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

Voicing the silence: Elizabeth's story

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

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

Or is it? 


Elsa:

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

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

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

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

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

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

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

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

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

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

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

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

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

References

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

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

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

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

Further papers from my study:

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

http://www.sciencedirect.com/science/article/pii/S0266613814001521

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

http://onlinelibrary.wiley.com/doi/10.1111/birt.12043/abstract


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

THERE ARE NO EXCUSES

 

Elsa can be contacted via Email: elsa.montgomery@kcl.ac.uk      Twitter @elsamwm

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

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

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

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

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

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

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

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

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

 

Let's change this.

 

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

 

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

Hello!

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

 

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

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

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

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

 

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

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

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

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

 

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

 

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

 

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

 

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

 

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

 

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

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    The Hague coastline

The Hague coastline

References:

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

Birth Choice UK (2011). National Statistics. Available at http://www.birthchoiceuk.com/Professionals/BirthChoiceUKFrame.htm?http://www.birthchoiceuk.com/Professionals/statistics.htm

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

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

Europeristat (2008,2013). Available at http://europeristat.com/. Last accessed 23 September 2015. 

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

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

Silenced and shamed - speak and reclaim - the journey of a midwife

This midwife contacted me and offered this post for my blog. She wishes to remain anonymous. Her message is hard-hitting, emotive, and real. Please take time to read, reflect and act. 

Image: http://www.freedigitalphotos.net

Image: http://www.freedigitalphotos.net

The book The Roar Behind the Silence: why kindness, compassion and respect in maternity care matters has highlighted issues, and given many practical tools that are so important in the on-going training and care that midwives and other maternity care workers provide. Reading about others’ experiences and gleaning from their wisdom has added jewels to my midwife treasure trove.

I would like to take this opportunity to talk about the “unspoken” and the not so pleasant things, the secrets that many women hold in their bodies, hearts, and minds. It’s my hope that in speaking out about these subjects, that it will give you courage on your road as a care provider, widen your perspective of the women in you are serving, and encourage you to be someone who creates safe spaces for pregnant women to share their situations. Don't be afraid to reach out for help when you need to.  One small opportunity or intervention, on your part may save a life, or two.

We midwives are humans too. 

The Royal College of Midwives chosen charity of the year has recently been announced as Women’s Aid. Women's Aid is a charitable organisation concerned with supporting women who are suffering from domestic abuse.  “Domestic abuse is a significant factor in the ill health and mortality of mothers and pregnant women (1). It can have significant physical and emotional impact on the woman and can lead to miscarriage, low birth weight, ruptured uterus and pre-term labour.” (2) 

Violence and abuse are usually secret and hidden. Victims are shamed into silence by fear and control. 

Women's Aid uses the Home Office definition of domestic violence which is: 
Any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members regardless of gender or sexuality. This can encompass but is not limited to the following types of abuse:

  • Psychological
  • Physical
  • Sexual
  • Emotional 

As a midwife in training I thoroughly enjoyed studying and learning skills, but when it came to hands on experience it was as if the connection between my acquired knowledge and my physical intuition to connect, was blocked. I knew the kind of midwife I wanted to be, I was surrounded by great role models. I felt disappointed with my apparent dysfunction to give what I had never experienced, human connection,  deficient in oxytocin and the container of it.  I grew up in a violent environment with touch and comfort withheld. I was punished and suffered violence daily, and observed other forms of violence and dysfunction in family life. As a student midwife, I felt extremely uncomfortable to offer any kind of physical reassurance to a woman in labour. Even rubbing her back was a huge obstacle for me. Witnessing someone, struggling to cope alone, and lost in her own fearful space, I was able to overcome my own lack of confidence, to reach out to show her kindness and compassionate care.

Being a midwife is one of the most rewarding life responsibilities in the world if you ask me. It has drawn out the best and the worst in me. It is demanding, pushes all my buttons and takes me beyond the limits I believed I once had. I have always been sensitive to pick up “cues”, to empathise and support, encouraging women to speak up, ask for help, and report violence that has brought physical and emotional harm to them and their unborn child. Some women may not disclose any such events but we can always do our best to create a safe place, following policies, guidelines, and instinct. More on the practical aspects later. A basic bottom line is to always offer your best to each woman, whatever her circumstance. 

