immersed in the fresh, eager anticipation of student midwives, I read a blog post of from a desperate midwife, wanting to remain anonymous, saying sorry to the women she cares for. The post is heartbreaking, and after being shared thousands of times, was picked up by the Australian press.

Even sadder, are the responses. The affirmations that this is midwifery reality, and potentially why midwives are leaving their beloved jobs, continue to roll in on Facebook and Twitter.  One of the many depressing comments also mentions not being ‘allowed to use the word normalising birth’. I believe this is ludicrous, and creating another, damaging problem. The most chilling part of the midwife’s words are at the end - 'It is increasingly difficult to be allowed to have a heart'

‘ I think this is an accurate representation of life as a midwife today. The saddest thing is that we (midwives) will recognise almost all of the things in this letter but are so far beyond knackered we don't even know where to start to make things better. NHS Trusts can have all the staff engagement incentives they want, but the truth is we won't make the slightest bit of difference. The political and fiscal drivers of our 'service' are very far removed from us. Staff engagement serves as a tick-box exercise for managers of all levels so they can score well on leadership and engagement. For every woman-centred initiative we start (aromatherapy, caseloading, a new/extra birth pool, booking appointments at home), 2 more things are created to take away the value of that - 'paperless' so we sit talking to a computer screen not our women, more 'high risk' inclusions for IOL (is there anyone that doesn't technically fall under the need for an IOL anymore??), not allowed to use the word 'normalising' birth as it has connotations about power struggles. the list goes on. I love my women, I love birth but I no longer love my job. It is increasingly difficult to be allowed to have a heart’.  

There is enormous pressure on maternity leaders too. I’ve talked to four heads of midwifery (HoM) recently, on separate occasions. All of them articulated the increasing pressures they face, unattainable goals, undoable workloads, that I wrote about several years ago. One HoM told me ‘We have just managed to achieve safe staffing levels, so women are receiving appropriate care. Outcomes are good, and we have positive feedback. But the Trust is in financial difficulty and Ernst Young are now contracted to 'sort out' the organisation, and we are being instructed to cut midwife posts. The answer to our desperate concern is ‘there is no other way’.  

Jeremy Hunt’s recent blog post on ensuring maternity safety clearly sets out the priorities. But there is no mention of the need for adequate midwifery staffing as identified by the RCM , or the important research evidence on the benefits of continuity of midwifery care. Can Hunt's goals be achieved, with exhausted midwives, with midwives leaving, or with midwives not being allowed to care, or 'to have a heart'? 

Is this the way to make services safer? To halve the number of stillbirths?

And finally, as we strive to make maternity services safer, childbearing women, with increasing medical interventions imposed, and maternity services mainly delivered in hospital settings, are feeling unhappy too. Devastatingly so. 

Why is this happening?

I continue to highlight issues and lobby for change for the daughters of my daughters, and of my sons. I am passionate and will continue for the future midwives, as I desperately want their lights to continue to shine. Go back to the top of this post, and check out those faces.

We need a rethink and your suggestions are welcome. 

Reference

Downe, S (2017) Personal communication 

The Land of the Respirators - #ENOUGH

Tired of the debate over cesarean section and normal birth? Well here is another way to look at it.

 

Hannah Dahlen making us think…. #ENOUGH

Once upon a time there was a land where more and more people began wearing respirators to breathe. In some places over 70% of the people were now wearing them. Every year around the world respirator use increased (except in the poorer countries where the uncivilised did not have the money or knowledge to access them). More and more companies produced them and there were many salesmen who got very rich. When people questioned whether this was a good thing the respirator salesmen said once upon a time before respirators many people died from the pollution they breathed and we don't want to go back to those days.

We are now in a modern world..

