What the national maternity review team should know: a mother's opinion

This is the second post in my #FlamingJune #MatExp action.


Women want to be given unbiased evidence-based information to enable them to make informed choices about their care.

Women want to be treated as individuals.

 Women want to be at the centre of all decisions made about their care.

Women want to be listened to.

photo 3.PNG

My name is Michelle Quashie, and I'm a mother. I'd like to share my views.

We all know that any pregnancy may present with 'risks', but it's important that these risks are not the main focus, and that the women's feelings are considered. The label "high risk" can makes women feel like a disaster waiting to happen. It can create a mindset filled with trepidation, fear and anxiety. This can have a negative effect on women’s emotional wellbeing and that of her baby. Risk is associated with many factors during pregnancy, i.e. previous caesarean, age, gestational diabetes, high blood pressure, multiple pregnancy, previous miscarriage, previous pre term labour, foetal presentation, post dates, growth of baby, infection, BMI, the list goes on and it can be quite daunting. When a woman has this label her care is often consultant led ensuring that medical support is in place as a precaution.  This is great, but it is so important that every woman has equal midwifery input into her care to balance the woman's needs. The word ‘midwife’ means ‘with woman’ we must not forget this and its importance. Even though there may be need for medical assistance we must not forget that the women is at some point going to give birth and will need the support of a midwife, her knowledge of childbirth and her care. This combined expertise of midwife and doctor, if needed, ensures that the risk and benefits of choices are considered, but it also helps to maximise safety and a positive birth experience. 

The label 'high-risk' can make women feel like a disaster waiting to happen....

Society needs to trust a woman's ability to give birth, to acknowledge and respect her intuition and instinctive ability to understand her body, and to feel confident about its capabilities. We should encourage women to use their voice and question or discuss any concerns they may have.  The focus of maternity care needs to ensure it is truly women centred. At booking, a woman should have the opportunity to discuss her plans for her pregnancy and birth. Opportunities to discuss fear or trauma in the past, whether it was result of previous pregnancy or a life event that could affect her ability to give birth should be identified, and appropriate support offered.  A doula or ‘one to one’ care could be offered, as continuity of care is linked to better birth outcomes.

Birth should not be approached with trepidation, but with knowledge, understanding and support. .

Every pregnancy should be treated as a new journey addressing problems if and when they arise, whilst carefully considering previous history. By identifying women’s needs and wishes early on, care can then be tailored to her needs. A woman who feels in control is better at digesting information and is more able to have open discussions, and build trust and respect for those caring for her.  Birth should not be approached with trepidation but with knowledge, understanding and support.

Birth has become very medicalised and Caesarean section rates are continually rising. It is often discussed in the tabloids, and by organisations such as the World Health Organisation. So what is being done to resolve this? I believe that perinatal metal health disorders, particulary postnatal depression, has increased in line with the over medicalisation of birth. Whilst no one disputes that a healthy mother and baby are a primary outcome, a mentally traumatised mother is not a healthy mother, and physical well-being is not the only parameter to be measured. 

It would be great if the maternity review could address this and put some real action in place to reduce Caesarean rates, and ensure interventions are offered only when medically necessary, and after  full, unbiased consultation with the woman.


My opinions are based on my own experience, but are similar to that of many women I liaise with on a daily basis. I hear stories from women across the country, who have very similar themes to my own maternity experience.  My story can be found here. 

In brief, here are the elements of my care that left me feeling disempowered, vulnerable, and sceptical about the birth ideology and what it represented.

- At booking in I was labelled high risk, trepidation set in and from that moment I felt like I was a disaster waiting to happen.


- My care was consultant led so I didn't have any midwifery input into my care plan.


- My birth wishes were denied due to 2 previous c sections even though reasons for these sections would not necessarily occur in third pregnancy and there was no robust evidence to deny my request.


- Care was given based on carers personal perception of risk, no discussions regarding my own considerations regarding risk perception took place.

- My previous surgical notes were not accessed or considered when decisions about mode of birth were being discussed instead the mode of birth was made on a systematic belief.


