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 

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 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.

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 would you like the National Maternity Review Team to know so that they can improve maternity care for UK families?”  The group has no particular emphasis when it comes to birth plans or feeding choices – the only things we have in common are that we are mothers and we have Facebook accounts.

 What is important to us?  What makes a difference?

• Continuity of Care
• Individualised Care
• Presentation and Provision of Information
• Listening, Respect, Control
• Compassion and Communication
• Collaborative Working
• Postnatal Care
• Breastfeeding Support

 Continuity of Care

This theme was probably the strongest.  Women want to know the people who are delivering their babies, they are unhappy with having to explain their story over and over again and with receiving conflicting advice and opinions from a number of different birth professionals.  Group members talked about building relationships with their midwives, knowing the professionals helping them to give birth and getting to know a small team.  This is currently not the reality, with one mum commenting “I didn't recognise anyone at the birth”.  Some families are choosing homebirth precisely because the homebirth team available is a smaller team and it is more likely that they will know the community midwife who attends their labour.

 Continuity throughout pregnancy, birth and the postnatal period is what women are so keen to experience, but even continuity and consistency whilst in hospital would be a step forward.  One group member explained:

“I feel continuity is a major factor too!  I was on a lot of strong painkillers postnatally and every time there was a new shift they questioned why & wouldn't give them to me until they checked (I was in agony by the time they came around again crying in pain!). Then they’d realise a consultant had ok'd it. I felt like they didn't read notes well & looked at me like I was a druggy! So knowing your patient prior to seeing them could be a good one / better handovers?”

With birth being such a personal and individual experience, and with very few women feeling comfortable discussing their mental and gynaecological health with a stranger, continuity of care can only improve outcomes.  As one woman commented:

“Without continuity it's so hard to build a decent relationship with your midwife, and therefore it's just not easy to be open with them and they with you. I think it's vital for mums.”

 Individualised Care  

As a partner to continuity is the idea of care being provided with the individual in mind.  The current feeling is that there a “boxes” pregnant women are forced into, and once you are in a “box” your care is structured accordingly, with little thought to your individual circumstances, personality, fears and wishes.  An understanding of what is important to that particular family can make a huge difference to their maternity experience.

 “...the midwives there (Ashford Hospital) knew that I was gutted I'd not got my home birth and so they basically recreated a home birth atmosphere for us (dimmed lighting, blankets, left us alone together) it was an altogether lovely experience and didn't feel high risk at all.”

Individualised care is even more important when a family have been told that their baby is seriously ill:

“I didn't fit into any box with my first born due to his antenatally diagnosed exomphalos (and postnatally diagnosed diaphragmatic hernia). Antenatal classes were all relevant but I felt so aloof. Who is giving birth at x? Who is giving birth at y? If complications arise you'll go from x to y so if you want to have a look around y then book that in (then we were shown round hospital x). But poor old me couldn't put my hand up as I was being induced at hospital z. Also in the breastfeeding class, no consideration was given to breastfeeding a baby in NICU. I had to speak to them at the end. And they didn't know much. We didn't fit in. Maybe specific antenatal classes for people in our boat at specialist centres would be better than the ordinary ones?”

Presentation and Provision of Information

Mothers talked about having to seek out information for themselves, and having to ask “am I allowed...?”  Antenatal classes were discussed and it was suggested that they focus more on birth as a normal bodily function and how hormones and environment play their part.

One message that came through strongly was that families would like to be given their birth notes as standard.  It is so important that parents can understand what has happened to them and to their baby.  Finding out that baby was back-to-back, that you had a PPH, that there were complications that made physiological birth unlikely – all of this is important for women and surely it is their right to know these details?

“For me the one thing I'd like to see change is for everyone to be given the option of having a copy of their notes when they are discharged from hospital. In hindsight, I felt like a bit of a failure after the birth and I was so fearful of giving birth again. If I'd known more about what had actually happened I'd have realised that I did blooming well under the circumstances. It was only after support from others on this group that I pushed to get access to my notes and I finally gained a bit more confidence.”

Listening, Respect, Control

Many women discussed feeling as though the midwives had not listened to them – had dismissed their pain, had questioned their stage of labour, even questioning whether their waters had really broken or whether they had wet themselves.  These women felt patronised, belittled and ignored.  There were also examples of women's concerns being dismissed leading to serious health complications for them and their babies.  Feeling as though they are listened to and are in control of their own birth experiences is very important to women. 

“I know both my pregnancies and births were full of complications, but there were still opportunities that I feel were missed, that could have given me more control and allowed me to lead my labours more effectively.”

Compassion and Communication 

The experiences where compassion was lacking were, for me, the hardest to read.  The language used, the way that some women are spoken to, the way that some are treated – at this vulnerable and important time – never ceases to shock me. 

“When I threw up I got told off for not using the sick bowl which was in the bathroom. To clean it up she took the sheet from the bed and swirled it round with her foot and left it all on the floor.”

All women deserve compassion and understanding, but this is never more true than when a woman's notes include the information that she has been a victim of abuse

“The matron I had post-delivery was very damaging - especially as I've been abused and find physical contact difficult. She would literally pinch my nipple into my baby's mouth and leave me not caring when I said it hurt.”

When care HAS been compassionate and communication effective, this is what the family remembers.  Women spoke about their midwife putting them at their ease, being someone they could talk to about anything, being patient and giving hugs and reassurance.

 “I know it’s a day-to-day thing for midwives to see women in labour but it isn't a day-to-day experience being in labour.”

Collaborative Working

There was some discussion of how midwives and consultants work together, and how this can be improved.  Women want to see the knowledge of these two groups combined, rather than used as a tug of war between professions.  What is most concerning is those women who appear to be caught in the middle of professional disagreement:

“My midwife and consultant openly disagreed on my treatment, to the point where the midwife told me she didn't agree with him and he was wrong and she refused to carry out the treatment plan he had recorded on my notes.”

Postnatal Care

Very few women had poor experiences antenatally, but postnatal care is the area most cited as being problematic.  The lack of time that midwives have to help with feeding and to give advice, especially to first time mums who will be anxious about things the midwives might see as “minor”, e.g. how to cope with the cord stub whilst changing nappies.  Many mums felt abandoned postnatally – after all of the preparation for birth, classes and discussions, once baby arrived they were alone. 

Two issues came through strongly:

 ·       The problem of fathers and partners being sent home from postnatal wards

·       The handover between midwives and health visitors

 “On the first night of OUR baby being in the world he had to miss it coz he wasn't allowed to stay.”

“I was solely responsible for baby after going through labour and I needed his support.”

“The handover to health visitors needs to be much slower and more gradual. With my first, I felt I'd barely given birth before I was shunted over to some other service that I had barely heard of and certainly didn't understand. I didn't have any faith in myself and was in no condition to form a trusting relationship with some new random professional.”

Mental health was also discussed, with one mother explaining that the noise on the postnatal ward made it impossible for her to sleep, and this sleep deprivation coupled with anxiety led to postpartum psychosis.  “Someone should have noticed my deterioration and tears.”

Breastfeeding Support

As always, breastfeeding support was said to be lacking.  Families are sent home too soon without a full feed being observed, and are then often readmitted or switch to formula feeding due to weight loss, nipple pain or a lack of understanding of what are normal breastfeeding patterns.

“All I wanted was for someone to just stop and really talk to me and address the issues, someone who ACTUALLY knew what they were talking about in terms of breastfeeding, not someone who was just going to come in to try and patch over the issues and tick me off as job done.”

I hope that these views from a range of geographical areas and different types of women are of use to the National Maternity Review Team.  I hope that ordinary, extraordinary and everyday maternity experiences can help to change childbirth in the UK.

Helen Calvert 2015

Follow me on Twitter! @heartmummy

The power of two: what the national maternity team need to know....

Blog post number four of my 'What the national maternity review team needs to know' #MatExp action, gives us a sobering nudge. The national maternity review team are offered a perspective on how to reduce perinatal deaths. 

Victoria Morgan is currently on sabbatical, developing the 'Every Birth a Safe Birth' methodology. Here she reflects on the MBRRACE-UK Perinatal Deaths and the London Maternity Strategic Clinical Network conferences:  and asks if they shed light on a way forward for clinical quality improvement in maternity care. 

Perinatal deaths in the UK

The Perinatal Mortality Surveillance Report was recently published by MBRRACE-UK (which runs the Maternal, Newborn and Infant Clinical Outcome Review Programme).  At the launch event, hosted by the Royal College of Obstetricians & Gynaecologists, two key findings struck me.

Key finding 1:  the UK mortality rate for babies is 6 stillbirths and neonatal deaths per 1,000 births

“Between 2003 and 2013, the rate and the number of stillbirths and neonatal deaths fell in the UK.  The fall equates to more than 1,000 fewer deaths, despite the fact that the birth rate has risen by 12% in the same period.”

But is this good enough?  The report went on to say:  “If the UK could match mortality rates achieved in Sweden and Norway…the lives of at least 1,000 babies could be saved every year.”

Key finding 2:  local rates vary from 5.4 – 7.1 stillbirths and neonatal deaths per 1,000 births

This variation is not explained by differences in the poverty, ethnicity or age of the mother – the rates have been adjusted to account for that.

This variation is not the variation which is part of any process – the rates have been stabilised.

When reviewing statistics, it is tempting to say the variation is due to factors outside our control – the demography of the population or normal variation.  However, the MBRRACE-UK team has addressed this in their analysis.

A call to improve the quality of maternity care

The MBRRACE team called for trusts with rates that are 10% higher than the UK average to “review both their data quality and the care they provide”.  Trusts were encouraged to get an outside person to help them look at clinical practice by David Field, Professor of Neonatal Medicine and the Perinatal Programme co-lead for MBRRACE-UK, at the University of Leicester.

However, as no organisation had rates matching the lowest mortality rates in Europe – in the Nordic countries (Norway, Sweden, Denmark, Finland and Iceland) of 4.3 extended perinatal deaths per 1,000 births – Prof. Field encouraged all trusts to consider if they were happy with the present situation and whether they had a desire for further improvement.  He asked if we were willing to aim at the Nordic countries’ rates.

London Maternity Strategic Clinical Network

On the same day, the London Maternity Strategic Clinical Network of midwives, general managers, commissioners, GPs, obstetricians, service users and those from education and quality improvement organisations met to learn from one another’s experience about how to improve maternity care.

In 2013, two months after the Network was formed, the CQC maternity services survey results revealed 6 of the 13 worst performing trusts were in London.  Network members chose to believe that improvement was both desirable and possible and have set about making it happen.

User experience

Florence Wilcock, consultant obstetrician and Chair of the Network’s Maternity User Experience Sub Group, is a driving force in improving maternity user experience and has a very personal take on the difference to wellbeing that compassionate care makes to mothers (see her on YouTube).

The Whose Shoes? approach is one Florence champions.  Five trusts have held user experience Whose Shoes? workshops.  The workshops bring together a wide range of maternity service users and staff from all disciplines (including CEOs, heads of midwifery, obstetricians, support staff and parents).  The benefits of the workshops were broad:

• Spending time on reflection helped clinicians and service users understand one another’s perspectives; common themes emerged.
• It helped staff to bond after a recent merger.
• Gave added impetus to change underway.
• The format of hand held notes was reviewed to make them more user friendly for mothers and clinicians.
• A service was provided for women with a previous traumatic birth experience.

You can read more about Flo and Gill's work here! 

The power of two

So what if we could bring the two approaches together?

• The approach to data exemplified by the MBRRACE-UK report, sharing outcomes data in rate form, so that comparisons – in this case, between Clinical Commissioning Groups - can be made; and
• the approach to quality improvement of the London Maternity Strategic Clinical Network - the meeting of multi-disciplinary teams from discrete geographical areas to examine other approaches and implement change to improve quality.

The Northern New England Cardiovascular Disease Study Group are a case in point.  The group saw a 24% improvement in six hospitals’ mortality rates for coronary artery bypass surgery (Peck 2005).    Improvements came through 'examining other systems of care and questioning your own system' (Malenka and Connor, 1998).  In my next blog I shall look at the lessons learnt from this Group and how they might help us answer the question:  how can we improve the quality of maternity care?

Thank you Victoria....

Victoria morgan

You can find Victoria on Twitter @VictoriaRM6

Student perspective: moving evidence into practice

This is the third post in the series 'What the national maternity review team should know' blog posts, my action for #FlamingJune #MatExp.

Hannah Tizard is an exceptional student midwife, and has already made her mark by highlighting the importance of optimal cord clamping at birth, in response to research evidence. You can find Hannah on Twitter, and below read her insightful perspective. 

For the best part of thirty years evidence based medicine has been an important and expected part of midwifery practice and it provides a way of integrating clinical expertise with the best evidence from research. Government strategies (Midwifery 2020) and standards for ethics and practice (The Code, 2015) provide an underpinning framework. UK midwifery sits within the structure of the NHS which is of course bound by governance, hierarchical relationships, policy and guidelines. That is not to insinuate these things are bad, they are necessary and signify our responsibility to safe practice, however, they also often present one of the challenges to moving practice forward in line with evidence.  