We midwives  enter into each appointment / birth experience evaluating what that woman needs to facilitate a good experience for her.

SILENCE - can be a refuge, but it may also be a prison. I spent most of my childhood in silence to the daily abuse I survived. We humans are pretty resilient and we can make it through most adversities, but we carry that stress, the trauma and the memories in our conscious and subconscious being, maybe even epigenetically through generations?  Add the dynamic of pregnancy, hormone changes, physical challenges and life’s daily problems. Women in your care may have already turned to alcohol, drugs, eating disorders, self-harm, or some other self-medication, in order to get through each day, numbing themselves as a self preservation method.  Of course this puts their health and pregnancy at risk, and they need help.

What do you notice when you are “with woman”? Do you notice when someone else is constantly speaking instead of her, keeping her in silence? How about the quiet and shy type? Will she look into your eyes? Does she flynch or jump at sudden noise or movement? Does she “zone out”? Does she come across as passive, agitated, guarded or anxious beyond a typical level?  Do you have women that never come to an appointment alone?

If perinatal mental illnesses go untreated they can have a devastating impact on women and their families. In extreme cases, these illnesses can be life threatening – they are one of the leading causes of maternal death in the UK (3)

mage: http://www.freedigitalphotos.net

mage: http://www.freedigitalphotos.net

Silence is not always a sign of contentment. Try to make an extra effort to find out the reason behind the silence.

More than 1 in 10 women will be affected by a mental illness during pregnancy or after the birth of their baby (4). This means that each year in the UK more than 70,000 families will experience the impact of these illnesses. We midwives are growing in awareness and our aim is to facilitate women's ablitiy to speak up about their unique situations, decisions and personal needs. 

SHAME - is  'the painful feeling arising from the consciousness of something dishonorable, improper, ridiculous, etc., done by oneself or another'.  Brene Browne defines shame as the fear of disconnection, 'Is there something about me, that if people know it or see it, that I won’t be worthy of connection' 

Do you ever read beautiful birth stories online? Birth story surfing is turning into a competitive sport these days with words and images of joy, peaceful and pleasurable birth, fantastic photography capturing the moment, the idyllic and the organic.

But what about the woman who is afraid to birth? Maybe she can’t quite put it into words but she has an unexplainable fear of a breast or vaginal exam. The thought of breastfeeding and skin to skin could be a challenge that makes her feel like she is suffocating? Maybe her life has been a chaotic and confusing, relational and abusive mess, so the mere idea of such unpredictable, uncontollable events such as labour and birth could be horrifying. There is no rational explanation in her head and it’s not the easiest topic to bring up, especially with her own high expectations of “perfoming” and being the best mother she can be.

In her family, or in her culture, issues of sexuality, birthing, problems and relational difficulties may not  be addressed and she has no confidence, or no one she can trust to voice what she has been through, or what she is constantly living. Perhaps you will be the first person in her life to ask questions that dig a little deeper, and provide an opportunity for help, referral, counsel, and medication when needed. The more we work at listening and observing with all our senses, we can become more sensitive to the women we interact with. 

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After a lot of theory and learning for my midwifery study, the practical part came along. I was in great anticipation of putting all I had learned into practice. I was shocked by some of my responses. When I had to perform vaginal exams I felt horrible, as if I was abusing the woman. I went to my supervisors on several occasions in tears, and stated that I could not be a midwife because I did not want to do vaginal exams. It was a strong emotion beyond my cognitive mind. My supervisors encouraged me not to give up, and that was it, I pushed through, but I would really have prefered to skip that part. I have since learned to observe and to only do vaginal exams upon the woman’s own request or when the pattern of labour is unusual. Of course they are useful to diagnose an aynclytic baby, or a surprise breech etc. 

Courage brings connection, which defeats shame, so enabling a woman to #breakthesilence of her current, or history of, abuse, in her vulnerability, which in turn will also facilitate the crushing of shame, and light the flame of connection. Where there is no longer fear, love dwells.