- Access to services like the ‘VBAC’ clinic was denied due to care givers personal views and labels accorded to me.


- Information given to me was biased focusing only on the risks of birth. The risks of third and fourth surgery were never spoken of even when I raised this as a personal concern.


- Birth discussions did not happen until 36 weeks leaving very little time for planning to take place and for any questions that I had to be explored. This proved to be very stressful and pressurising.


- I was booked for surgery without my consent even though I had expressed I did not want surgery.


- I had called ahead and tried to discuss this with the midwife on the phone but was told that it was my consultant who would make that decision. (Feedback that I have received in response to telling my story at midwifery training events  is that sometimes midwives feel they are not supported by their peers when wanting to support women and her wishes when they are outside of the norm? “On your head be it” is a phrase that has been used.)


- No consideration was given to my emotional well being during discussions that focused on risk.


- I was told I could die leaving my children motherless, which was very upsetting, and made me question my mental health.


- No one responded to my request for help and support, and I was told that they had never experienced anyone give birth after 2 C sections.


- Fear based practice was evident, as a result my individual needs and wants were neglected.


- Interventions were offered to reduce risks without any discussion regarding alternative options. Information should have been given to enable me to make informed choices.


- My ability to birth was constantly questioned and doubted. This made me feel inadequate and less of a woman.


- No consideration was given to my future life plans; I was ridiculed for mentioning them and reminded to focus on here and now.

- Risk of uterine rupture was constantly focussed on and described as a major catastrophe, yet women are being offered induction daily with this possible risk not being highlighted in such a way?

I consider that ignoring my wishes, scare mongering and the emotional blackmail that I suffered were all breaches of the health professional codes of conduct, and guidance on interacting with patients. Regulatory organisations state that a patient’s informed choices must be respected, even if the individual professional is not in agreement. Some health professionals feel they can simply ignore the requirements of their regulating organisations and violate legal and human rights. Are there any plans in place to address this as part of the Maternity Review?


Here are the elements of my care that made me feel empowered, happy and confident:


- Previous pregnancies and complications were not considered a threat to this pregnancy.


- I was told that 2 previous c sections did increase my risk but even though the risk was there, it was small and put into perspective alongside risks to surgery and future pregnancies.


- Midwifery support. This was absolutely key to restoring my strength and emotional well being.


- I was able to openly discuss the risk and the benefits of a vaginal birth with the main focus being on me as the individual and my own perception of risk. Consideration was constantly given to my feelings and my wishes. I felt respected and empowered and in control of my body and fully supported.


- A consultant obstetrician who discussed risks and benefits to both surgery and VBAC. The conversations were very balanced and open,  and I felt that I was supported either way.

- Impact on my future pregnancies were also discussed and recognised as an important factor to consider.


- The consultant midwife attended the consultant appointment with me, supported and contributed to the discussions. I was at the centre of these discussions facilitating real 'woman centred' care. Our unity was my maternity experience.


- I left these appointments feeling informed, supported, happy and empowered as I was able to make educated choices about my care.


- Faith in my body and my ability to birth were never doubted. I was given some great advice on active birthing, what to expect and the physiological changes that would happen to my body were fully explained so I really felt that I understood birth.

- My midwife discussed oxytocin, and its important role in birth so in turn encouraged me to be happy.

Just sitting having these lovely, very womanly discussions were so important. I felt excited to about giving birth and grateful that I was being given the opportunity to experience it.

All women should feel empowered, in control and supported during pregnancy and birth.

It is a very vulnerable time for women and there is no way out. Consideration should be given to the woman’s emotional well being as well as her physical needs. It is not about 'allowing' or 'not allowing'; it's about considering, facilitating and supporting.

 

Experiencing birth has truly been life changing for me. The positive effects I am experiencing have been overwhelming and surface in some way on a daily basis. I want all women to have the best possible chance of having a positive birth experience and I hope the National Maternity Review does too.