Student context

As budding student midwives entering the world of midwifery we also enter the world of medicine, some of us for the first time. For me this is significant and whilst it represents a challenge it is also defines our commitment to provide care in a diverse and ever changing field of work, adapting practice to suit. In my opinion there is no room for complacency, we accept through practice we develop experience but that experience must never over shadow a requirement to continually develop skills and understanding. The way we are taught today will be different from those who enter the profession following us. Indeed that’s part of the appeal – new research innovates, illuminates understanding and highlights improvements for the future – it’s exciting!

As students we are fortunate in our position to be privy to this plethora of new research, we have access to well respected informed lecturers, university research clusters and expensive databases full of papers, some of which cement previous understanding while others challenge practice. We do take for granted the accessibility of knowledge, having the internet at our fingertips, flicking through threads on social media, stumbling across a new article that blows your mind. For us the ‘light bulb’ moments happen on a weekly basis! And we have a desire to share.

Emotion work

We are very privileged but equally bringing new research to the table can pose difficulties. In 2005 Billie Hunter wrote a paper about emotion work of midwives in hospital based settings, it emphasized the importance of colleague relationships in midwifery which provided feedback on individual practice, but also highlighted these relationships were often difficult to manage and a major source of emotion for midwives and students. Hunter (2005) found senior and junior midwives frequently held contradictory models of practice, resulting in competing claims for occupational authority and senior midwives attempted to maintain their position through unwritten rules and sanctions. We are now ten years on but I believe Hunter’s claims are still relevant today, differing paradigms of practice and professionalism create conflicts, cause barriers and are part of the maternity workplace, perhaps they will still be relevant 10 years from now, but I sincerely hope not.

Tenacity

Certainly, there is much going on in midwifery today which attempts to change culture, to give everyone a role, working together with service users and practitioners to promote communication and collaboration rather than foster unhealthy competition and barriers. It is always fantastic to hear about midwives and students helping to change routine, inspire each other and develop more efficient ways of working – social media is the best place to find these stories.

At a recent conference consultant midwife Tracey Cooper discussed her midwifery journey characterised by her determination to challenge boundaries to try to improve outcomes for women. Tracey has been confronted, her practice has at one time or another been scrutinised but Tracey says “using the evidence makes us strong”. I’m always impressed by her ability to use quiet questioning and her advice, which is, when unduly challenged ask politely for the statistics which are proposed to contradict your work, as often there aren’t any!

Effectiveness

Obviously all new research must be independently reviewed and extensively critiqued before being accepted into practice and institutional structures should operate efficiently to ensure the newest evidence is included into policy before it becomes out of date. Practice development midwives must also ensure evidence based guidelines are implemented effectively so health outcomes are achieved. Michie (2005) states a lack of theoretical understanding of the processes involved in changing the behaviour of healthcare professionals may be to blame when this fails. Midwives need to understand why new policies exist, be informed about the evidence and be able to translate that to the women we care for. It’s a complicated process.

Possibilities

Questioning our current delivery of care, day to day ingrained practices and interventions, some of which cause harm and are used without a sound evidence base is of the utmost importance and easily overlooked. Sheena Byrom explores the use of language in care, Amanda Burleigh has challenged the lack of evidence behind the practice of immediate cord clamping and its damaging effects, Denis Walsh proposed birth centre model and Sheila Kitzinger fought against the medicalisation of childbirth. These are just a handful of individuals who have shaped a profession, developed and enhanced women centred care and improved outcomes for women and babies. They listened, questioned and sought answers, they are importantly passionate about ensuring maternity care is protected and delivered with compassion. It only takes one enquiring mind and a little courage to set the wheels in motion, find those who will support you, collaborate and enjoy celebrating achievements, no matter how big or small.

As discussed by Mary Steen (2012) in her paper, teamwork and motivation make systems work and together we can make a difference, enjoying the adventure and having creative ideas and vision along the way helps - “the journey is the reward”.

References

Hunter, B. (2005). Emotion work and boundary maintenance in hospital-based midwifery. Midwifery,21(3), 253-266. doi:10.1016/j.midw.2004.12.007

Michie, S. (2005). Making psychological theory useful for implementing evidence based practice: a consensus approach. Quality And Safety In Health Care, 14(1), 26-33. doi:10.1136/qshc.2004.011155

Midwifery 2020 Delivering Expectations. (2010) (1st ed.)

Steen, M. (2012). Pushing boundaries and making it happen | RCM. Rcm.org.uk. Retrieved 16 June 2015

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

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

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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.

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 

What the national maternity review team should know: action for June

Baroness Julia Cumberlege

The news that a national review of maternity services in England was going to take place, led by Baroness Julia Cumberlege, was more than welcomed. The process is now underway, and information of the progress is filtering through, and more is eagerly awaited. 

I am hopeful for the future, given the growing body of evidence, data from surveys, national policy documents, and feedback from those who use and deliver maternity services. Being an avid user of social media, I am regularly in the centre of discussions about childbirth, and most importantly, I find myself reading blog posts of detailed stories and accounts of childbirth written usually by women who feel compelled to share their experiences. I also read about wonderful maternity care celebrated by staff working in nurturing environments, and other less positive revelations of over-worked demoralised maternity workers, usually midwives. I’ve written before about the ever-increasing opportunities of social media, and the virtuous circles that can emerge when childbearing women and their families, and all those involved in providing maternity services come together to enable change. But action is needed, and those members of the maternity review team, tasked with collating evidence and opinion, will be looking for ways to enable this to happen with efficiency.  There are processes in place for individuals and organisations to provide feedback to inform the review process, and the team are planning more ways of engaging with interested parties. 

So, in the month of June, I invited guest posts for my blog from individuals who felt they have information or ideas to offer the team. The first post was by the dynamic duo Gill Philips CEO of Whose Shoes?, and obstetrician Florence Wilcock, who together have developed an ever expanding and inclusive #MatExp dialogue via workshops and social media. Gill and Flo are working so hard to try to influence the way maternity care is delivered....here is a reflection of their first year! 

 

WHAT ARE FOLKS SAYING?

Then came the rest... one post by mother Michelle Quashie, who had a vaginal birth after Caesarean section, inspirational student midwife Hannah Tizzard's views of evidence and practice, Victoria Morgan, who is developing the 'Every Birth a Safe Birth' methodology,  Helen Calvert asked lots of mothers what there views were, mother and campaigner Leigh Kendall, who tragically lost her baby boy Hugo aged 35 days, and Natalie Meddings, doula, has given us an insight into her antenatal group choices for place of birth! 

If you would like to write a post too, please contact me here and I'll get back to you....

What the national maternity team should know: action for June #MatExp

The news that there was to be a national review of maternity services in England, led by Dame Julia Cumberledge, was more than welcomed. The process is now underway, and details of progress is filtering though.  So, in the month of June, I am inviting blog posts from individuals who feel they have information to offer the team. I hope this will be a helpful resource for all. Read here for more information.

To start us off, who better than the originators of #MatExp…a grassroots community established to maximise opportunity for improved maternity care. Gill Philips and Florence Wilcock started the campaign. Gill is the creator of Whose Shoes?, and a chapter author for our book, The Roar Behind the Silence: why kindness, compassion and respect matter in maternity care, and Florence Wilcock, is an obstetrician and clinical leader.  

Please welcome Florence and Gill...they wrote the post below!

Hi!

We would like to kick off Sheena's June blogging series with a strong call for the Maternity Review Team to engage with our fabulous #MatExp grassroots community. We need to build on all the amazing work that has been happening over recent months through this passionate inclusive group.

So what is #MatExp and how did it come about?  Well, Florence wrote about it here.  

AND

we made this short video when, due to the phenomenal grassroots energy it had inspired, #MatExp was included as a major campaign in NHS Change Day, 2015. 

Users of maternity services came forward not only to join the various actions but to initiate and lead them themselves. You can check out the actions here but they cover everything from appropriate language, postnatal support, best practice and experiential learning – including many male obstetricians spending time in the lithotomy position!

Florence is a passionate obstetrician and clinical leader, who was asked by the London Strategic Clinical Network to find ways to improve maternity experience in response to a poor CQC report identifying that six of the seven worst trusts in the country for maternity experience were in London. Florence approached me, Gill, the creator of Whose Shoes?,  to co-produce some challenging Whose Shoes? maternity scenarios and run a series of workshops, getting users and professionals and all other interested parties – NCT, MSLCs, everyone! - to work together as equals and come up with imaginative solutions. 

With support from NHS England, five very successful and fully subscribed workshops were held across London.

 Queen’s Hospital session in action

The combination of the face-to-face workshops and the social media network have been extraordinary, with lots of overlaps. For example Helen Calvert and Leigh Kendall, two of the mums now helping lead the campaign, came down to London to join the workshops and they also contributed to the #MatExp NHS 6Cs webinar.

The Whose Shoes? Workshops, supported by a full leadership and facilitation toolkit kit developed in partnership with the London SCN and NHS, are now planned at other London hospitals and spreading to other parts of the UK, including a session in Guernsey at the end of June. There is a lot of cross-fertilisation of ideas between localities and between hospitals, with a strong emphasis on building relationships and collaborations. Each workshop culminates in pledges and a local action plan, formulated by the people at the workshop and encapsulated in a powerful graphic record. Inevitably the themes are similar between the different sessions but with a strong local emphasis and most importantly local ownership, energy and leadership.

It would be easy for the NHS Change Day campaigns to lose momentum after the big day itself, (11 March 2015). #MatExp has done the opposite, continuing to build and bring in new people and actions. #MatExp #now has 110 million Twitter impressions. We have just finished the '#MatExp daily alphabet', a brilliantly simple idea to get people posting each day key issues related to the relevant letter of the alphabet. This has directly led into the month of action starting today....see below. 

Mother Helen Calvert set up and ran a survey of health care professionals. She had 150 responses within about 10 days and analysed and reported the results – an extraordinary contribution.

We have a vibrant Facebook group (please apply to join) and the brand new website, set up by the #MatExp team of mums who are incredibly focused, working long hours - all as volunteers. We are all absolutely determined to keep working together to improve maternity experience for women everywhere. In the month of June we are calling for ACTION, starting TODAY on 1st June, and we have lots planned-including Sheena hosting this series of informative blog posts...

Come and join us!

Gill Phillips and Florence Wilcock

The dark side of Social Media

It’s been a long time since I have felt so distressed about work related issues. The bleakest moments are known by so many, as they are detailed in Catching Babies. And I’m not an apprentice when it comes to being in the media spotlight in a negative way, indeed I wrote about it for the March edition of Essentially MIDIRS.

Lots of you will know that I am also an advocate for social media and the amazing benefits it brings, I regularly give talks on the subject and have written about it extensively.  During the sessions and in my written work, I always mention the ‘dark side’, when social media has a negative impact, and how it's important to protect yourself. There is an abundance of clear guidance  to help with this.

But nothing prepared me for the events recently, and I am still processing the effects it has had on me personally. I won’t be mentioning any names. Firstly, I don’t want to draw attention to individuals who make it their life’s work to damage the lives of others. Secondly, I am clear about my professional boundaries, and personal integrity. But for those who continue to intimidate, harass and bully individuals and professional groups, and to undermine evidenced based models of maternity care, I have one message.

I have wobbled, but your actions have made me stronger.   

Postscript:

After writing this post, my supportive and inspirational friend @JennyTheM sent me this. What more can I say?

Another attack - when will it stop?

6th November 2015

Those of you who know me won't need to hear this. But for those who don't, please let me tell you that I've never bullied anyone in my life, let alone bereaved parents. I don't know what pleasure individuals get from being slanderous and cruel to others - it's beyond me. I suppose it's fuelled by the same emotions and hatred that starts wars.

Ignoring libellous allegations is all I can do, but I am saddened and perplexed how my name can be used maliciously with no recourse. It seems unjust, but I will not respond. I will not succumb to negative exploits with more anger, instead I will show compassion - which is more than the pity I feel. That's not to say I don't suffer in my silence. 

I am privileged that my career has been totally dedicated to serving others, and for many years when working in the NHS, my role was focused on those in need, bereaved, or traumatised. I retired from my employed midwifery position with the NHS in 2010, to study, travel and to help with my grandchildren.  Because of an incessant drive and passion to improve maternity services, based on decades of experience, I continue to work mostly voluntarily, supporting and encouraging maternity care workers, and parents.  I gift my time and energy to others, and I love it. 

Nadia and Paul tragically lost their beautiful baby son Ellis, when he was stillborn. Nadia sent me this, earlier this week.

Compassion, love, kindness and respect are the foundations of life. 

May, 2017.

She's done it again. Why does anyone have so much hate of someone they don't know at all, enough to spend time writing lies and vitriol? It is bizarre. This time I have declared the attack on my Facebook wall, and I've been absolutely overwhelmed with positive comments, support, and love. 

So of course I won't respond, there's no point.

I will continue to spread the sunshine. 