When people suggested we should clean up the pollution and seek more green ways of energy production and so the need for respirators would decline, the respirator salesmen said things have changed today and people will not want to give up all their energy producing equipment and we are now in a modern world that needs these things. When people suggested experiments had been done reducing pollution through innovative new models, reducing the need for respirators and these studies had even been published in the journal of Can Simply Reform (known as CSR for short) the respiratory salesmen laughed and said the experiments were flawed and the Modernisation Interventions Department of Wind Innovation & Friendly Environmentalists (known as MIDWIFE for short) were simply trying to take over and this was a dangerous trend as they were mostly women and quite emotional. In these lands where the experiments were undertaken the MIDWIFE researchers were getting incredible results and showed you only needed respirators in some valleys where pollutiion still existed. They also said that children connected better with their parents when their faces were not covered with a respirator and that long term exposure to the real microbe laden air was actually enhancing immunity. But the respirator salesmen laughed and dismissed the research saying breathing without assistance was deadly and that there was now a fundamental biomechanical mismatch between polluted air and the lungs. The respirator salesmen developed more and more beautiful respirators for people, some encrusted with diamonds and others so soft and lined with velvet that the people barely knew they were there. They fitted these respirators in beautifully decorated rooms with piped music and a free glass of champagne to celebrate. The people were impressed (well many of them).

Submissions in the basement

The government officials who went to school with the respirator salesmen backed them and said after all respirator sales are good for the economy. The journalists (many who owned nice respirators themselves) remained generally silent about it except when they could pitch an entertaining war between the MIDWIFE researchers and respiratory salesmen. When the MIDWIFE researchers said, 'what about the evidence and quality of life, long term effects and just generally the scientific evidence' the government said 'send us a submission and they stored in the basement with all the other submissions and then they went and had drinks at the club with all their respirator salesmen friends. Some lands had less than 20% respirator use and better outcomes than those lands with high respirator use but it all fell on deaf ears ...until the people rose up and said #ENOUGH 

The End...

Can you help?

HISTORY OF INTERNATIONAL CONFEDERATION OF MIDWIVES

(Previously the International Midwives’ Union or it might have been the International Union of Midwives)

 

CAN YOU HELP?

 

The IMU started in Europe in the late 1910s/early 1920s. Under the leadership of Joyce Thompson the ICM has commissioned a history of the organisation to be written.

Unfortunately the early organisational documents were lost either in Ghent in 1939 or Berlin in 1942 (further work required to determine what was lost when). Please can you look through your great grannies’ papers/attics/basements for the IMU Communications 1 (published October 1925), 2 (published July 1926) or 3 (published June 1927).

Does anyone know of the whereabouts of the final version of the ICM history written for the 50th anniversary in 1972 but not published before 1975 by Marjorie Bayes? Do you know of any midwives, historians or archivists who might be able to help? We are searching the ICM archive in the Welcome Institute but so far it is not much help.

The countries involved in the start of the IMU were:  Belgium – both parts, Bulgaria, Czecho-Slovakia, Denmark, England, Germany, Hungary, Italy, Moravia, Prussia, Silezia, Slovakia, Switzerland, Tcheco-Slovakia, The Netherlands, Yugoslavia.

We also know that midwives across Europe were talking to and visiting each other from the late 19th into the early 20th century. We know that midwives were inviting colleagues from across Europe to attend local and National meetings. For example we know that the Manchester and District Midwives’ Association gave Madame Bocquillet (founder and Secretary of the Syndicat General des Sages-femmes de France) Honorary membership in 1898, and that over 500 midwives met at the Berlin Midwives’ Association meeting in Berlin in 1900. Midwives from Denmark, Hungary, Romania, Russia, Sweden, Switzerland and The Netherlands attended this meeting. Do you know of any reports of these early meetings?

Can you put me in touch with midwives, historians or archivists who might be able to track down reports of these early meetings and/or publications so that we can map the midwifery interaction and thus the growth of the organisation.

Please spread this request around by any means and ask people to contact me. I apologise if you have already received this.