You can follow Michelle on Twitter @QuashieMichelle 

 

Why women don't often get the birth they want: my thoughts on the topic

crying-baby-mum-420x0

At the beginning of last week, Kirstie Allsop guest presented a BBC Radio 4 Woman’s Hour special. During the programme, Kirstie ‘embarked on a personal journey to investigate why women often don’t get the birth they want’. I was initially asked to participate in the programme, and I gave it a lot of thought. I have commented on Kirstie’s views about childbirth before. Once following her public criticism of NCT antenatal classes, and another post in response to a letter she wrote to the Telegraph newspaper, concerned that women were being made to feel like a failure if they didn't nave a 'normal' birth, or chose not to breastfeed.

I was pleasantly surprised when I listened to the radio show. The guests gave some fairly balanced viewpoints, around topics such as women’s expectations and preparation for childbirth classes. I was delighted that Kirstie chose this topic for her guest session, as it gave the issues some airtime.

Kirtstie began the programme by asking how society has gone from being thankful for the birth of a healthy baby, to ‘desiring an experience’ at the time of birth. Good question I suppose. But then should women not expect what they plan for, with some understanding that there may be deviations? I have to wholeheartedly agree with Rebecca Schiller  (@HackneyDoula) who was part of the panel on the programme, when she reminded listeners that how women experience birth plays a huge part in how she bonds with her baby. Indeed, childbirth has far reaching consequences on the whole family. Whilst a positive birth is what women and her childbirth carer should be aiming for, we know that most women want a normal or straightforward birth; one with minimal intervention.  This is usually one of the main reasons pregnant women (and partners) attend childbirth preparation classes. Kirstie debated childbirth preparation sessions, and their content, during the programme, in a quest to discover why women are frequenly ‘disappointed’ by their birth experience.

BUT I didn’t feel the matters discussed really addressed the issues of ‘why women don’t often get the birth they want’. I believe the reasons are far more complex and go unnoticed by most, and yet are staring us in the face. I am going to use an example of a birth that demonstrates some of the detail and dilemmas that potentially lead to a negative birth experience, or a sense of 'disappointment'. The story is not unusual. In fact, it is incredibly common.

My good friend’s daughter recently gave birth to her first baby. This is what she told me.

I had done a ridiculous amount of research into childbirth.  From the moment I found out I was pregnant, my whole focus was on the birth, the birth, the birth, and if I’m honest, not so much on what came after.  I decided quite early on, that is was very important for me to be in a calm environment to ensure a good flow of oxytocin.  I have always been pretty sensitive to my environment, and not a huge fan of hospitals.  Therefore,  my husband and I, after a great deal of thought, decided that home would be the most natural place for me to stay calm and relaxed throughout.  I liked the idea of being in control of my birth, and creating a calming sanctuary to bring our new boy into the world.  As the weeks went by, excitement mounted as we  prepared for the big day.  The community midwives (all of whom were very experienced midwives) were all very pro-home birth and made us feel really excited.   We had the birth pool up, gas and air delivered, millions of towels and waterproof coverings, candles  and even a selection of cakes to keep the midwives going.

Johnny came 6 days late.  My waters broke at 4am and I knew straight away that something wasn’t right as the water was a funny colour.  Staying calm, we rang the hospital and spoke to a lovely midwife who told me to save sanitary towels and call the community midwife first thing in the morning.  She said it could have been the ‘show’ causing the strange colour. At this point, I remained extremely calm and felt excited that things were moving and our boy was on his way.  

So the contractions were regular throughout the early hours of the morning, and by 9am, they were coming every 6 minutes.   The community midwife called at 9.30am, took one look at the sanitary towels I had saved, and told me it was meconium in the waters, and I would have to go straight into hospital.  Instantly, I felt anything but calm.   My plans for a home birth shattered, we headed straight to the local hospital, and sure enough my contractions had stopped as the adrenaline kicked in. 