Neighbourhood Midwives' Mothers Fund: guest post by Annie Francis

I first met Annie Francis many years ago....and realised almost immediately that she was a woman of incredible substance: a wonderful midwife who was passionate about her work, about childbearing women having the best care possible, and who was willing to stand up for what she believed in. Since then, Annie and I have shared the same spaces, striving to maximise opportunities for all women to have a positive birth experience. Recently Annie invited me to become part of her exciting new venture, and of course I accepted. What an honour. I asked Annie if she would write a guest post for my blog, explaining more about this exciting news, and to tell us a little more about  and her plans for the future. 

Hi Annie! Thank you so much for agreeing to write this post, when I know how incredibly busy you are. Can you tell me a little bit more about Neighbourhood Midwives (NM), and about the new Mother's Fund? 

Annie Francis CEO Neihbourhood midwives

'Hi Sheena....I'll try! I've never done this before, so here goes....

Here at NM we have a simple organisational purpose:….to become an exemplar of a way of delivering midwifery care.

For every decision we make and every action we undertake we ask the question… does this serve our purpose? It is an incredibly powerful way of ensuring that we remain focused on our goal, but also helps when discussing difficult issues - it’s easier to have honest and open conversations when you can keep the shared vision in mind. This week has seen the four of us - all midwives ourselves - who set up Neighbourhood Midwives make a real and significant shift in our understanding of the practical ‘how’ we try and make our purpose and our vision a lived reality.

It has come about through our reading of a book – ‘Reinventing Organisations’ by Frederic Laloux and the case study of Buurtzorg, (which means neighbourhood care), a self managing, Dutch nursing organisation based in the community. Everything we have read about Buurtzorg has chimed with what we are trying to achieve with NM and so, as advocates of active learning, we wasted no time in getting in touch with Jos de Blok the founder, to see if we could go over to meet him and the result is a ferry booked and a trip planned for mid April…'

This sounds really interesting! I am in Holland at the moment, and will make some enquiries. Annie, what would you say to those who suggest that NM is another example of the privatisation of the NHS?

'Firstly, it is important to remember that the NHS has always used private contractors. GPs, dentists,  pharmacists and opticians are almost all privately owned. There have always been private providers of various services in mental health. The private sector is involved  throughout the NHS providing IT systems, drugs, buildings etc. Most Foundation Trusts use the income from private services to subsidise their NHS work so it is a much more complex picture than is often portrayed.

One anxiety often expressed is about private profit going to the shareholders but as an employee owned, social enterprise, any surplus made within Neighbourhood  Midwives will not be siphoned off as dividends for external shareholders, but reinvested into the organisation to improve our service and the welfare of our employees. Our constitution has been written to reflect this position and, should we ever be faced with a hostile takeover, we also have it written into our Articles that any profit from that forced sale would go to a suitable women's charity, not to any individual.

As independent businesses, GPs have a contract with the NHS to supply their services  - we would be no different and would be paid the current tarrif for maternity care, no more and no less - just as any other provider giving care under the NHS banner. 

The third sector - social enterprises, co-operatives and charities have always had an important role in providing services to the NHS and there are some important benefits attached - smaller, lean and flexible they can more easily target 'hard to reach' groups and can in fact often provide care much more effectively and efficiently than a large and unwieldy bureaucratised system.  They have an important role in increasing choice for women/ patients and breaking up the monopoly which can lead to lack of innovation and complacency on the part of the sole provider.

With the correct safeguards in place, my belief is that increased third sector involvement from small, community based providers such as NM can only be a good thing and, with the emphasis on improving outcomes as well as needing to save money, it is time to give us the opportunity to demonstrate what we can do'. 

Thanks for clarifying. Would you like to tell us a little about your new initiative?

'Yes! Last week we had the first meeting of the fabulous trustees of our new charity – the Neighbourhood Midwives’ Mothers Fund. The reason we have taken the decision to start a charity is simple, it helps us meet our purpose. Having successfully launched our private service in July 2013 we have been busy building our track record as the first step towards being ultimately commissioned by the NHS. We know that isn’t going to happen overnight though and, through the Maternal Health Alliance’ campaign, Everyones’ Business, we are increasingly aware of the critical lack of perinatal mental health provision in the UK.  

Even where this service is provided, the reality is that most areas are unable to offer it through a caseloading and continuity of midwife model. As a social enterprise, always looking to fulfil our social aims and knowing that there is considerable evidence that this type of care can make the difference for women struggling with such issues, we have come up with an additional step along the road to our first NHS contract – to register as a charity, called the Neighbourhood Midwives’ Mothers Fund.

We envisage that it will work in a similar way to the Macmillan & Marie Curie model but with a dedicated midwife providing individualised, holistic midwifery care for each woman referred, who can also act as her advocate and co-ordinate her care with the appropriate NHS/multi-disciplinary teams according to individual need… We are really excited by the possibilities and now we get to have lots of fun doing the fundraising!

So far we have three Trustees, selected for their expertise and dedication to to the cause. These are Cathy Stoddart, Emma Mortoo, and you Sheena!' 

Thank you again Annie, what a privilege this is for me. I'm excited to get going now, and to help you to support families most in need. For me, I think this could be a blueprint for other areas, and a catalyst for change for the whole country and beyond. 

Lastly Annie,  I believe you have been selected to be part of the national maternity review team, brought together by NHS England! 

'Yes, I was delighted and honoured to received an invitation to be on the panel. We were already aware that the Five Year Forward View has some very helpful comments about future models of care in maternity:

'To ensure maternity services develop in a safe, responsive and efficient manner, in addition to other actions underway – including increasing midwife numbers - we will:

·       Commission a review of future models for maternity units, to report by next summer, which will make recommendations on how best to sustain and develop maternity units across the NHS. 

·        Ensure that tariff-based NHS funding supports the choices women make, rather than constraining them.

·       As a result, make it easier for groups of midwives to set up their own NHS-funded midwifery service.  

And so, with the indefatigible Baroness Cumberlege at the helm, I’m really looking forward to contributing my thoughts, knowledge and experience to help make this review a genuine opportunity to explore some new options and different ways of working… the evidence is out there, we just need to be prepared to think outside of the box and, in the words of Goethe:

‘Knowing is not enough; we must apply. Willing is not enough; we must do’

I am delighted that you are part of the panel Annie, and I know my friends and colleagues are too. We want this review to be the lever for change to enable improvements in the way we deliver maternity services in England, and beyond. Please let us know how we can help you! 

There are several ways to connect with Annie, and Neighbourhood Midwives:

Website: neighbourhoodmidwives.org.uk

Twitter:  @neighbourhoodmw

Facebook: www.facebook.com/nbrhoodmidwives

Part of the tipping point: a time to ROAR

Reflecting on the roar....Torquay, Australia

What a month February 2015 has been so far.  We are in Australia on an extended holiday, and as well as enjoying the positive culture and bright skies, I’ve been lucky enough to be part of so many inspiring maternity related conversations, twitter chats, initiatives and book publications. The ‘Tipping Point’ in maternity services, that I often talk about, is ever closer.

From the other side of the world I am excited and encouraged to see the connection of so many like-minded individuals in the UK, ‘meeting’ on Twitter, helping to improve the maternity experience for women and families in England. Initiated by the wonderful Kath Evans, head of patient experience for NHS England,  Gill Phillips, founder of 'Whose Shoes' is working closely with midwives, obstetricians, policy makers, parent organisations, academics and most importantly those using maternity services, to find out what really makes a difference to those using maternity services. Florence Wilcock, #FabObs obstetrician and divisional director at Kingston Hospitals in London, and a member of the London Maternity Strategic Clinical Leadership Group, is helping to lead this much needed initiative. You can read about, follow, and get involved on Twitter here #MatExp. The project is gaining momentum and beginning to influence services in London, and the fact that social media is being used to spread the word, to engage and to influence is adding to the success. It means the potential for exclusion is reduced, and collaboration increased. I can’t wait to get involved in person when I return to England.

I’ve also been privileged to review two fabulous books. The first is Milli Hill’s inspiring book 'Waterbirth: stories to inspire and inform' which is a collection of personal accounts of waterbirth, by mothers, fathers, siblings and maternity care workers and you can read my thoughts about the book here.

I finished reading the review copy of Rebecca Schiller’s new book ‘All That Matters: Women’s Rights in Childbirth’ yesterday, and I was rocked. This superbly crafted and revealing book, written for the Guardian, is a ‘must-read’ for all those providing maternity care, and if we really aim to tip the balance, policy makers, parents to be, teenagers, in fact each member of society would do well to read and act on Rebecca’s words.  Rebecca is a mother of two young children, a writer, doula and birth activist, and she begins by making it clear that her book is about women, yet acknowledges those who support her during childbirth. She also clarifies early on that her book, whilst highlighting many appalling situations around the world, suggests that the problems are usually systemic and cultural, and not the fault of individual practitioners.

As well as detailing the horrors of reality that women experience in  several countries, All That Matters is full of insightful conclusions, which gave me assurance that Rebecca really understands personally and politically, what is happening around childbirth practices globally, and what needs to be done. There are examples of excellence too, where organisations and countries have responded to potentially damaging reproductive care practices and are providing positive approaches to supporting women around conception, pregnancy and childbirth. Connecting ‘childbirth’ as a reflection of societal attitudes, and feminism, really resonated with me…

'As a mirror to society, childbirth, the attitudes to it, practices around it and experiences of women going through it, reflect the progress that has been made in advancing women’s rights'

I could carry on here explaining why you should buy and read All That Matters. I could fill two pages or more. However Maddie Mahon, doula extraordinaire, has written an excellent review of the book here, which represents my opinion and reflections too. Rebecca Schiller’s book is more than timely. It is being released just shortly before our book, The Roar Behind the Silence: why kindness, compassion and respect matter in maternity care.

Screen Shot 2015-01-23 at 15.58.27

This is incredible, as collectively these books hold the potential to inform and influence the ‘tipping point’ by adding to the evidence already available that improving maternity care and respecting women’s rights enhances societal wellbeing.

Claire with baby, and Lynda her midwife and friend

And finally, I want to share this beautiful photograph of Claire having skin to skin with her newborn baby, and her midwife, Lynda Drummond. I worked with Lynda many years ago, and also supported her after a traumatic birth experience. I saw this photo on Facebook, and contacted Claire to ask if I could use it. This is what Claire said:

‘I'm so glad you like this photo, I really do. Through each of my 3 births my midwife has seemed like my angel and I'll never forget the roles that they each played. Although Lynda was at my 3rd birth as a friend to me, she was the one who helped me get the birth I had always wanted, having her there gave me the confidence I needed to believe I could do it, she had me laughing and dancing throughout the labour, she managed to persuade the midwives on duty that I could go in the pool even though my first birth was an emergency section . This photo to me sums up how utterly amazing she is, gentle, caring, supporting, angelic. I hope she knows it.

I've also included a photo of me at 7cm dilated, the big cheesy grin is totally drug free and totally genuine. All down to Ina May and Lynda Drummond......... oh and the cheesy radio station playing Valentines day songs, I think Rod Stuart ‘If you think I'm sexy’ had just been on!’

Claire Riding

With our book in mind, I look at Claire’s birth photo and description of her midwife, and I sense the Roar Behind the Silence.

Men, Love & Birth: 'being present'

This book, Men, Love & Birth is out this Spring, and is eagerly awaited by many of us! Here I've actually interviewed the author-midwife extraordinaire, Mark Harris! Hope you enjoy it...please leave comments for Mark at the end of the post...

Hi Mark! We’ve never met in real life; I’ve only read about you, and your brilliant reputation as a midwife and speaker. We've connected via Twitter, and when you told me that you were writing a book, I was delighted for you. What a privilege to interview you for my blog site...thanks for agreeing! And this is the first time I've used audio, so I really welcome your input-let's see!

[These are the questions I proposed to Mark, and he recorded himself answering them...see the clip below]

Can you introduce yourself, and tell us about what you do?

I know that you are a father and grandfather. Does this influence your work at all?

Denis Walsh once told me that after he studied feminism, he change his opinion slightly on male midwives. What are your thoughts on male midwifery? It would be great to have your perspective.

Do you feel that fathers engage with you differently, being the same sex? Also, during your work, do you get any feedback from how dads about their experiences of the birth of their baby?

Mark, what are your thoughts about the publication of the new NICE intrapartum care guidance, in relation to recommendations on place of birth?

What are the three highlights of your health service career Mark ?

I know that you are currently writing a book, and that it’s due to be published early next year! Wow. How exciting. Can you tell us a little bit about it? 

http://youtu.be/R04alDJ9fao

And lastly, if you could change one thing, anything, in maternity services, what would it be?

'If I could change one thing is maternity service I'd want the ratio of midwives to match the population of women giving birth to be one to one.

The role of 'being with' women as support of and pointer to her inner power to birth amazingly takes attention and 'un rushed' time, waiting, watching connecting to the emerging family she is being privileged to meet.

It's very challenging to offer this type of care to more than one woman at a time, regardless of how complex or not their needs area....'

Wow. Thank you so much Mark for the insight into your thoughts on your career, midwifery, 'being present', men and birth, and feminism! I feel like I know you already, and so look forward to meeting you this year.