 

Ann M Thomson

Professor (Emerita) of Midwifery

University of Manchester

Ann.thomson@manchester.ac.uk

What’s in a name: inciting blame and fear, or instilling courage?

This is a post about the term Obstetric Violence.

It isn’t about doctors.

It isn’t about midwives.

It’s about both.

BUT, it’s really about childbearing women.

Before you read on, please watch this film (WARNING - it is very distressing).

I use this clip in some of the talks I give in UK and internationally, on compassionate, respectful maternity care. I ask delegates if they have witnessed any of the practices they see. There is usually a full show of hands.

One of the questions I ask is - 'Why do you think the maternity care workers in the film look so unhappy?' And then there's usually a lengthy debate...

I could write a whole blog post on the film itself. 

What is Obstetric Violence?

It appears the concept gained momentum in Brazil during the 1990's. From there, other countries are highlighting the problem, and in England there is research planned to explore how the law can be used to  'meaningfully address obstetric violence'. 

Earlier this year (April 2017), a clear message went out on social media from Europe:  World Health Day: Time to speak up about postpartum depression. Within the text there is a very clear definition of OV: 

'Obstetric violence may be defined as the appropriation of women’s body and reproductive processes during birth by health professionals which is expressed by dehumanising treatment, the medicalisation of natural processes including excessive use of c-sections, resulting in a loss of autonomy and ability to decide freely about their bodies and sexuality, negatively impacting their quality of life. It is a reality in Europe which remains under reported, under researched and largely unaddressed within health systems'. 

So, there are two issues. One is the word 'obstetric' being potentially misinterpreted as 'that done by an obstetrician', and the other is that recently it was suggested to conference delegates in England that the term should not be used, as it could instil fear into childbearing women.  If then, we change the phrase to 'Maternity Violence', which has been suggested more than once, could we then address the problem? We know that this phenomena is closely linked to the Disrespect and Abuse agenda, so should it not receive the same attention? 

I’ve had a long-standing interest in the language we use in maternity services, and nearly always mention it in the talks and workshops I deliver.  The list of words-not-to-use extends on almost a daily basis, with an overarching aim to improve the care we give, to maximize the potential for women to feel empowered yet supported, cared for, yet in control.

But recently I’ve been in a quandary, as I try to understand the implications of NOT saying a particular word or phrase for the above reasons – yet the consequences are potentially damaging. 

Obstetric Violence.

So I asked an open question on Twitter:

There was a mixed response, and some incredibly useful comments. Obstetricians understandibly feel they are being named and singled out as the perpetrators in the title. It should be noted that the term Obstetric Violence is used mainly in a global context, and 'ostetrica' is the name for a midwife in Italy. Others, usually women who feel they are victims, don't ponder on the detail of the term; their comments are about the fact that it's happening. 

Take a look at some of the tweets here, in my Stellar story (swipe the pages) 

Why do I care?

I remember being a young student midwife in the 1970's, seeing uncomfortable situations, and not knowing what to do about it.  The first time I saw a woman having a difficult vaginal examination which was distressing for her, she was crying, and the carer continued, eyes directed somewhere above the woman’s, as if there was a solution in mid-air.  Even though the woman had someone giving her a reassuring ‘it’s OK’, the event was highly disturbing for me. I remember feeling sick, as tears tried to burst forth like a raging sea behind a poorly constructed dam.  But I looked at others in the room, and they seemed calm, and unperturbed by the unfolding scene. So I thought that’s what I had to do – try hard to detach from the emotion, but I couldn’t.  These uncomfortable situations continued to occur throughout my career. Sometimes I was able to intervene, to act as a true advocate – but sometimes I wasn’t able, perplexed by the fine-line between urgency, authority, uncertainly, experience and fear.

In those days, I’d never heard of the term Tokophobia. Nor Obstetric Violence. I wasn’t aware of human rights, and ‘consent’ as a process was hit and miss. Like with other aspects of my life and career, when I read about topics that helped me to rationalize my broad experiences, it helped me to comprehend certain dilemmas. 