At hospital, by 10.00am ish, I was measured at 2cm dilated and told I would have to go to delivery suite as lots more greenish-tinged fluid was coming out of me.  I knew that this was the doctor-led unit and continued to try to remain calm in an anxious state. The very young male doctor told us we would have to have to have a synthetic -Oxytocin drip, to speed up labour as there was a 1 in 4 chance that the baby was in distress.  From prior reading, I knew that interfering with my own oxytocin could be problematic, and despite my husband and I questioning the doctor asking if it was absolutely necessary, we really felt backed into a corner.  It was our first baby and we were being treated as though it was an emergency, that we must get the baby out as quick as possible.  The contractions I had felt in the early hours of the morning had still not come back and we really didn’t feel as though there was any other option.

The drip made the contractions stronger and more painful, I was told, and I would probably want an epidural as most women do in these circumstances.  Already my labour was already proving to be the exact opposite to what I had envisaged.  The one thing I could still control was my pain relief.  So, despite not having the active birth, subtle lighting, birth pool, hyno-birthing, calming music, I battled through the pain with no pain relief other than gas and air, a tens machine and controlled breathing with my husband and mum for moral support.  At least I was in control of something. 

The contractions came strong and quick and I soldiered through them despite the anxiety-inducing sounds of the monitor transmitting Johnny’s heart beat, interrupted frequently by various midwives/doctors anxious that our baby’s heart beat and oxygen levels were dropping. 

At one point, the heartbeat machine stopped picking up Jonny’s heartbeat. The doctor suggested it could be the TENS machine, so I had to stop using it. Then the staff decided to place a tag on Johnny’s head to monitor him more effectively. The worst point of the whole labour was when the young male doctor, accompanied by a young female doctor (whom he was training it seemed) burst into the room declaring that they needed to take a sample of blood from the baby’s head as they were worried about oxygen levels and needed to make a decision on whether an emergency Caesarean was necessary.  Legs in stirrups, their poking around was the single worst experience of the whole birth. So utterly painful.

During this episode, they told me I was fully dilated.  Thank God.

The pushing stage started as a relief as it felt much less painful.  I got on to all fours on the bed, and pushed with all my might. However, it took a long time (2 hours) for Johnny to come out, and I didn’t feel very encouraged by one particular midwife, who kept telling me I needed to push harder with no acknowledgment for the serious pain I had just endured and the effort I was giving to push my baby out in such an unnatural environment.

Johnny arrived at 20:50 after around 12 hours of labour. They had turned me onto my back, and placed my legs in  stirrups, to perform the episiotomy.  There were 8 people in the room including my mum and husband. As soon as he was born, the cut was cord immediately by a medic and he was whisked away after a brief moment on my chest.  I had requested that the cord stop pulsating before it was cut by my husband.  However, they were so anxious about the baby that it was all done so quickly to check that he was okay. 

Despite all this, we were elated to see our son who was a completely healthy little boy, with Apgar scores of 8 and 10! We are grateful for the care we had received.  However, on reflection of the whole labour and birth experience, we both, despite all the anxiety, had had a strong feeling all along that he would be okay.  Was this because we were in the safe hands of the medics in hospital? Or did we instinctively know he was safe?   Could we have had the natural home birth we had planned? 

So many thanks to lovely Kate and husband Nick for allowing me to use the story of Johnny's birth.

My thoughts:

I do feel that Kate's transfer to hospital was appropriate. But I do question the increasing use of intravenous synthetic hormones (Oxytocin in UK). Whilst there were clinical signs that her baby may have been compromised (this is debatable, and more information can be found here), the detail in Kate's story around being induced is often similar for women with pre-labour rupture of membranes or those being induced for post-dates. We know that the use of Oxytocin to induce or augment (speed up) labour 'has an impact on the birth experience of women. It may be less efficient and is usually more painful than spontaneous labour, and epidural analgesia and assisted delivery are more likely to be required'(NICE 2008). Yet in general, women are happy to be induced.

When there is a risk that all may not be well with baby, and dependant on how this is articulated, labouring women will naturally go along with suggestions from midwives/doctors. Midwives and doctors follow hospital guidelines or protocols, with the mother and baby's best interests at heart. But they are also protecting themselves, and are frequently fearful of reproach.  I fear that in many circumstances there is over treatment, and defensive practice.  My intention is not to blame maternity care workers, but to highlight the fact that the maternity care system doesn't help them or the families they care for, and neither does the legal system, nor the media.