Good luck with your book!

You can follow Mark on Twitter @Birthing4Blokes

Feeling the power & tasting the satisfaction: a circle full of water

In the early 1990’s I was lucky enough to be a community midwife, supporting women to have home births. When one of the women I was caring for, Helen, told me she was planning a water birth at home, I was both excited and fearful. You see I had never seen a waterbirth, let alone facilitate one, and so off I went to speak to my supervisor of midwives. With support and adequate education I felt more confident when Helen went into labour, and with a trusted colleague I helped as Helen’s baby was born calmly into warm water, in the candle lit living room of his parent’s home. This photograph was taken sometime after the birth, after I checked to see if any stitches were needed! Happy, happy, memories for all of us….

Several years later when I was working in the same organisation, but in the obstetric unit as a senior midwife, I became aware of midwives feeling unable to facilitate water birth on the main delivery suite, as the pool was being used for storage! In addition to that, one particular midwife who didn’t approve of this mode of birth, was creating barriers for other midwives to use the pool, which was causing distress. After giving them support, several enthusiastic and passionate midwives (Joanne and Katriona leading) went on to develop their skills in the use of water for labour and birth, organising study days and developing flexible guidance. There was significant change after this, and water became an option for labouring women using our service. Today, women using East Lancashire Hospitals maternity service have 9 water-pools to choose from, women are actively encouraged to use them, and the water birth rate is 15% in the overall service, and 40% in birth centres!

So why I am telling you all this? Well, last year the fabulous Milli Hill put out a call for waterbirth stories, via social media channels. Milli was editing a book, and wanted positive experiences of waterbirth to be shared to help and inspire others. I contacted staff at the same maternity unit mentioned above, and shared the request with local mothers too, via our Facebook page. Two individuals responded, and I have mentioned them below!

I’m in Australia at the moment, and after the exciting and much awaited publication of Milli’s book ‘Waterbirth: stories to inspire and inform’ this month, Milli offered to send me a copy to review! I read the book from cover to cover in a couple of hours, and I loved it. Apart from feeling totally in awe of the women who shared their positive tales, I learnt lots.

This title of this blog post Feeling the power & tasting the satisfaction: a circle full of water is taken from Milli's introductory chapter and epilogue, and the last sentence of ‘Lisa's story’ (Lisa Hassan Scott page 25). This book gripped me from the beginning; it is full of stories of the power of birthing women, of personal emotions, and of relationships between birth partners, parents, and health professionals.

After a short but revealing and well written introduction to the book, Milli tells two of her own birth stories. This helps to put the reader in the picture from the beginning, and brings perspective as to why Milli decided to produce the book. It’s the first time we read the word ROAR, music to my ears, and used several times in other birth stories too!

I loved the inspiring quotes at beginning of each chapter…I’ll definitely use them in my work.

The stories are varied, from around the world, and include accounts of personal water births from researchers, siblings, doctors, stay home mums, dads, midwives, birth activists, and doulas. Some of the births were in hospital or birth centres, and some at home. Midwives who featured in the stories included those that are independent (private) and others working for the NHS, and whilst some mothers experienced barriers to their choices from staff, most stories are complementary of the empowering approach of their care-givers. Confirming my own experience and knowledge, it was the attitude of maternity care staff that seemed to have the greatest impact on a positive birth experience. An example of this was when a mother had a breech vaginal birth after a previous Caesarean section (VBAC) at home, and after her baby had been born the emergency services were called, and both mother and baby were transferred to hospital. Jenn found the whole experience enormously empowering and positive... and excited to do it again (Page 61)! It seems from her words that the way Jenn was treated, and her choices facilitated, that made the difference.

Many mothers used the term 'sacred space' to describe the protective element of the birth pool. I found this enlightening as I had only thought about the other more commonly described benefits that water brings to a laboring women; ability to move, warmth, natural element, pain relief, and body weight disappearing. These too were highlighted by the authors of the chapters, but the circular structure of the pool, and being almost ‘untouchable’ to others seemed to have an impact on reducing fear. Some of the stories included accounts of a previous traumatic birth, and the space and structure of the pool seemed to give them the power to have the birth they wanted second or third time round.

Some of the mothers used hypnosis in addition to the water, and one used the shower instead of a pool, and another a standard bath, which worked perfectly for them. I read stories of breech water birth, twin water birth, and water birth after three previous Caesarean sections. Another interesting observation I made was that several of the babies where born in their ‘caul’, which means the membrane sac around the baby in utero was still intact and protecting the baby throughout the birth process. A sure sign of minimal intervention.

For me, there was personal satisfaction and humble pride in holding this book in my hands, and reading the two stories from our local maternity service, where I used to work. Both babies had been born in Blackburn Birth Centre, an establishment I helped to develop in 209-2010. One of the mothers, Rachel Barber, mentioned the fact that a student doctor had been present. Now isn’t that the way forward?

Whilst all the stories are inspiring and reassuring, Diane Garland's lovely account of a mother getting in the water-pool with her young frightened daughter made my heart sing. However, Diane was baffled when the young mum texted and Facebook-ed her friends following the birth, and states that she doesn’t understand ‘young people’s fascination with social media!’

I would like to tell Diane I’m not that young!

So Milli, thank you so much for editing this amazing little book. I will be recommending it to all my friends, colleagues, pregnant family members, student midwives (a MUST read), midwives and doctors. What a gem. I hope it becomes part of the suggested toolkit for women and their partners to believe in birth as a natural social event, instead of a medical illness. Bravo!

Follow @waterbirthbook on Twitter!

Reflecting on 2014, and the social media party....

Sat in the sun today, on the last day of 2014 feels wonderful...the Australian climate, especially here in Victoria, is comforting. I'm thinking constantly about and missing my family in UK and Europe, where the snow is falling or the frost biting...especially because it's the festive season. And in a few days we will see our son Tom for first time in 2 years, now that's something to be excited about!

It's been an incredibly interesting year.

We've travelled lots, spent precious time with our family and friends (although sometimes not enough), and met so many new lovely folks. The thing that's really helped me to stay in touch, connect and re-connect, is social media. I can't believe the power it has to bring people together, support, offer opportunites....

Here are some of the highlights:

At the beginning of 2014 my midwife daughter Anna Byrom and I wrote an article about social media for MIDIRS...you can access it here. It was our first article together, and quite symbolic. The article highlights all the benefits of using social media, and some of the pitfalls...and includes this diagram of myths and fears of social media, and offers some solutions, so I won't repeat these here!

After being invited to help with the social media activity at the ICM Congress in Prague in June, I encouraged midwives to join Twitter and become Twitter Buddies to help others to benefit from the enormous benefits it brings. We had 115 midwives, future midwives, doulas, obstetricians joining in from around the world...and from that others were encouraged too. One of those midwives, Deidre Munro, has become quite a phenomena in the tweeting midwifery world...she established the #globalvillagemidwives concept which is gaining momentum by supporting student midwives and midwives, and increasing social capital. And Deirdre keeps us all updated on the latest evidence on maternity matters which is invaluable #EBP.

I have been privileged to help the wonderful charity Best Beginnings with their amazing new Baby Buddy App, by testing it and disseminating the benefits .

Our new book, The Roar Behind the Silence is due to be published in February. Edited by Soo Downe and I, the book explores why kindness, compassion and respect matter in maternity care, and has over 20 chapter authors from around the world. Because of social media, I found and connected with potential contributors-mothers, midwives, doulas and doctors all wanting to help us to try to make a difference. Some of these remarkable individuals are already know in the maternity world, and others are breaking through the 'silence' and have written words of inspiration to highlight issues, support others, and provide ideas for change. I've yet to meet some of them, and I hope 2015 brings us together! We've already been invited to give talks about the book at various events, which is what we hoped for. We really would like the book to be used as a resource for supporting positive change in maternity care. Here's short excerpt from the final chapter....

I have been joined by two fabulous midwives in running WeMidwives, which has been an enormous help. The wonderful Jenny Clarke, known fondly by all as @JennyTheM is our Skin to Skin specialist, and our lovely Caremaker midwife Dawn Stone @HelloMyNameIsDawn  and I are now a team!  @WeMidwives has an ever increasing membership, and helps to positively support student midwives, midwives and all interested or working in maternity care.

Student midwives are our future...and they are certainly making an impact. There is an incredible increase in the number of Midwifery Societies lead by students, and they are unstoppable. Instead of worrying or complaining about the cost of high profile conferences, they organise their own study days...inviting the same speakers from the events they cannot afford to attend. How brilliant is that? I've been privileged to attend many of the days, and have witnessed the passion, determination and courage of our future profession.

Because of Twitter, and meeting the wonderful @KathEvans2, I am helping NHS England to support maternity care workers to provide the best maternity care they can, through learning and sharing good practice. I participated in some filming about the importance of communication; a topic close to my heart.

As an Iolanthe Midwifery Trust trustee, I've set up their first Twitter account @IolantheMidwife. This has been an exciting step forward, and it's so encouraging to see the interactions between student midwife and midwife award winners. Long may it continue.... And lastly, there's my blog...what a privilege to interview Soo Downe, Hannah Dahlen, Toni and Alex from One World Birth, Petra ten Hoope-Bender, Alison Baum CEO of Best Beginnings...quite something! Yesterday I received a report on my blog...here's an excerpt:

The concert hall at the Sydney Opera House holds 2,700 people. This blog was viewed about 47,000 times in 2014. If it were a concert at Sydney Opera House, it would take about 17 sold-out performances for that many people to see it.

Click here to see the complete report.

I love writing my blog...and follow many other blogs too. Do YOU write a blog? Do you have any favourite blogs relating to maternity services to recommend? Please let me know in the comments section below, as I'm planning to publish a list....

So now it's time to plan for 2015

Will you be joining the party on Twitter?

The mother, the midwife and litigation: coming full circle

Professor Soo Downe OBE:

The first time the story below was told, it was as a dramatic performance to the third international UK normal birth research conference in 2006. My intention in asking Kate and Sheena to do this was to highlight the fact that doing normal, out of hospital childbirth may end up exposing mother and midwife to litigation, because this choice is not seen as the standard, ‘safest’ option, despite evidence to the contrary. I was particularly keen for midwives to recognise the need to be courageous in facing this possible outcome. The argument was that facing our fear of litigation may reduce the risk of defensive practice: once the worst has been faced and accepted, there is nothing more to fear.

Kate’s part of the story illustrates the fact that, often, women are caught up in litigation in a way that can be as damaging as the original trauma suffered in unexpectedly pathological childbirth. No-one is a winner in this circumstance. Sheena and Kate show in stark and clear-sighted detail what this experience feels like, and how it is possible to work through it, overcome it, and still maintain faith in normal birth processes, and in mutually respectful relationships.

Mother meets midwife

They met on a winter’s morning in 1994. Kate was a 30 year old woman who had recently returned from four years living the East, working in refugee communities, with her Tibetan husband. Although she had grown up in Lancashire she was living in Swansea, South Wales, working full time in a hostel for homeless people, when she became pregnant with her first child in July 2004.

Sheena was a community midwife with experience of home birth and ten years in a GP maternity home (similar to a birth centre) where there was no medical cover.

For Kate choosing a home birth seemed quite normal: she was born at home, as were her siblings. Her mother is Dutch and so home did not seem so unusual. She had read up on the subject and had direct experience of how things can be in hospital. Kate had been by her younger sister’s side when she was taken for an emergency caesarean, the direct result of over intervention.

For Sheena home birth was the ultimate practice for the use of her midwifery skills.  She had worked in the GP maternity home where there was no technology other than emergency life-saving equipment, and had seen the benefits that brought. More than this, her desire to assist women in their choice was and still is her passion.

Kate had received her antenatal care in another area, where she was booked for a home birth. She wasn’t given GP cover but the midwives were very supportive and discussed the home birth guidance and support with Kate. However Kate lived a house shared with two other men, both smokers, attached to the hostel where she worked. When a friend suggested that Kate move to a more beautiful peaceful area close to where her parents lived, to give birth and stay in the friend’s spare house, Kate wrote to the Head of Midwifery to explore the possibility of transferring the home birth option there.   In the last month of the pregnancy Kate moved up to the Ribble Valley and met Sheena, the midwife who was going to provide her care. Sheena had been asked to care for Kate by her manager, who had read Kate’s letter out during a team meeting.

 Our story

Kate: Sheena and I clicked right from the start. She was so open and respectful, and interested in me as a person. I trusted her and was delighted that she would be with me on this amazing journey into motherhood.

Sheena: I sat on the floor in Kate’s home and she offered me Tibetan tea. Kate told me her story of pregnancy so far, and her desire to birth at home. It was Kate’s first baby and she was so excited. I didn’t meet Cheophel her husband but heard all about him, and felt privileged and happy to be their midwife. I told Kate I would try to be available for the birth by being on call for the three-four weeks necessary.

 Normal procedures were followed. There wasn’t much discussion about the choice of home delivery as the decision had been made in Wales and discussion had taken place there.