Often women who have suppressed memories of childhood sexual abuse (CSA) will start to get flashbacks when they become sexually active, or during pregnancy, labour, or birth. For me the process of being a student midwife stimulated those subconcious memories into that present time, with flashbacks, intense feelings of shame, and an inherent impression that I was doing something wrong, or that I was not worthy to be a midwife. The truth was, I was doing nothing wrong, but the exposure to something new had triggered something hidden. It’s important that you find someone you can talk to if you are struggling with your own responses, or a situation in which you feel needs specialised attention and is beyond your scope of care that you can provide. I have always found that asking for help has been both a relief and a solution to my own struggles in my personal and professional development. I had to take time out at times, to deal with my own issues, so I did not carry them into my work, and to learn to be kind to myself, so I could give compassion to others.

Some women have suffered so much trauma that a vaginal birth is out of the question and an elective cesarean would be a kind and relieving option. Some women need to have specialised care, counseling and yet still be the decision makers for their own care. With the appointing of specialist mental health midwives, women will get the much needed support and counsel throughout the UK. 

We midwives give our best, our combined efforts, together with colleagues bring optimal care and support to women and their families. 

Speak – As I grew as a student or as a midwife my skills have been enhanced. There are study days, conferences, social media, and more, to glean knowledge. I have found that reading books, studying, workshops and team learning opportunities have given me insight and assisted me to grow.

Enhancing my communication skills through observation, reading, workshops, role play, listening, and reflecting have been vital instruments. Consider the language we bring to each conversation. Is it enabling a useful discussion? Is it creating fear or kindness? Women are exploring language and different methods as tools to undergo a gentler birth experience. We can support this by being flexible and giving choice and using alternative words as options. Examples of this are surges, instead of contraction, opening instead of dilation, not putting emphasis on a nuchal cord delaying progress, aiming for the positive rather than bringing a fearful approach. Our verbal language combined with body language and attitude, can make all the difference to how safe a woman in our care may feel.

Image:   canstocck.com

Image:  canstocck.com

The systems in place in hospitals across the UK have plenty of resources, and referrals to a community midwife, mental health midwife, consultant in mental health, community psychiatric services, depending on severity.

If a service is run in a way that enables a woman to see the same midwife at all or most of her appointments, she is more likely to feel able to disclose concerns about her mental health. However, evidence shows that too many women do not receive continuity of care, and that this makes it harder for women to discuss their mental health with a midwife. (5)

We midwives have the tools, skills and resources,  to speak words that enable the woman to be powerful and positive, no matter what their background or current cirmumstance.

Reclaiming something for yourself is an achievement. Overcoming seemingly impossible obstacles can be a daunting, yet not impossible task. Believe me, I’ve done it several times. A woman who has a phobia of needles (a possible effect from CSA, but not solely related) could have a positive experience by meeting a care provider who specialises in providing sensitive and specialised care. I have witnessed a woman completely at ease during a planned elective cesarean, yet previously terrified. After meeting and asking questions from a kind and experienced doctor to perform needed procedures involving needles, she was able to cope remarkably well and even surprised herself. A gentle approach involving the woman in the decision making can make all the difference.

Another woman voiced that she would prefer absolutely no vaginal exams in labour. It was easy to observe, in labour, that she was progressing well, no vaginal exam was done, she birthed in water and was clearly pleased with the birth experience afterwards.

I hear so many stories of women who had a traumatic birth the first time around. For their next birth, they were proactive to seek a different experience. Some choose a homebirth to avoid procedures that had caused stress in their previous birth. I have witnessed firsthand how women reclaiming their birth and their power, their decision making autonomy and their circumstances, go on to birth in a calm, loving and supported manner. What a beautiful way to enter parenting and what an imprint on the baby, begininning it’s life in perfect love, peace and a safe embrace.

We midwives  hold the potential to positively influence society by bringing compassion and kindness to the forefront of our practice.

References:

1. Price, S, Baird, K and Salmon, D (2007) Does routine antenatal enquiry lead to an increased rate of disclosure of domestic abuse? Royal College of Midwifes 

2. Granville, G and Bridge, S (2010) Summary of findings and recommendations from the independent evaluation. PATHway: An Independent Domestic Violence Advisory service at St Mary’s Maternity Hospital, Manchester. 

3. Saving Mother’s Lives: The Eighth Report of the confidential Enquiries into Maternal Deaths in the United Kingdom (2011) British Journal Obstetrics and Gynaecology. 