Now I am more aware. As I witness, write and read about maternity care around the world, my eyes are increasingly widening, and the dam is even weaker.  I understand the complexities, the varying context of abuse, and the implications. It's what drives me to influence change. In our book, The Roar Behind the Silence: why kindness, compassion and respect matter in maternity care, there are chapters on the topic.   Birthrights, the The White Ribbon Alliance and World Health Organisation are amongst the organisations highlighting and tackling disrespect and abuse within maternity services globally.

Elizabeth's story is portrayed in Voicing the silence - an animation exploring the maternity care experiences of women who were sexually abused in childhood. In my experience of listening to women following self-declared birth trauma, these reactions could be from any woman. We should treat ALL women with this in mind. 


4th April 2017, posted on Twitter.

The following message came through to me just a few weeks ago, from another person.

We know that most maternity care workers want to provide exemplary services, yet we know about the systemic problems within health care organisations that potentially influence the care women receive. We also know that in both resource rich and resource poor countries, women are choosing to give birth without medical assistance because they are afraid.  I could go on.

So, does OV incite fear, or place blame on one set of professionals? I believe we need to keep an open dialogue about this issue, whatever name is used, to enable women to understand their bodily autonomy, and human rights. 

Please leave your comments...

Normal birth - a moral and ethical imperative

Updated on the 14th August, 2017 

It has been a very troublesome weekend. 

Using old news, from one particular source, the UK press have run with a story based on the above press cutting. Same information - except the click-bait used was that midwives were to stop promoting natural childbirth, and the Royal College of Midwives had removed their Campaign for Normal Birth site, and were 'dropping' the use of the term 'normal birth',  Right, now I want to make some things clear.

 

1. The Royal College of Midwives discontinued the Campaign for Normal Birth (CNB) THREE YEARS AGO. I was actually part of that decision, and it was due to the fact that the College felt it was important to encompass antenatal and postnatal care within the initiative, and public health. So 'Better Births' was born. It had nothing to do with the Morecambe Bay Report, which was published after the decision had been made. But even though the 'Campaign' ceased, the support for normal birth has not. The RCM have a normal birth resources page. Some of the resources developed for the CNB have been removed following a request, and will hopefully be replaced with more up to date material. Since writing this post, Cathy Warwick CBE, CEO of the RCM, has written to confirm the College's continued position to support midwives to promote and facilitate normal physiological birth

2. THERE IS NO EVIDENCE that the RCM's Campaign for Normal Birth had any direct influence on the tragedies that occurred at Morecambe Bay, or any other service. The adverse events at Morecambe Bay were attributed to five elements of dysfunctionality, one of which was the 'over-pursuit of normal birth'. The report does not apportion blame to any one of the five individual elements, but to the whole five. In any case - why is the one element linked to resources supplied by the RCM? 

3. I believe in choice, autonomy, and safety. Out of our 9 grandchildren, none have been born 'normally'. They needed expert medical intervention, medical support, and I am eternally grateful for the attention they received. I also understand the evidence that physiological normal birth is the optimal way to give birth for most women, and that most women want it.  

4. I hear and fully respect that some women feel that the word 'normal' in relation to birth is divisive, and upsetting, leaving them feeling like they 'failed'. I can understand this, that women may feel disappointed if they wanted a particular birth experience, worked towards that goal, then it didn't happen. But that's it. I would like to suggest that it is the end result is the disappointment, more than the word. Would women feel less disappointed if birth was called physiological? I liken this debate to infant feeding. If a woman has problems and ceases to breastfeed her baby, she feels disappointed - no matter what the term is. Normal birth is a normal physiological bodily process - as is normal respiration, and digestion. The terms physiological, natural and any other are fine too, but let's not blame a word for disappointment. We need to listen to the experiences of women when they are unhappy with their birth experience for whatever reason, then aim to change services so that optimal childbirth is the goal, for a healthy mother and baby. I will not stop using the term 'normal birth' and I will support midwives to facilitate women's choices safely, 

The reasons why I say this are in the original blog post, below. 