Kate: I didn’t think to ask lots of questions about travel time and distances to hospital: I assumed that if the midwives were happy to take me on, and had done the same for other women, it wasn’t an issue

Sheena: I didn’t go into any great detail about distance from hospital etc as I rightly or wrongly assumed Kate knew how far the hospital was. It wasn’t my practice to do so, as I had a worked in a maternity unit for ten years that was quite near to where Kate lived, and transfer hadn’t been a problem. Kate wanted a home birth, she was very healthy and happy, and ready to meet her baby.

Kate called Sheena the morning she went in to labour and she attended shortly afterwards. Kate’s labour was amazing; she was active and alert, calm and serene, and very excited. Cheophel and Lucy (Kate’s friend) were present, and providing wonderful support.

Sheena: I loved caring for Kate. I remember her movements, her smile, the lambs in the fields outside and the loving touches of her birth partners. She was agile, and worked with her labour like a strong, proud woman.

When there was spontaneous rupture of membranes, Sheena performed a vaginal examination to exclude cord prolapse (practice at the time). Kate was standing for the examination, and her cervix was found to be fully dilated. The head however, was still above the ischial spines, and Kate had no desire to push. The second midwife listened to the fetal heart, and there was acute prolonged bradycardia.

The emergency services were called……………

Kate: I had felt strong and centred, but now I started to feel powerless.

I knew things were not going as they should, but there seemed to be nothing I could do about it. I tried to remain calm, to not panic, to breathe deeply. It was my first child, so I had no experience to measure it against. I looked to Sheena for guidance; she my anchor. Time seemed to stretch out and slow down, I recall an incredible sense of clarity but huge waves of fear rising within that..

Sheena: The fetal heart beat was still 60bpm. Immediately my feelings lunged from fear, hope and an urgency to protect. The fear was the strongest sense, and increased with each passing second. I couldn’t do anything. Kate was mobile, so changing her position was a constant thing, and the baby couldn’t be born yet. When the baby’s heart beat increased slightly, hope returned but disappeared as quickly as it came. I knew emergency services had been called so in terms of ‘correct procedure’, all was in order. But it was not. Reality was the person in front of me, Kate, who trusted me implicitly and whom I couldn’t help. I will never forget Kate’s eyes, looking into mine, searching for something that I found so hard to give. I wanted to say; ‘it’s good Kate, you are going to be fine’ but I couldn’t because I wasn’t sure that it was. How could I lie to her. Words that have always come so easy to me during my career were now unsuitable and inappropriate. Neither could I say ‘I am sorry’, as I would have done had fetal death occurred, because the possible outcome couldn’t be spoken about. I had an incredible overwhelming desire to take Kate in my arms and make her safe, or to somehow speed up the birth. But I could neither.

The ambulance arrived 40 mins after the call to the hospital. A local GP was present, but couldn’t assist. The procedure at the time was still the ‘Flying Squad’, where an ambulance was called as an emergency, but it necessitated calling at the hospital to collect the necessary clinicians. The communication between the hospital and ambulance control initiated a response to send one ambulance with obstetrician, midwife, paediatrician and full resuscitation equipment. The room where Kate was small, and yet the paediatrician began to set up the equipment, and the doctor urgently proceeded to examine Kate.

Kate: The house seemed to have been invaded; people upstairs, downstairs, on the stairs, in every room; women and also men that I didn’t know, disembodied voices, glimpses of uniforms. The registrar examined me and didn’t inspire confidence or trust; she seemed authoritarian towards me, but scattered in herself. I looked to Sheena trying to keep the connection, trying to find the direction. My impression was that she had been blocked out by the registrar who had taken over control, and yet didn’t seem in control. It felt as if I had been cut loose, adrift on a sea of emotions I hadn’t been prepared to negotiate.

Sheena: The ambulance was here, and familiar faces. Fetal heart still 60. The doctor was experienced, the midwife a trusted colleague, the paediatrician and his equipment. An examination, questions asked, and a flurry of activity. The doctor wasn’t happy to try to deliver the baby, and asked for Kate’s transfer in. Another ambulance was needed, as Kate and the equipment could not fit in one ambulance. The baby could have been born during the journey. Despair increased and fear intensified. Doctor’s instructions. Confusion and uncertainty. Cheophel looked so afraid, yet I wondered if he really understood the seriousness of the events. How could I make him feel better? I couldn’t speak his language and even if I could, I was unable to say the right thing. I touch his arm but I can’t smile.

Kate asks ‘should I push?’ ‘No’ says the doctor, ‘baby’s position is not good, head too high’. I knew this was so, as I had examined Kate. Kate looks to me not the doctor. Eyes burning into mine. What could I do? Fetal heart still 60 bpm. Despair.

The second ambulance arrived, and transfer began a further 44 minutes later

Sheena: Some relief when 2^nd ambulance arrived but only because something could progress. The fear was still strong, what was to be?

Kate: I started to feel annoyed with everyone else apart from Sheena; I just wanted them to go away and to get back to the birthing we had been dealing with together. I felt that I was no longer present as a person any more; that the whole birthing had been taken out of my hands. I was no longer a woman giving birth to a baby, but a body out of which a baby had to be extracted. I was both acutely aware of myself and at the same time felt entirely disconnected from myself. There was an almost tangible feeling of alienation, which I can only describe as an out of body experience as I observed all of those things happening to me but without my being involved. My body was led down the stairs, my nakedness barely concealed as I stepped out into the spring day on to the street.

The hospital is 12 miles away, and it is peak time. Transfer to hospital began to with the assistance of the blue light. Kate was with Choephel, doctor, Sheena and another midwife who came in 1^st ambulance. The 2^nd ambulance followed with paediatrician and equipment.

Choephel was sat at the bottom of the stretcher that held Kate. Sheena was stood close, trying to listen to the fetal heart. The other midwife recorded the activity. Kate wanted to push during the journey.

Sheena: The journey was so difficult for Kate. Fetal heart still 60. She was desperate and scared, and I could sense such sadness in Choephel who I knew understood the level of urgency. When Kate wanted to push, I could see the baby’s head advancing Lots of black hair. From his position, Cheophel could see too, and looked at me for a solution. As I would normally do, I encouraged Kate to push and to ‘go with her body’. The doctor intervened and told Kate not to push as the hospital was in sight. She (the doctor) didn’t want the baby born at the roadside. Kate found this hard and looked at me for guidance. I felt it appropriate to continue to tell Kate to do as she felt necessary and to push if she wanted to.

Kate: It didn’t help that I was being given conflicting advice-don’t push-push. I felt intense anger (often associated with transition). Who was holding me? How long would I continue freefalling?

Pema was born on April 12^th 1995, a full term baby weighing 7lb 8oz. It was a vaginal birth with an episiotomy.

Kate: She was blue, she seemed big and strong. Cheophel told me that she looked dead and he burst into tears. I was just so relieved that she was out, and alive; that was it, we did it, the baby is born end struggle, I thought. I didn’t realise that the struggle had only just begun.

Sheena: We arrived in hospital and Pema was born immediately. Her condition was poor and she went to NICU. This was the worst experience of my career. In bed that night I thought so much about Kate and Choephel and their sadness and worry. I didn’t sleep much and went through my actions, feeling sure that I had acted appropriately, although I remember wishing I had taken Kate in my car to hospital: an action worthy of instant dismal.

Two supervisors of midwives scrutinised my records and called for me the following day. The meeting was unnerving due to its formality, but my seniors assured me that there were no discrepancies with my care and that my record keeping was good. I visited Kate twice that day, and became part of the grief and concern that enveloped the whole family. Sometimes I wondered if my colleagues felt blame towards me as some didn’t really know the story. I also felt alienated by midwives who believed in 100% hospital birth system, as they said nothing to me. Not much support really.

Kate: I remembered meeting the doctor the next day by chance on the corridor. She enquired after ‘baby’ and then said to me ‘so next time you will be having baby in hospital yes?’ I was too socked to reply, but felt like slapping her.

Kate and Pema came back to their borrowed home after 3 weeks in Intensive Care.

Kate: We had not been in contact with hospital Social Workers. We had not been offered any counselling. We came home with drugs for Pema and a telephone number for SCOPE given by one of the nurses. I remember thinking at the time ‘’ SCOPE, that used to be the Spastics Society- why has he given me that?’’ The words cerebral palsy had not yet been used in connection with my baby. She was so beautiful and precious, our first born child, nearly lost to us. But as she gradually came off the phenobarbitone, a sedative which had kept the seizures under control, she began to scream. She screamed round the clock. She could not be put down even for a second, without hyper extending and screaming. She slept in 5 minutes snatches around and then only if she was being jogged about and bounced vigorously. Thus began a three year round the clock marathon. Our arms grew strong, but our spirits grew weak. We became exhausted. There was no let up. No involvement from Social Services, no respite care, no professional support apart from visits to the consultant for scans and check ups. More drugs were given to help Pema sleep. They were ineffective and that was when the epilepsy kicked in, leading to more drug, prescribed by trial and error.

Over the next year, no-one addressed the emotional side of what we had been through and continued to go through. We were expected to cope. Four lives could very easily have been lost at this point; Choephel tried to take his life, I seriously considered aborting my second child, and then taking my own life; and there were times when we had to leave Pema alone screaming just to prevent ourselves from harming her. We were just so tired. We couldn’t see a way forward. No-one knew how things were for us

Sheena: My work location had changed, but I stayed in touch with Kate and her family. My desperation continued, seeing the distress and despair of this young family. What could I do?

18 months after Pema was born Kate had another baby

Kate: There were medical reasons why I couldn’t go for a home birth this time, even though the system for transfer to hospital had changed. I requested permission for Sheena to be my midwife. I wanted to do it with her by my side again; I wanted it to be a shared experience which could help us both, and it was. I think it was at that point that I reconnected with my own inner strength.

Sheena: It was important for me to be asked by Kate to care for her when she was pregnant with her second child, and it gave me hope and confidence in myself as a midwife.

Some two and half years after Pema’s birth, Kate and her family were at a charity event for disabled children. A solicitor who was a personal friend of Jane the charity founder, was speaking at the event on the litigation process. After the talk Jane introduced me to the solicitor, told him the bare bones of Pema’s birth and suggested that he take a look at Pema’s birth circumstances to see whether he felt that there was any negligence on the part of the NHS Trust.

Kate: I went along with it; I felt that it would be quite clear cut.: either it would come out that they had messed up with the transfer to hospital, or it would be shown that everything was done properly. It seemed like a good idea to have someone ‘independent’ look at the facts. I was still very upset about things, used to burst into tears in shops, at meetings, whenever Pema was mentioned really. I suppose I was looking to the solicitor for a form of closure, and for support. But I was very naïve; I had no idea how litigation works, having no previous experience

Sheena: Kate and Choephel told me they had met a solicitor who was going to look into the birth of Pema. They respectfully asked me what I thought about this, and if I had any objections. They were clear they didn’t want to hurt me, and that they were totally happy with the care I gave. Their concern was in relation to the doctor and the transfer to hospital. I felt unclear about the litigation process, and was naive in my belief that as I had given good and appropriate care to Kate and Pema to the best of my knowledge and ability, I had nothing to fear. I gave them my blessing and said I would do anything to help them.

After some years there was a change in the litigation process

Kate: From the initial investigation the solicitor decided that there were strong grounds for a claim as there had been negligence during the transfer to hospital. This did not surprise me .I was asked to write an account of how I came to be giving birth at home and what happened just prior to labour, during labour and something of our life since then. It was very painful but I managed to detach myself from the process enough to write about it. Things took a long time, it was years, before we received any reports from witnesses and expert witnesses. From the expert witness reports there were new allegations which focused on the care of the midwives, which we had never been worried about. We were told that the case would now have to include all these new findings. After the statement which I sent in I was not asked to give my comments on any of the reports that came in; I was told that as Pema’s litigation friend I had a duty to accept the reports of experts I order to seek justice for her. My role in the process became very passive. It seemed to have a life of its own.

Sheena: The Trust’s solicitor emailed me to ask me to call her immediately. New allegations, this time challenging my care. She would send the account, but told me not to worry. I read them with horror when they arrived. My first thought….did Kate believe this? Wasn’t allowed to find out. Did she think I had cared for her inappropriately, without skill and judgment and that I had failed her? She signed to say she did. Oh God this can’t be true.

Anger towards the ‘expert’ midwife who wrote things about my care, that was good and provided with such passion.

Local press, two separate newspapers. Front page news, detailing names and allegations against Sheena. Kate was out of the country and unaware of the events unfolding. The papers were local to the town where Sheena was born and lived most of her life, and where she worked as a community midwife.

Sheena: My colleague had bought the paper on her way into work on a late shift. She brought it straight to me. Horror. It couldn’t really be happening. How can this be allowed when nothing was proven and no case heard? My name, my career, my reputation.   What will the mothers of whom I have cared for over the many years think? I felt sure they would think… ‘lucky escape’ or liken me to Harold Shipman. This may seem ludicrous and far removed from reality. But reality for me. Need to leave my job. My children had comments at school. My neighbours quietly mentioning it to my husband at the bottom of the garden. Pointed fingers.