4. NICE (2007) Clinical Guideline 45, Antenatal and postnatal Mental Health. http://guidance.nice.org. uk/CG45

5. MMHA SMHMs Report P.6

 

 

 

 

 

 

To the NHS Maternity Review team: a message from a midwife

Photo: Midwiferyaction.org

Photo: Midwiferyaction.org

It's incredibly encouraging that those interested in the future of maternity services in England, are continuing to engage with the NHS Maternity Review team. I've been collecting views via social media for my blog, and have sent links to Baroness Julia Cumberlege, and received a positive response. Ideas and opinions are still being sent to me, and this one is from Dr Tracey Cooper, who is an inspirational consultant midwife at Lancashire Teaching Hospitals NHS Trust. I was delighted that Tracey took the time to write this; she has a wealth of midwifery knowledge and tirelessly and passionately supports evidence-based woman centred care. 

Tracey (pictured above):

'We are so lucky to have superb professors and academics in the midwifery profession. Some of them have joined a wide range of experts from other disciplines to produce the Lancet Midwifery Series (Renfrew et al 2014), which provides maternity services with an evidence based framework to base care on, now and in the future. This framework is for low, middle and high income countries, therefore it is an ideal tool to use in the UK.

The framework for quality maternal and newborn care

The framework for quality maternal and newborn care

The Lancet Midwifery Series is the most critical, wide-reaching examination of midwifery to date, and it includes a broad range of clinical, policy, and health system perspective (Renfrew et al 2014).

Within my own Trust we are going to use it to process benchmarking - where we are now and where we want our services to be in the future. We will use it as ‘our vision’ tool. As a group of north-west consultant midwives, we are also discussing it with Heads of Midwifery and the Strategic Clinical Network, to use as a vision tool across the whole of the north-west region. 

Key messages

- The findings support a system-level shift, from maternal and newborn care focused on identification and treatment of pathology, to a system of skilled care for all, with multidisciplinary teamwork and integration across hospital and community settings. 

- Midwifery is pivotal to this approachThe views and experiences of women themselves, and of their families and communities, are fundamental to the planning of health services.

- Midwifery is associated with more efficient use of resources and improved outcomes when provided by midwives. Midwives are only effective when integrated into the health system in the context of effective teamwork and referral mechanisms and sufficient resources.

- Promoting the health of babies through midwifery means supporting, respecting, and protecting the mother during the childbearing years through highest quality care; strengthening the mother’s capabilities is essential to longer term survival and wellbeing for the infant.

- Strengthening health systems, including building their workforce, makes the difference between success or reversal in maternal and newborn health. Since 1990, the 21 countries most successful in reducing maternal mortality rates—by at least 2·5% a year—have had substantial increases in facility-birthing, and many have done this by deploying midwives.

- Effective coverage of reproductive, maternal, and newborn health (RMNH) care requires three actions. These are:

  • facilitating women’s use of midwifery services
  • doing more to meet their needs and expectations
  • improving the quality of care they and their newborn infants receive.

- Evidence so far shows that midwifery care provided by midwives is cost-effective, affordable, and sustainable. Around the world the return on investment from the education and deployment of community-based midwives is similar to the cost per death averted for vaccination.

Quality improvements in RMNH care and increases in coverage are equally important for achieving better health outcomes for women and newborn infants. Investment in midwives, their work environment, education, regulation, and management can improve the quality of care in all countries.

Efforts to scale up QMNC should address systemic barriers to high-quality midwifery— eg, lack of understanding of midwifery is and what it can do, the low status of women, interprofessional rivalries, and unregulated commercialisation of childbirth

For more information see the Executive Summary

Reference:

Mary J Renfrew, Alison McFadden, Maria Helena Bastos, James Campbell, Andrew Amos Channon, Ngai Fen Cheung, Deborah Rachel Audebert Delage Silva, Soo Downe, Holly Powell Kennedy, Address Malata, Felicia McCormick, Laura Wick, Eugene Declercq (2014) Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care The Lancet , Volume 384 , Issue 9948 , 1129 - 1145

 

Dr Tracey Cooper can be found on Twitter

Is change is on the way? Place of birth

The National Maternity Review Team in England are working hard to gather evidence, opinion and visionary ideas for the future of maternity services. I have been invited to participate in two separate meetings, but am sadly unable to attend due to pre-booked holidays. I have lots to offer.