For childbearing women and partners

Try to find out as much as you can before you go into labour. There is so much positive information out there to help you, and as Milli Hill of the Positive Childbirth Movement says, DON'T BE AFRAID TO PLAN FOR THE BIRTH YOU WANT! 

For midwives/doctors:

How can you make sure you know and understand the evidence base to share with families you care for? How do you pass on the evidence? Do you give unbiased and balanced information in an accessible way, or do you use 'protective steering' because you feel anxious about the choices women may make?

Kate's labour stopped due to the release of adrenaline associated with unfolding events, and going into hospital. This happens on a daily basis, everywhere. Have you ever 'walked in the shoes' of a labouring woman coming into your maternity service? What does she see, hear, smell? Who greets her? What is the environment like when she enters the birth space?

We know that Syntocinon puts more pressure on baby, so should it be used when a baby is deemed already compromised? Do you tell that to women when advising the drug? By using Syntocinon, do you consider that you may be replacing one risk with another?

Kate was directed to push during her labour. What is the evidence around directed pushing?

Why did the CTG machines (heart rate monitor) need to be audible (and even too loud), even when there is no healthcare professional in the room?

Do TENS machines interfere with CTG machines? And are we focusing on the machines here, instead of women?

If a woman is pushing on all fours (and having an intervention because of fetal compromise) would you encourage her to lie on her back with legs in stirrups, to perform an episiotomy and 'deliver' her?

If Kate had agreed to an epidural (should this be offered?), do you think the outcome would have been different?

Do you think the baby was in good condition at birth because of the intervention, or in spite of it?

In response to Kirstie's radio programme:

Should Kate not have expected or planned to have a home birth in the first place, free of intervention, then she wouldn't feel disappointed? Next time Kirstie, can we address some of these issues?

And finally, a note for our Governmental Ministers

The shortage of midwives that persists, and is letting mothers (and babies) down. You gave promises to increase numbers, and your lack of attention continues to influence the experience of childbirth. The effect of this is both short and long term, and is both physical and psychological. As a midwife, mother and grandmother, I plead with you to  really listen.

Photo credit 

On the other side of the fence-the relative

Image

During each and every one of the 36 years I worked for our glorious NHS, I always tried to put myself in the shoes of those I cared for. It's strange and quite nerve wracking to be on the other side of the fence, and to be receiving care. When I was a patient myself last year I was ever alert to what was happening around me, and I was truly nervous.

Last week my eldest daughter gave birth to Elizabeth (Betsy), and I was 'the relative'. This was yet a different experience; I was still as anxious and even more out of control. But I was delighted with the care and attention; in fact it was first class. I expected high standards, as I know the maternity service is second to none and receives excellent feedback. Even so, we found the staff to be exemplary, and they went out of their way to make sure us 'relatives' were OK too.

I have to mention two people (there are many more but A will tell all). The first is Leigh Halliwell, the wonderful midwife who worked hard with Anna, loving and supporting her for 12 solid hours. Thank you so very much Leigh. And then there is Mrs Liz Martindale, the obstetrician who supported choice, gave commitment and encouragement, and even supported me via text in the hours leading up to Betsy's arrival. Just moments before the birth, Mrs M told us she was going to make A's birth experience (emergency caesarian section) the most positive ever, and she did just that.

Image

Those who know me, or who have heard me talk at conferences will know that I frequently sing the praises of this particular doctor. This is because she is exceptional in so many ways; pushing boundaries to ensure women feel in control and happy with their birth experience. Mrs Martindale is quite famous for her innovative work (1), especially the 'Martindale Manoeuvre'. Do you know what that is?

So an enormous THANK YOU Liz from all our family for all you did for daughter A, and Betsy Byrom.

Image

(1) Byrom S, Fardella L, Sandford J et al (2010) Collaborating to push boundaries to promote positive birth :an inspirational reflection MIDIRS Midwifery Digest 20(2): 199-204

Photograph of fence