Kate: We returned from a very difficult but amazing trip to visit my husband’s family in Tibet; he hadn’t been back since leaving as a refugee 17 years earlier. I was pregnant with my 4^th child. We were all ill and exhausted. We were fighting to get adaptations done in the home before my pregnancy advanced much further, so that I wouldn’t have to lift Pema so much. We were waiting for a date for major hip surgery for Pema whose left hip was fully dislocated. She was in constant pain and spent much of the time screaming. And to top it all we were presented with the front page newspaper article. Everyone we knew assumed that we had consented to the article. Everyone we knew assumed that what we were doing was taking Sheena to court. And without any knowledge of the facts everyone assumed that we were wrong.

A petition to the newspapers was circulating, saying that it was wrong to print these unproven accusations about Sheena. We agreed that it was wrong, but felt hurt that the petition didn’t say that it was also wrong to portray us as enemies of Sheena. We were following a legitimate legal process but were being treated as if we were the wrongdoers not the victims.

Comments form mums at schools, insults from people who had formerly supported us. Accusations that we were money grabbers. Support form no-one. Even close friends urged us to drop the case due to the damage it was doing to our family and to Sheena’s

Deep depression for the next few months. Isolation. Hated living in Clitheroe. Wishes for it to all be over, solicitor encouraging us to keep going and soon we would have the financial security to be able to move away

But things didn’t work out that way….

Kate: The Solicitor had only met me one time after that initial meeting. Now he came to visit us with the Barrister. I had made it clear that our concerns did not involve the midwives but of the emergency services. They explained that although negligence had been firmly established with regard to the transfer to hospital, causation had not, because It was difficult to prove that the delays caused by the negligence were the cause of brain damage. The expert witnesses were saying that Pema could have been born sooner, if transfer had been more efficient, but probably not less than 1 hour after the bradycardia. They would be using all the evidence including the evidence against the midwives to support the case, and as Pema’s litigation friend I had a duty to allow them to proceed. There had been an offer of a small out of court settlement which was less than the amount than they would be paying in court costs, so no risk. The solicitor warned me that if we didn’t go to court I would spend the rest of my life wondering what would have happened if we did.

I had just had a baby, I was very open ,quite emotional. I knew that I couldn’t stand up in court and pretend that I believed the midwives had to been to blame even if it was necessary to do so. I also knew that whatever part I played in the proceedings if the case was won on those grounds and not on the grounds of the mess up of the hospital transfer I would spend the rest of my life regretting it.

We telephoned the solicitor a few days later and asked to accept the out of court settlement and withdraw the case. The offer of a settlement was then withdrawn, and it had to go to appeal. Eventually we received an amount of money which has not changed Pema’s life much, except that we could buy her a wheelchair adapted van. We still live in the same place, we can’t afford to move. We still feel isolated, let down by the community. Unsupported. Outsiders. Pema the brave and the beautiful continues to be the epicentre of our lives.

Kate has her own perspective of how this system has failed her:

I believe in the right of a woman to birth in the place she feels is most appropriate for the type of birth experience she wants for her child and herself. The right to have unbiased information to make an informed choice, and support in the choice she makes.

I believe that birthing can be an amazing spiritual experience. I believe that intervention should be available for emergencies but that it should not be the norm, and sensitivity is one of the greatest attributes of a good midwife- when to help, how to support, when to hold back, when to do nothing, letting woman and child lead the way.

Pema’s birth was such a shock; nothing in my life could have prepared me for that experience. But I think that the shock waves which have coloured my whole life since then could have managed better, and I could have had support in integrating the experience, rather than being left with a huge open wound.

I have lived with anger just below the surface for years now. There has been no real closure of the events of the day that Pema was born. I had expected the litigation process to clear things up, and allow me to find the type of resolution that no-one else had allowed. Apart form the legal system no one was looking at Pema’s birth at all, not even from the point of view of how it affected us as a family, or me as a woman. But the legal process made things less clear, muddied the waters and confused me even more. I still had no resolution or closure, just new issues to deal with.

We were abandoned by the services that should have supported us. We were then taken on a desperate journey through the process of litigation which promised a way to escape from some of the problems we had been left with, but which ultimately only added to our problems. I feel that we should never have had to go through that process, and that justice is a game in which you have to play dirty if you want to win. We became pawns in that game, and it took a certain amount of moral courage to get out of it.

Although Sheena and I weren’t allowed to communicate during the whole process.               I felt it important to send cards and letters to reassure Sheena that there was no personal animosity, no change in my feelings for her. Why did we have to be placed on opposite sides of this artificial fence? Discussion of the case with Sheena since it was closed has been the only thing that has really helped me to face what happened and come to terms with it, and start unravelling the threads of anger running through my life.

I was not free to choose the place of birth for my 3^rd and 4^th children, who were born without any intervention or medication and could have been born at home. There were too many issues, and it was clear I was not going to get support. I wasn’t going to do home birth as a battle: I had other battles to fight on Pema’s behalf.

I don’t regret my decision to enter into the process of litigation; what happened at Pema’s birth was swept under the carpet and litigation was the only choice on offer for me to face what happened so that I would be able to close that chapter. I do regret that there is no system in place in this country that can allow a family to honestly and openly request what happened in such circumstances as ours to be looked at, without the need for someone to blame; that there isn’t a supportive way to acknowledge events and their far reaching consequences, even accept shortcomings, provide redress, and enable us all to get on with our lives, integrating the experience however difficult. And while we struggle to support Pema, millions of pounds of public funds have been spent, both on the side of the NHS and through legal aid provided to Pema, most of this going into the private sector of solicitor firms. Would those millions not have been better spent supporting the damaged child?

I have no regrets about withdrawing from the court case; it was the only way for me to remain whole, and in my case I could see that the outcome would constitute neither justice, nor clarification, nor the closure I sought.

I do very much regret that the key players here, Sheena, Sheena’s family, myself; and my family, have had to go through so much heartache, and that my birth damaged daughter does not have what she needs to make the best of her difficult life.

Sheena also has her perspective as a midwife about how the system failed her, and how it should change:

I believe in a woman’s ability to birth her baby, and that unbiased information should be offered to all women to help them choose their birth environment, with appropriate support for ultimate safety. Risks and benefits should include those in hospitals, as well as home.

Pema’s birth taught me that I can’t always make things right, and sometimes, no-one can. It has, however, destroyed part of me that believed and respected British systems, and it has borne in me disgust in the purpose and philosophy of the press.

I didn’t know how to act appropriately following Pema’s birth. Kate was too traumatised to discuss events in detail, and I was unsure of doing so. No discussions between senior medical teams or managers with Kate as to the sequence of events and how things could be better. This has now changed, and there would be dialogue with Kate and her family, and potentially more support.

Once the litigation process began, the destruction started, for me and for Kate. I wasn’t allowed to communicate with her at all, which became harder following the press incidence. I wanted to speak to her and to tell her the allegations were false and that my care was good, but couldn’t.

Since the closure of the case and we have discussed events at length, I feel betrayed by a system that wouldn’t let me care for Kate when she had her third and fourth babies. I would have cared for her at home if Kate desired.

What changes should take place? Sheena and Kate feel:

Sheena: In midwives training, students need to learn about the litigation processes and their effects, without the fear of blame.

Kate: Parents of damaged children need to know about what they could be letting themselves in for entering litigation, and perhaps a solicitor is not the best person to offer that advice.

Sheena: Health services to continue to commit to transparency and openness within their services, and acknowledge failure with an apology if appropriate.

Kate: There needs to be acknowledgment of the events and their emotional impact, the questions that arise-even the ones with uncomfortable or no easy answer. Different aspects will need addressing at different times, but without open acknowledgment this can’t happen. Litigation should not be the only way for this conversation to take place.

Sheena: Parents of babies born damaged or in need of long term care should receive immediate support, without the need for blame.

Kate: The birth of a damaged child should not require parents to turn into fierce warriors continuously fighting for support and services. Litigation should not provide the only way for families to guarantee that their child’s needs will be met.

Sheena: The media should be prohibited by law to publish details of health care professionals, unless they are a proven danger to the public.

It seems that women are loosing out in all of this, and that solicitors are the only ones to gain. And yet, due to our belief in each other and in spite of what has happened, we have travelled a full circle and are firmly back to together again, where we started.

Kate: I trust and respect Sheena as a midwife and friend and given the right circumstances I would have no hesitation in asking her to support me in delivering my baby at home. I would advise my own daughters that given the right circumstances, home is the best place to bring your child into the world.

Sheena:   I still believe in home birth, and supported my daughter in her home birth choice recently. My philosophy is clear that women must do as they feel, and be given unbiased evidence based information to make their choice. Kate and her family are an important part of my life, and I will always feel privileged to be part of theirs.

So what next?

We were almost destroyed by this experience, for very little gain, and although we are back together, the litigation system continues to drive women and midwives apart.

In 2003, the government consulted on a document entitled Making Amends (DoH 2003), which set out proposals for reforming the approach to clinical negligence in the NHS. These ‘redress’ reforms however, have never been implemented.

In 2004/05 422 million was paid out in litigation costs, an example of how costs can run so high is that Kate’s case tool almost 8 years to complete, and her solicitor charged £100 against the case every time a phone cal was made to Kate. We feel that public money needs to be targeted where it is needed as opposed to lining the pockets of the legal profession. New Zealand, Scandinavian countries and France have introduced no fault schemes for medical injury, Virginia and Florida in America are introducing no fault compensation for babies with birth-related neurological injuries. The advantages of these systems are that lawyers are not routinely involved, reducing the amount of costs to legal profession and enabling more efficient targeting of resources.

Kate wanted to tell her story for clarity, to make sense of what happened, to assist in the integration of the experience. She feels it may promote a connection- with other women, midwives and mothers- to encourage them to have courage and to give insights into how the current system is failing women. Sheena feels the same, by telling her story she wants to strengthen professional courage and belief in women and midwives as true partners.

Chapter from Byrom S, Murry K (2009) In: Walsh D, Byrom S Birth Stories for the Soul Quay Books, London

 Reference

Department of Health (2003) Making Amends: A consultation paper setting out proposals for reforming the approach to clinical negligence in the NHS London

Inspiration and technology: Alison Baum blending the two!

I have been observing Alison Baum's phenomenal achievements for many years, and have been captivated by her passion, energy and charisma. Alison is the CEO of the charity Best Beginnings, and there's more about the brilliant work the organisation does in this post. After becoming increasingly involved in Alison's latest project, the Baby Buddy App I wanted to interview her, to find out a little more about the inspiration behind her successes. In particular, I wanted to know more about this app, and why she was driven to make it happen!

Alison, Hi! Can you tell me what the Baby Buddy phone app is?

Baby Buddy is a personal baby expert that guides mums through their pregnancy and the first six months of their baby’s life. It has been designed to help mums give their baby the best start in life and support their health and wellbeing. The app is free to download, and it allows you to create your own personalised avatar (your “Buddy”) and has lots of lovely features, including useful “daily information”, some great videos, a cool goal setting function called “You can do it,” a “What does it mean” feature where you can find out what words means, and a very helpful “Appointments” feature. Baby Buddy focuses on empowering young mothers, as well as increasing their knowledge, improving confidence, enhancing bonding and attachment and reinforcing the importance of accessing health services.

What is the inspiration behind the creation of the app?

Our charity Best Beginnings is all about ending child health inequalities in the UK. This means giving every baby the best possible start in life. Our vision is a future in which all children in the UK enjoy excellent care from the very beginning. My own personal experience has been a major influence on what we are trying to achieve. My first son David was born with a cleft palate as well as breathing and feeding problems. My second son Joshua was also born with a cleft palate and developed viral meningitis at 8 days old. My nephew Joe has a condition called Tuberous Sclerosis, he has multiple and complex healthcare needs, including severe learning difficulties, autism and epilepsy. Sometimes things go wrong, and some health problems are unavoidable, and we all do what we can to make the best of a situation. But as I became more and more aware of the shocking child health inequalities that exist in the UK, I realised some things are avoidable. For example, it’s totally unacceptable that a baby born in Bradford is six times more likely to die in infancy than a baby born in Tunbridge Wells. For the most part these inequalities are avoidable and that is what I decided to focus my energies on. Best Beginnings was set up in 2006 and the Baby Buddy app is an important part of that vision as it is designed to support parents-to-be and new parents in the social, emotional and physical transition to parenthood, and in giving their baby the best start in life. Baby Buddy focuses particularly on engaging young parents, who based on the evidence, are more likely to find the transition to parenthood harder and their babies are more likely to have poorer health outcomes. We as a society have failed to give them information in a way that works for them. Young parents want to give their babies the best possible start and we’ve created this app as a way to help them do just that.

How is it different to all those other parenting apps on the market?