My action when participating in #MatExp #FlamingJune activity was to gather views of maternity services from willing individuals, by inviting them to write a post for my blog. Whilst it's now July, I am continuing with the action as contributions keep coming!   Please do get in touch if you want to have your say. I will send the link for the posts to the Team in good time.

So here is post 7. Natalie Meddings, mother, doula and active birth teacher, has a revelation. You can read about it below.

Natalie: 

Something astonishing has happened. Something that has caught me by surprise. A couple of weeks ago, while doing our usual how-are-you ? go-round in my  Active Birth Class, it hit me that more than half of the women in attendance were planning to have their babies at home. For the first time in the seven-year life of my yoga class, the MAJORITY were planning a homebirth.

It’s a microsample, it’s true. But 60% is 60%, especially when year in, year out, it’s been more like ten - one sole mother, keeping quiet in the corner in case her unconventional choice got challenged over tea.

Photo: Hannah 

Photo: Hannah 

Last week there was no self-silencing though. Neither was there any noticeable announcement. Quite the opposite, which is why I almost missed it.

As one after the other, they aired their plan to book a community midwife and see how things went, there was something ordinary about it - an almost casually-arrived-at agreement that this was common-sense, the most natural thing in the world to be in the most natural place in the world to give birth.

There were no faces made by those whose preference was hospital, or gasps of ‘you’re brave’.  Like many birthworkers, I’ve been spreading the female idea for years - why a safe and familiar space gives the female body full physiological chance of a straightforward labour . And suddenly here we were. Here we are, with that message starting to mean something.

To be fair, I think the ‘normal’ part of it had been helped by the group’s  avoidance of the word homebirth. Instead we’ve focussed on the all-options-open aspect to booking a community midwife - the in-built safety and control of having someone visit you in labour at home so that you can decide how you feel and what you want to do on the day.

Free of the homebirth heading, the idea was less loaded, less of a leap and as a result, an idea they could envisage.  Without a big, fixed plan, the women could more easily imagine themselves in such a situation, as well as the immersive benefits that setting offered biologically - deep privacy and quiet.

But there was something else behind this new turn too.  These women had heard lots of positive birth stories.

As recently even as three years ago, that wasn’t the case. A mother with a good birth story to share usually felt unable to. Pejoratively pigeonholed by the media as a ‘type’; silenced in NCT groups for fear she’d be crowing.  What could she to do but stay quiet?  Meaning that the stories pregnant women got to hear were overwhelmingly worrying ones - traumatic tales of long labours and apparently inevitable medical rescue.

But the word-of-mouth miracle that is social media has changed that. Instead of negative birth experiences installing fear and that fear going on to inform more negative experiences, the cycle is reversing. Women are now hearing lots of positive birth experiences, getting inspired and encouraged, and going on to have positive experiences too.

Support networks like my own tellmeagoodbirthstory.com and Milli Hill’s Positive Birth Movement  saw the super-powerful resource women could be for other women - and created an outlet for it.

Tellmeagoodbirthstory connects pregnant women with women who’ve had positive birth experiences by email; the now countless Positive Birth Groups around the country are a place where pregnant women can hear stories and share wisdom first hand. And from our kitchen tables, we keep the fire burning beneath it all with a busy and very buzzy presence on facebook and twitter.

‘I think about my birth every day of my life.’

‘At home, I understood what I had to do and the part I had to play – which was to let my body get on with it. It was much easier doing that at home, where I didn’t have to make any decisions to make or to think about anything else at all.’

 ‘In labour, there’s more rest than work – no one ever tells you that.’

These are the kind of comments women are hearing now – on their feeds, at groups, by connecting – so that it’s not so much the choosing to homebirth  that’s significant, but the increase in confidence.  Those women in my class being calm and in command of their experience.

Louise saying:  ‘I want to be able to listen to my body without distraction, to allow it do what it instinctively knows how to do.’   

Claire saying: ‘When I first found out I was pregnant a home birth was the last option on my mind. But having heard from other mums about labour, I’ve realised it’s being in the comfort of my own home, in my personal space that’s going to help me relax and let go.’