May 2017

Sheena Byrom OBE with Professor Soo Downe OBE

I found the article at the top of this page, and one several days later, particularly disturbing. First of all, the harrowing stories of where a family has lost their baby are beyond shocking for the reader. There are no words to express the intense, life-changing grief those involved are feeling. I must mention the health professionals involved, also. I am fully aware of the trauma for them too. No-one working in health care services goes to work to do harm, and the suffering when mistakes are made is also traumatic and devastating.  Yes, there needs to be learning from incidents, and development where needed. But blaming one professional group, or a particular type of birth, does little to improve any situation. 

Why does 'normal birth' matter?

A review of all the relevant studies of what matters to women, from around the world, including the UK, has found that: Women want and need a positive pregnancy experience. This includes: maintaining physical and sociocultural normality; maintaining a healthy pregnancy for mother and baby (including preventing and treating risks, illness and death); effective transition to positive labour and birth; and achieving positive motherhood (including maternal self-esteem, competence, autonomy) [Downe S, et al 2016].

The issue here is increasing sensitivity, in the press and among politicians, a few activists, and health care providers, to the word ‘normal’. All these studies made it clear that the vast majority of women want to go through pregnancy, labour, birth, and the postnatal period relying on their own capacity to grow, give birth to, and nurture their babies themselves – ie, in the usually accepted sense of the word, ‘normally’. Indeed, supporting women to achieve this as far as they want and are able to do so, while helping them and their babies to be as healthy as possible, is the fundamental function of ‘midwifery (Lancet Midwifery, 2014).

the term ‘normal birth’, and all that it relates to, is being rapidly relegated to a rarity in practice...

However, it seems that the term ‘normal birth’, and all that it relates to, is being rapidly relegated to a rarity in practice, or even (negatively) to cult status among the media and other powerful stakeholders (who are mostly not childbearing women, it should be noted). I regularly spend time with student midwives from around the UK and beyond.  They tell me they are worried about practising as qualified midwives, as, during their training, they hardly ever see women who have had a normal, physiological, straightforward pregnancy, labour and birth. This section of a letter the RCM received from a student midwife in 2014, summarizes these concerns. 

'However, I became very disheartened and concerned about my own experiences. As a student midwife, I completed my second year of training after having witnessed and participated in 52 caesarean sections, 16 instrumental deliveries and very sadly, only 11 normal deliveries.  I can vouch for the fact this story is not unique and many students are having a chronic lack of exposure to normality. In fact what the International Confederation of Midwives and Royal College of Midwives seemed to call 'normal', to me seemed like a fantasy, not the world in which I was training and learning. I was saddened to realise that I'm now a third year student and have never used intermittent auscultation in practice and have never seen a women give birth off her back'. Student Midwife to RCM 2014

The situation remains the same three years on, or potentially worse.  

How are student midwives and eventually midwives able to support women to achieve what they want to achieve, AND call for assistance when there is a deviation from the normal, if they have never seen it? 

Recent press reports add to the fear already embedded in maternity services. This fear is real in high income countries (Shaw et al 2016), and influences the decisions of women, mothers and families alike.  Many maternity units in the UK are being challenged by the Care Quality Commission to increase their normal birth rates, and to reduce their induction and CS rates. If the culture of the organisation is to intervene ‘just in case’ out of fear, and to avoid litigation, recrimination and negative press- how do they achieve these targets? And if there is a widespread problem where midwives 'pursue normal birth at any cost', why are the statistics below so stark? Surely, the opposite would be the case? 