Some apps are offered at a cost but Baby Buddy is free to all. Another important thing is it contains content that can be trusted. Everything in the app has been approved and endorsed by organisations including the Royal College of Midwives and the Royal College of Paediatrics and Child Health. Pregnancy or parenting apps give daily information based on the mother’s pregnancy stage or the baby’s age. No other app straddles pregnancy and birth with content which covers the emotional as well as the physical, which mentions the mother, baby and partner by name which is different content whether or not the mother has a partner and/or is or isn’t breastfeeding, all of which has been endorsed by many key maternal and child health organisations. This means the user gets the right information at the right time. We’ve had a huge amount of input from parents and professionals too. Through this, and with a clear vision of what is possible, we’ve created something that has never been done before. Baby Buddy is unique in its combination of endorsed content, friendly chatty style, its practical and interactive features, and in the ways it is being used. Baby Buddy has also been designed to be used as a tool by healthcare professionals to both support and complement their work. We have been working with local areas to actively embed the app into care pathways.

Is it easy to use?

Yes, installing the app on to your phone could not be easier and only takes a few minutes. Anyone can access it – mums or dads, health or social care professionals, peer supporters and other charity workers – as long as you have either an Android phone – in which case visit this, or an iPhone – in which case visit this link. Everyone who registers gets access to all the app's features. We ask that people please register as who they really are not as who they are imagining being. We are (as an anonymised dataset) keeping track of who is using Baby Buddy, where in the country users are and (if they complete the in-app questionnaires at 7 and 8 weeks) what they think of it. For example, we are keen to see how many midwives, health-visitors, paediatricians, obstetricians, psychologists etc are using it in different parts of the country. So, tempting as it may be to go in as a 19 year old pregnant woman when you are an interested professional, please register with your real age and profession. Once you are registered you'll end up having exactly the same experience as the 19 year old pregnant women you have in mind when testing the app. The in-app data will help us get the app ever better. We've only released the 1.0 version and this will be a multi-year project informed by in-app and site-based evaluations. Our web page has it all spelled out here. The app itself is very visual, and uses lots of images and video clips. Many mums who have been giving us feedback tell us how much fun it is to use the avatar, which can be customised. There are well over a million different avatar Buddies you can create, each with their unique combination of body shape, skin tone, eye shape and colour, nose, lip shape and colour, outfit and hairstyle, and if the user chooses, virtual earrings, necklace and sunglasses.

Why do mothers need an app when we have so much information on the web available?

Very few young parents with babies are far from their smart phones these days and it makes sense to deliver key messages and support to them in this way. Mums have been telling us that, frankly, they are overwhelmed by the amount of information out there and searching the web for an answer is a minefield when you don’t know if the source can be trusted or not. Baby Buddy has a fantastic Ask Me function that gives them answers to all their questions on pregnancy, birth and parenting, as well as a “what does it mean?” feature. But Baby Buddy does more than give information, it is also highly interactive. This means as well as sending regular messages with timely reminders, daily alerts and video advice, it also enables the parent to set goals, manage health appointments and find local groups and resources via a map. A phone app is a great way to reach out to younger mums, who as a group are among the highest users of smartphones. Younger mums may not always be accessing health services in the same way as older mums, so it provides a way to connect them to a resource that maintains regular contact and alerts.

When will it be ready to install on my phone?

Right now! Version 1.0 is available to install. Visit the web page now to install it. I would actively encourage everyone to download and use it. We are seeking feedback from parents and health and social care professionals ahead of the official launch in mid-November 2014 to make the app even better. When you install it you’ll be asked to give feedback in the app and you can also email us directly. We are particularly keen for multi-disciplinary healthcare professionals to understand its functionality and content, so they can recommend it to the families they support, and use it in appointments. When you register as a user, just choose the options that fit you best.  This way we can separate out feedback from parents and professionals. I really would be delighted to hear any suggestions anyone has for additional content for example new FAQs for the “Ask me” function via: hpapps@bestbeginnings.org.uk. Midwives may even want to rate it and write a review of it on Google Play or iTunes App Store. The more reviews there are for parents-to-be and new parents looking for help, the easier it is for them to decide if Baby Buddy is worth downloading. So if you’re readers, (after using the Baby Buddy app), want to take a few minutes to write a review that would be wonderful.

How are parents going to hear about the app?

Well, there are lots of ways and your readers can play a big part in this, if they wish!

1. Special posters and postcards are available to display in areas where pregnant and new mums visit, and they can be downloaded or ordered free of charge here!  Some areas are putting the leaflets in pregnancy booking appointment letters and other maternity services are working with us to develop ideas on integrating the app into local maternity and children's care pathways.

2. We have a social media campaign building on Twitter using @babybuddyapp @BestBeginnings and @AlisonBaum and we are very keen for you to get involved. We are a growing 'family' and would love you to be part of it! See the video below...

3.  We are planning a press launch on November 19th 2014 - so please do join in the Twitter and Facebook chat, and let us know if you would like your local area to be part of the press launch. Email us at hpapps@bestbeginnings.org.uk

Is the app complete?

No not at all, we are very much at the beginning of a multi-year journey.

We have an abundance of helpful content in the app, but we are constantly looking for more Questions and Answers for the "Ask Me" function and I am always keen for suggestions, all of which have to be endorsed by our team of experts before inclusion. We are also in the process of making more than 100 new films to go into the app which will include everything from young mothers preparing simple healthy meals, to mums at antenatal classes talking about what they get out of them, films about creating wellbeing plans, creating birth plans, films about active labour, about baby communication, spotting a sick child and much much more. We are actively recruiting young pregnant women and young mothers from across the country who are happy to be filmed during their pregnancy and/or their baby's first months. We are also keen to recruit and film mothers with older children who experienced mild, moderate or severe mental health problems to tell their story retrospectively, with the purpose of raising awareness, destigmatising and informing app users about mental health and wellbeing.  For more information please see the dedicated webpage on our website. We'd be delighted to hear from healthcare professionals working with young parents or from parents themselves.

In addition to new content coming on board, we are also adding in new features to Baby Buddy. Within the next few weeks three long-awaited features will go “live”:

Bump Around/Baby Around: this new feature helps users of the Baby Buddy app to find local services and classes based on their locality, using a map. The aim of this feature is to use technology to increase social capital by supporting more young mothers to attend classes and use local services.

Bump Book/Baby Book: this new feature allows users to keep their own private diary with photos, thoughts and reflections. Users can, if they choose, share individual daily entries with friends and family and their wider network). In creating this feature we have created a reflective space within the app to support mind-mindedness and the emotional transition to parenthood. Our aim, in the future, is to create a way for users to easily make a hard-copy version of their Bump or Baby Book if they choose.

Text to voice: that users will be able to tap a button and their Buddy will speak her message to them

Here is a special message from me about how you can play a key role in this project and make a difference to babies' lives in the UK. Thank you!

Here is a special message from me about how you can play a key role in this project and make a difference to babies’ lives in the UK. http://vimeo.com/101627566 Together we can make a difference for future generations. Thank you! PS: If you want to find out more about the dad’s app I mention in my special message click here.

For my Four

Between the moment you were not and you were, I gasped.

The breath was the one before love struck. Like never before.

And into my arms each one of you came, and into my heart and my soul.

None more, nor less. All the very same.

It was then I really understood my own mother.

It’s just how it is.

 We will never walk on equal plains, you and I. Because this love isn’t reciprocal.

Not to be undermined, or misunderstood.

When you feel joy, my heart sings. Your frowns cause a crumble that can’t be controlled.

It’s just how it is.

And that’s why my step is not far from yours, even though I urge you to fly.

 It’s just how it is.

In one moment, I would give all up for you. 

In the end, I ask for nothing, but that you know.

It’s just how it is.

For Anna, James, Tom and Oliva by Sheena Byrom

What I think about birth centres: an interview

Laura Iannuzzi is an Italian midwife, currently studying for a PhD at Nottingham University in England.  After qualifying as a midwife in 2001 Laura has worked in different areas of practice, and since 2004 Laura has been employed by the University Hospital of Careggi, latterly at the Margherita Birth Centre.  Laura's research topic for her study is 'An exploration of midwives' approaches to slow progress of labour in English and Italian birth centres'.

Laura emailed me and asked if she could interview me about my thoughts on birth centres-not for her study, but because she is interested in the relative success of birth centres in England. I agreed of course, as I usually interview others!

Dear Sheena, first of all thank you very much for your availability for this interview. As you know, this is for me a great pleasure and honour; you are indeed largely recognised as an inspirational midwife inside and outside UK. And it is quite intuitive to see why, given your apparent innate ability to communicate the beauty of midwifery, to capture and amplify voices of women and midwives from all over the world, to show that change is actually possible wherever, and to support any initiative aimed to improve midwifery practice, education and research.

We could discuss about many things, but today I would like to talk with you about birth centres and their management, taking the most from your experience. You worked in fact as Head of Midwifery in the East Lancashire Trust where your played a key role in the establishment of the Blackburn Birth Centre, one of the most successful freestanding birth centres in England.

1. As someone might not be familiar with the language and the models, how would you define/describe a birth centre? What are the main features that differentiate a birth centre from other birth settings (e.g. hospital labour ward, maternity houses, home)?

Thank you Laura. What an introduction…I am flattered and grateful, yet as always I am taken aback….

It’s a pleasure to answer your questions!

Birth centres are places where women who have no expected complications can go to give birth, in a calm, non-medical environment, to be cared for by midwives and support workers. There are two types of birth centres, Alongside Birth Centres (AMU) are situated on the same site as an obstetric unit, and Freestanding Birth Centres (FMU) are in a separate building to a hospital, in a community setting. Birth centres should be managed by highly skilled midwives, who carefully monitor women in their care, and encourage and support them to give birth at their own pace, with minimal interference.

In an attempt to describe my thoughts on how birth centres differ to hospital (obstetric unit) birth facilities, I want to tell you about a period of my midwifery career. During the 1980’s I worked for 9 years in a ‘maternity home’, which was the same as a birth centre, except the woman’s GP (family doctor) came to the birth. The maternity home was several miles away from the host hospital, so was ‘freestanding’. Working there taught me how to be a midwife, in the truest sense of the word. I learned from experienced midwives and the women who laboured and gave birth there. There were no electronic fetal monitors, and so I became proficient in using my midwifery skills, my eyes, ears and intuition to give safe, high quality maternity care. I saw women labouring un-interrupted; it became second nature to me to support normal physiological childbirth, and to witness the immeasurable joy and satisfaction of parents as they met their baby for the first time. They did it themselves. We had a progressive manager (Pauline Quinn OBE) who introduced birth mats and birth stools (this was in the early 1980’s)…women rarely used the bed except for resting and sleeping. As I mentioned, this was early in my career, and whilst I had witnessed ‘normal’ birth previously, it was in a hospital setting where women laboured on their backs, on beds that resembled those in an operating theatre. Normal birth mostly happened by chance in the hospital, for example if the woman came in advanced labour or was multiparous, or as a result of the midwife’s strategy to protect the woman from the rigid policies and protocols of active management of labour (O’Driscoll and Meagher 1986). When I returned to the hospital to work after the maternity home closed, I saw that there had been a radical shift in the way women were being cared for. Epidural anaesthesia for pain relief had been introduced, and caring for semi-paralysed labouring women was new for me. I felt like a nurse again, in in a critical care environment. From that time (1990) until now, I have witnessed first hand the increasing medicalisation of childbirth, where pregnancy and birth are pathologised, and risk averse practice dominates. Fear prevails, both from the maternity care workers perspective, and women using the service. Yet maternal and fetal outcomes have not improved during that time, indeed, there is growing concern of potential iatrogenic harm as a result of unnecessary medical intervention (Dahlen et at 2013, Renfrew et al 2014). I must be clear at this stage, that some interventions in childbirth are crucial, and life saving. The task we have in maternity services is identifying those women who really need it, not treating every pregnant woman ‘just in case’.

So birth centres for me provide the space for women to give birth safely and with the least interference, and they act as a catalyst for change.

2. What does it mean that birth centres are midwife-led structures?

It means that midwives, experts of normal physiological childbirth, provide care for childbearing women who don’t have expected complications, in an environment that supports them to labour and birth undisturbed. The midwives should be appropriately skilled, and able to recognise any deviation from the normal and respond and refer appropriately. Safe transfer of care, where collaboration and respect is the prevailing culture within the reciprocal service, is crucial.

3. Why should women and their partners consider a birth centre as place of birth for their baby?

The large study in England (Birthplace) revealed that birth centres are safe for mother and baby, and that giving birth in a non obstetric unit setting significantly and substantially reduces the chance of having an intrapartum caesarean section, instrumental delivery or episiotomy. These are crucial considerations, given the increasing Caesearian section (CS) rate, consequential potential iatrogenic damage, and financial costs. A recent Lancet paper (Renfrew et al 2014) cited a WHO study (Gibbons et al 2012) that estimated 6·2 million unnecessary Caesearean sections were being performed in middle and high-income countries. Avoiding unnecessary intervention in pregnancy and childbirth has been shown to lead to better outcomes for women, they have a quicker recovery and there is improved satisfaction (NCT, RCM, RCOG 2012). Women experiencing a normal birth are more likely to breastfeed, will require less postnatal care and are less likely to visit their doctor with postnatal complications.
Being afraid of childbirth is another important consideration (Ayers 2013), and documented reports of disrespect and abuse add to the picture (Birthrights 2013). However, women giving birth in midwife-led settings report feeling more satisfied with their birth experience, and that their birth positively influenced the way they felt about themselves (Birthrights 2013).