A few years ago, I questioned Mavis Kirkham, professor of midwifery at Sheffield Hallam University about the relationship between mothers and the maternity service.

‘The organisation of maternity services encourages women to take the attitude towards labour and birth that they would have towards a plane journey,’ she said.

‘Just as we buckle ourselves in and hope for the best on a flight, women are encouraged to do the same in labour. We feel there is nothing we can do to influence holding the plane up in the sky and so we switch off completely. Birth is a bit the same. Women can feel there is little they can do to affect the unfolding of the labour, that it is out of their hands, so they give responsibility to the pilot and trust they’ll get them to where they are going.’

But uninvolvement is on the wane. Women are starting to take charge, realising they can affect how their labour unfolds – and by listening to and learning from others, working out ways in which they can do that.

Self-assurance is growing from the ground up – and what the Maternity Services Review might consider are ways to foster that.

When tellmeagoodbirthstory first began, one hospital got in touch, interested in the difference a free mother-matching network might make to their birth outcomes. But they quickly grew hesitant when they realised they had no control over the information women were sharing. My local GP surgery was the same. When we asked to put up posters, the practice manager said: ‘how can we know what they are saying to each other?’

Though a degree of caution is understandable in a litigious society, paternalism like this misses a trick.  By trusting women, you engage women - they take part in and responsibility for their birth experience, and this in itself is a way to increase safety.

Mavis Kirham may have highlighted how disengaged the pregnant population has been in recent decades, but she is also the first to stress how easily reversible that is – through mother-to-mother education. Through community.

In particular, she has pointed to an estate in the north of England where a homebirth project was piloted. At first it was slow to take. But it only took a few mothers telling their neighbours what having a baby at home was like – and minds quickly opened. In no time, everyone was wanting one.

I think there’s a similar knock-on happening now. Slower to spread perhaps, but a chain of confidence nevertheless and this time the  community is country-wide.

Natalie Meddings

Natalie Meddings

 

Natalie Meddings is mother to Constance, 13, Pearl, 11 and Walter 9 and lives in London. Natalie trained as a doula with Michel Odent and Liliana Lammers in 2003 and has been supporting women in birth ever since. Natalie became an Active Birth yoga teacher around the same time and have been running classes in Barnes, South-West London since 2008. Natalie set up 'Tell Me a Good Birth Story' a few years ago and ran it voluntarily with the help of hundreds of lovely, amazingly generous mums nationwide.

Thank you so much for this post Natalie! I refer lots of women and families to your site, and frequently mention you at conferences. You are an inspiration - Sheena 

You can follow Natalie on Twitter 

What I want the National Maternity Review team to know: Hugo's Legacy

I 'met' Leigh via social media, over a year ago. We became connected due to our common interest in improving women's experience of childbirth. Leigh is passionate in her quest to maximise the potential for women to be listened to, for the language health care workers use to be sensitive and appropriate, and for open, respectful communication.  I am grateful to Leigh for her time writing this blog post as part of my #FlamingJune action for #MatExp, to inform the National Maternity Review team of important issues. I hope Leigh's words help to make a difference. 

Leigh:

The National Maternity Review is going to be assessing current maternity services, and consider how services across the country should change to meet the needs of women and babies.


My son Hugo was born in February 2014 when I was just 24 weeks’ pregnant because I had the rare, life-threatening pregnancy complications HELLP syndrome and preeclampsia. The day before Hugo’s birth, I had been transferred to a specialist hospital two hours away from my home. Hugo died in my arms aged 35 days.

I have written about my experiences extensively in other posts on my blog. To very briefly summarise, there is nothing I can fault in the clinical care either Hugo or I received. However, there were many issues surrounding communication that could have prevented further stress in an already heartbreaking situation.

adviceneonatal.png

Hugo’s Legacy is about helping other women who suffer birth trauma, other families with a baby in neonatal care, and parents who lose a baby. Anyone who experiences any of these things deserves compassionate care, and a streamlined system that enables people to get the support they need, rather than battle against it.

So this is what I would like the National Maternity Review to know:

That every woman is individual.

That evidence is vital in the context of providing safe care. But to recognise that evidence cannot tell you everything. Each woman, each situation needs to be considered according to its own merits.