We don’t have a problem talking about normal weight, or normal urination, or normal breathing

The term ‘normal birth’, and all that it means, has been debated for years. Some have argued for alternative terms, that are seen as less judgmental (though it isn’t clear if women have been asked if they are being judgmental when they talk about their normal birth). These alternatives include terms such as natural, physiological,  uncomplicated, or straightforward.  However, the term ‘normal birth’  is used by the World Health Organisation and Scotland's recent directive for future maternity and neonatal services. We believe the term will be used by the new digital data collection system that will be set up as part of the implementation of England's Better Births report. It is on the list of terms that the EU think should be used in this context, it is in the title of the international normal birth research conference, (which has been running successfully for 12 years around the world).  We don’t have a problem talking about normal weight, or normal urination, or normal breathing. It seems very strange that ‘normal’ childbirth, in contrast, should be so very contentious for some commentators in this area.

 

WHO says that 80% or more of women should be able to give birth normally around the world (which means more should be able to do so in the UK, given the overall level of health in the UK as a high income country). The fact that only about 35% of women are supported well enough to actually achieve this in the UK (and that many of the remaining 65% feel failures as a consequence) is an indictment of our maternity service provision, and not of women themselves. If we actually were successful in supporting women to achieve the rates of physiological birth that should be possible for them, at the same time as helping the small minority of women for whom this is not possible to feel positive about the interventions that are really needed for themselves and/or their baby, we would not be in the position we are in now, where normal is seen as something exotic that should not be promoted.  

There does not seem to be much debate about the move to increase breastfeeding, for the wellbeing of mother and baby in the short and longer term. It does seem strange, then, that there is so much debate about any project to increase rates of normal birth, for the same public health reasons (and, indeed, for reasons of improved mental health, for mother, baby, and family). It seems that we might be being distracted with this debate, when the underlying issues are much more about the continuing undermining of women’s confidence in their bodies and in their ability to grow, give birth to, and mother their babies. Indeed, the pressure, in contrast, seems to be in the opposite direction, as women are increasingly being persuaded to buy in to monitoring, technical intervention, and the need to meet narrow standardised  ‘norms’ (that are not physiologically ‘normal’ for them as individuals), which, in turn, makes them more prone to a diagnosis of ‘(potential) abnormality’, which  renders them increasingly unable to believe in their own capacity – and so on, in a vicious cycle that actually increases risk for mother and baby.

A moral and ethical imperitive 

The debate seems to have become polarized as ‘either a healthy baby OR a normal birth’. The vast majority of women want both. While it is right to ensure that as many women and families have a baby that is healthy, it is equally right to work towards ensuring that as many women and families as possible have a birth that is as physiological as possible. Promoting normal birth while also maximising the wellbeing of mother and baby is therefore not a cult, or a professional project, or a conspiracy. It is a moral and ethical imperative, that should be supported by all of those with any interest in the wellbeing of mothers, babies and families, in the short and longer term. This includes professionals, journalists, politicians, health service managers, childbirth activists, and lawyers.

It is very far past time to turn the tide. 

References:

Downe S, Finlayson K, Tunçalp O, Metin Gülmezoglu A 2016 What matters to women: a systematic scoping review to identify the processes and outcomes of antenatal care provision that are important to healthy pregnant women. BJOG. 123(4):529-39

Lancet Midwifery Series (2014) 

Shaw et al (2016) Drivers of maternity care in high-income countries: can health systems support woman-centred care? The Lancet Vol 388 No 10057 Available at: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)31527-6/fulltext

 

 

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.

References

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:http://dx.doi.org.ezproxy.uws.edu.au/10.1186/s12884-016-0798-y

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.

References:

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

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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:  GThomson@uclan.ac.uk

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.

 

 

 

 

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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 www.birthyouinlove.com

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. 

#ENOUGH

 

 

 

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:

MidwifeDiaries.com (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.

 

 

Reference:

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

 

CALL TO ACTION: FUTURE OF UK MIDWIVES

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

Strategic

  • 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.

Organisational

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.

Individual

  • 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:

carmel.mccalmont@uhcw.nhs.uk

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 www.CostsOfCare.org.  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