Postnatal care – Hospital

That any new mother separated from her newborn baby for clinical reasons, as Hugo and I were, should be reunited as soon as it is clinically possible.

That no new mother should be left in an intensive care bed, her baby in the neonatal unit fighting for his life, feeling that she is the least important patient on that ward.

There should never be a delay due to interdepartmental squabbling about beds, and to which department the responsibility of taking the mother to see her baby belongs. (This happened to me in intensive care).

That postnatal wards need to have a greater awareness of the needs of mothers whose babies are being cared for in a neonatal unit. It is difficult enough for us being on a ward with women who have their babies with them. Please don’t delay us visiting the neonatal unit to see our babies because of a lack of coordination between maternity and neonatal about timing of rounds. Please don’t force us to make our own meal arrangements because the food that is provided sits getting cold on a tray next to our postnatal bed, while we are spending precious time with our baby.

Me and Hugo

Postnatal care – Community

That better consideration needs to be given to the postnatal care needs of mothers whose baby is in neonatal care, especially when the woman has been transferred to a specialist hospital away from home. The pathways need to be clear, sensible, and appropriate staff aware of them. For example, at first I was told I would need to make the four-hour round trip to see my own GP – impossible. Then I was told I would need to register with a local GP – challenging. Eventually I was able to see a community midwife at the hospital.)

Support for Birth Trauma and Bereavement

That no bereaved parent should return home with empty arms and feel cast adrift from the hospital. To have to find their own support. To have to make telephone call after telephone call explaining an illness they do not yet quite understand and have to say the ‘D’ word again and again. To feel like such a failure as a woman and as a mother. To have to relive everything that happened again and again because services in the 21st century seem not to find the capability to communicate with one another.

That there is support for women who have experienced birth trauma, and for bereaved parents, but people need to know about it – professionals need to know about it so they can direct parents accordingly. Let’s use some of that 21st century communication capability to close those circles, make those connections.

That when a woman makes a complaint about her care, (or feeds back about her care in any way) they are listened to respectfully. That they are made to feel like a human being with emotions with a response that includes words like ‘sorry’ where appropriate. That they do not receive a response that feels like a report to the trust board, a box ticked. That they are reassured learning has been made so no other woman has to suffer the same upsets, the same heartbreak, the same trauma. The same nightmares.

That Language Matters

No mother should ever be told by a panel of consultants their recommendation to ‘withdraw treatment’ for their child while that same panel of consultants stands, mouth agape as the mother lies crumpled on the floor, sobbing as though her heart has been ripped out of her chest. Which it has.

No mother should have to be told dismissively “all mothers feel guilty”, as if that is a salve on their pain.

No mother should have to read in a referral letter inaccuracies about the details of her son’s life and death, and for the GP who wrote it to phone her to apologise with the excuse that they did not read her notes because they were ‘too busy’.

No mother should be made to feel like she is abnormal because of what the trauma of her own life-threatening illness and grief over the death of her son has done to her mind. Instead, she should receive compassionate support to help her understand, and live with the trauma.

This is part of my story, a snapshot of my life and experiences since February 2014. There is nothing that can be done to undo what happened to me, or to Hugo. There is nothing that can be done to bring Hugo back.

But there are things that can be done to prevent other women suffering such unnecessary additional upset and torment.

That is why I would like the National Maternity Review to read, to listen, and to take account of my experiences.

In Hugo’s memory.

 

Contact Leigh via her website, or Twitter 

 

What one group of mothers feels the National Maternity Review Team should know

I am delighted to introduce Helen Calvert, mother, play-group leader and campaigner, who positively supports parents and maternity services. Helen's post is number 5 of my #FlamingJune action for #MatExp, to inform the National Maternity Review team of key issues, and she actively sought out the views of parents using social media.  Thank you Helen! 

 

For the last 3½ years I have been running a Facebook group for mums.  What began as a way of talking privately to my “mum” friends has turned into a group of over 1,500 mothers across the country. 

 A desire to share some of the birth stories from my group was what first drew me to #MatExp and I have since become more involved in the campaign.  As one of her ACTIONS for #FlamingJune Sheena Byrom is publishing a series of blog posts about what the National Maternity Review Team should know, and she asked me to contribute.

 Last week I asked the group “what woul