4. Do you think organisations should invest in birth centres? Why?

There is robust evidence that obstetric unit birth is not appropriate for women with low risk pregnancies. If women are more likely to have a normal physiological birth in a birth centre, and normal birth is a public health issue (Sandall 2004), then organisations should provide these settings for women with low risk pregnancies.

In addition, planned birth at home, in a freestanding midwifery unit, or in an alongside midwifery unit generates incremental cost savings compared with planned birth in an obstetric unit (Schroeder 2012). Further, occupancy rates for freestanding midwifery units (30%) were under half that of obstetric units (65%) and much lower than alongside units (57%).

5. As you probably know, while in Italy birth centres are still a rarity (it has been reported around 4-5 in the whole country) in UK there is an increasing presence of these models ( > 100). How would you explain this phenomenon? What factors contributed, in your opinion, to the onset and development of these midwifery models of care in your country?

Intuitively and anecdotally, midwives have always known that out of hospital birth is safe, and more satisfying for mothers, families and midwives. Because of this, midwifery innovators and leaders have striven to establish birth centres, and to promote and support home birth. The difference now is that we have strong, clear evidence to back up the knowledge.

Globally, maternity care workers and politicians are becoming increasingly aware of the human and financial costs associated with the escalating unnecessary intervention in childbirth in high and middle-income countries (Renfrew et al 2014). Because this can be addressed by providing midwife led settings for women to give birth, the draft Intrapartum Care NICE Guidance (2014) is advising low-risk nulliparous and multiparous women to plan to give birth in a midwifery-led unit (freestanding or alongside) as the rate of medical intervention is lower and the outcome for the baby is no different compared with an obstetric unit.

Maternity care leaders also considered midwifery skills. If midwives only work in obstetric led settings, with increasing unnecessary intervention rates, the skill and expertise needed to facilitate normal physiological childbirth become diluted. This compounds the already potentially catastrophic consequences of unnecessary intervention in childbirth (Dahlen 2013).
To demonstrate the reality of this phenomena, here is an exert from a letter recently sent by a student midwife in England, to the Royal College of Midwives (RCM), raising concerns about her lack of exposure to normal childbirth:
[I became very disheartened and concerned about my own experiences. As a student midwife, I completed my second year of training after having witnessed and participated in 52 caesarean sections, 16 instrumental deliveries and very sadly, only 11 normal deliveries. I can vouch for the fact this story is not unique and many students are having a chronic lack of exposure to normality. In fact what the ICM (International Confederation of Midwives) and RCM seemed to call 'normal', to me seemed like a fantasy, not the world in which I was training and learning. I was saddened to realise that I'm now a third year student and have never used intermittent auscultation in practice and have never seen a women give birth off her back].

I believe this is unacceptable.

6. It is a common belief, especially among those who would not advocate for birth centres, that these models are too expensive (and we know that none can ignore the global financial crisis) and provide care just to 'small privileged groups of women' compared to traditional hospital models. What is your opinion and experience about that?

The Birthplace study mentioned above provides evidence that centre birth is less expensive than obstetric unit birth, taking all aspects of the care of mother and baby into consideration. In East Lancashire in northern England, 30% of women give birth in a birth centre, and those women are from culturally and socially diverse communities. We cannot ignore the evidence we have of potential harm if we do not provide these services; nor the emerging evidence (Dahlen et al 2013). The issue of women using  birth centre facilities if available is an important one. Pathways of care must support women making a decision to give birth in a birth centre, with midwives who work in them providing the information. I know this is one of the reasons why the birth centres at East Lancashire Hospitals mentioned above are so successful. 

7. Given the international problem of the shortage of midwives, denounced by many organisations including the International Confederation of Midwives, it seems important both to lobby for more midwives for women and families, and to use the current resources at their best. In this situation, directors and managers might prefer to 'centralise' midwives in big labour wards rather than encourage their employment in new/different units... Did you come across this kind of debate? Do you think there is a room for birth centres in time of crisis? Why?

Yes, since the 1950/60s there has been the desire to centralize maternity care into hospital in the UK, and more recently reconfigurations of maternity services has seen the amalgamation of smaller maternity services into larger, centralized units. However, national policy drivers (DoH 2007) directed services to offer the choice of midwife led facilities, and the response has been positive with an increase in the number midwife led establishments (see BirthChoice UK chart below).

Other countries such as Catalonia are paying attention to the importance of childbirth as a measure of societal health, and to prioritise midwife led care, and choice (Escuriet & Oritz 2014).

The Birthplace Study is clear that it is less expensive for low risk women to give birth in a birth centre, which included the number of midwives needed to care for them. In fact, given the evidence of increased unnecessary intervention for low risk women giving birth in hospital, there are financial considerations for this. The model of midwifery care in all settings needs to be flexible and responsive to the need of the service, and there is no ‘one size fits all’. However, the general principle that the midwives ‘follow’ the women, i.e. they are able to work in all settings, helps with workforce planning and promotes safety.

8. Always connected to the shortage of midwives, anecdotally, some organisations seem to assume that as midwifery-led units are caring about low-risk women, there is less need for midwives than in obstetric units. What or who establishes the number of midwives needed in a setting? What are the criteria you used or you would suggest to calculate, even within a limited number of midwives, the minimum acceptable staffing especially thinking about birth centres?

I asked the Head of Midwifery, Anita Fleming, from East Lancs Hospitals NHS Trust in England (mentioned above) to help with this question, and her service provides 3 birth centres with 30% of women giving birth in the facilities. Anita said:

[Birthrate Plus (Ball et al 2013) provides guidance for midwifery staffing; it is advantageous to calculate the numbers of midwives needed for your service overall and not necessarily how those midwives are allocated to each area. Professional judgment is essential, and will depend on several things such as number of birth rooms and also on what other activity goes on there, in addition to birth. There needs to be enough staff to provide one to one care in labour and to retain safe numbers if a midwife goes on a transfer.  We have a lot of other activity in our BC’s (checks, clinics, immunisations etc) to make best use of the midwives time when unit quiet; it isn’t appropriate for midwives to be sitting round waiting for women in labour. NICE is currently developing guidance staffing guidance for maternity settings which should be out for consultation in October / November this year, prior to publication of the final guidance in January 2015].

9. What are the current features you think should be reduced and which increased in order to improve maternity care?

I am quite clear about this Laura. I think today’s maternity care systems are focusing so much on preventing risk, that they are blindly increasing it (Dahlen 2014). I believe we should try to reduce the ‘tick box’ culture, which focuses on ‘it’s done’, rather than trying to give individualised care based on building compassionate and trusted relationships both with women in our care, and all members of the maternity team. We are processing women through a strangled system, all the time being reminded to ‘protect ourselves’ against litigation and recrimination. This leads to fear and defensive practice that potentially increases serious harm. Governments and maternity care providers should examine the evidence and respond appropriately, and assess their maternity service on the global Framework for Quality Maternal and Newborn Care [see below] (Renfrew et al 2014). Leaders must also remember that where resources are limited, unnecessary medical intervention is more expensive, and financial costs unsustainable.
What is more important than the birth of a baby?

10. As you know, midwifery-led care and midwifery-led models where midwives work autonomously are highly supported by evidence but may be poorly supported in the reality of daily practice. I have in mind many realities in Italy where brilliant midwives are struggling with a highly-medicalised culture, but this seems to be true also in other more midwife-friendly environments, such as the English one. What are the facilitators and what the barriers to translate evidence?

In believe the key to the success of midwifery led models is for midwives work collaboratively with medical and academic colleagues, and to build trusted relationships. This approach, where possible, reduces the polarisation of models of care, where no-one benefits, least of all the woman and family using maternity services. For this to happen, all parties have to be willing to understand the part that they play in ensuring safe maternity care, and to respect and appreciate each other’s roles and philosophies.

11. Would you like to send a message to all the Italian midwives, especially to the ones that are currently struggling in seeing positive signs for the future of midwifery?

The maternity service where I worked has recently been awarded Maternity Service of the Year, by the Royal College of Midwives. Within the service there are 3 birth centres and an obstetric unit, and 6,500 babies are born each year. It wasn’t always like this. I remember times when we felt desperate-the climate was oppressive and hierarchical, and there was little hope for a positive future. A few of us were strong. We had passion and believed in woman centred care. We engaged academic colleagues who helped us to find and articulate the evidence, and were determined to change. The strength of leadership was changeable, so we tried to lead ourselves, and it worked. This took many years, it didn't happen over-night, and there were many disappointments!

Remember the change needs to start with you-don’t wait for others to do it.

Laura Iannuzzi can be found on Twitter

References (unlinked)

Ayers, S. (2013). Fear of childbirth, postnatal post-traumatic stress disorder and midwifery care. Midwifery 30:2 Feb pg 145-8

Dahlen H (2014) Managing risk, or facilitating safety? International Journal of Childbirth Vol 4, Iss 2

Department of Health (2007) Maternity matters: choice, access and continuity of care in a safe service. DoH London

O'Driscoll K, Meagher D (1986) Active Management 2nd Ed. London: Bailliere Tindall

Sandall J (2004) Normal birth: a public health issue Practising Midwife Jan 7 (1) Pp 4-5

Additional reading:

Coxon K (2013) Freestanding Midwifery Units: local, high quality maternity care RCM publication
https://www.rcm.org.uk/sites/default/files/FMU%20Mythbuster%20-%20Web%20Final.pdf

The Lancet Midwifery Series: by a 'Midwife's Midwife'

At the end of June, and amidst a flurry of excitement and extensive publicity,  the much awaited Lancet Midwifery Series was launched.   The Series, produced by an international group of academics, clinicians, professional midwives, policymakers and advocates for women and children, is the most critical, wide-reaching examination of midwifery ever conducted. The papers systematically summarise the current global picture of maternal and infant health, and provide a framework for policy makers and maternity providers to maximise potential for improvement.  

The Series also highlight key issues on the role of midwifery in the world today, and challenge much of the current thinking and attitudes about it among health professionals and decision makers.

For me, the papers have given us the additional tools to enable and strengthen the drive to lobby for change. The paradox of lack of timely and coordinated life saving interventions in some countries, and over-use of the same interventions in others, needs to end.

Dutch Midwife Petra ten Hoope-Bender , who works as the Director for Reproductive, Maternal, Newborn and Child Health at the Instituto de Cooperación Social INTEGRARE (ICSI) in Barcelona, Spain, co-ordinated The Lancet's Series on Midwifery. I was recently connected to Petra, via Soo Downe, and after reading about her here, felt it would be great to ask her about her role, and about what she hopes her work will achieve.

Hi Petra, thank you for so willingly agreeing to be interviewed for my blog. I know how busy you are! I think many individuals will be very interested to hear about the role you played the development and co-ordination of The Lancet Series on Midwifery, recently published.  Would you introduce yourself please, including a little about your professional background?

I'm a midwife by trade and held an independent midwifery practice in Rotterdam for 12 years before moving into the area of international health. I started as Secretary General of the International Confederation of Midwives in 1998 and later I moved to Geneva to start the Partnership for Maternal, Newborn and Child Health.

Could you explain briefly what the papers are, why and how they were developed?

The idea for a series on midwifery started during the development of the State of the World's Midwifery 2011 report, when the author team realised there were many gaps in evidence about midwifery that urgently needed filling. They approached Zoe Mullan and Richard Horton of The Lancet to find out whether they would be interested in publishing this and received a positive response. There were many topics suggested for inclusion in the series, but after several discussions the content settled down around the four topics we have now. These include an evidence base for quality maternal and newborn care from the perspective of women and newborns that expands the notion of what needs to be provided to how and by whom. It sets out an evidence based definition for midwifery and measures the impact of the lives that can be saved by the midwife working to her full competence and scope of practice. The series also identifies the steps that some countries have successfully taken to deploy midwives and thus reduce their maternal and newborn mortality and finally provides an international policy brief that calls for effective coverage (coverage + quality) of midwifery care and shows how this can contribute to the achievement of international targets and initiatives.

What was the extent of your involvement?

I was the coordinator of the series as well as the lead author on ' The improvement of maternal and newborn health through midwifery'. I was also a co-author on two of the other papers in the series.

If midwives or maternity care workers want to influence political agendas using the series, what advice could you offer them?

The first step would be to lay their maternity services against the Framework for Quality Maternal and Newborn Care to see where the differences are and then identify what the most important issues are in their services that they would like to change.

These can be changes in the midwifery curriculum, or in the way the profession is regulated, but they can also be about service delivery and how the care providers are enabled to provide respectful care that optimises normal processes and strengthens women's capabilities to take care of themselves and their families.

What impact do you hope the papers will have? Has there been any influence so far?

The series has already gathered a lot of support and positive responses. We have started a website called Solution98 where we explain for the general public, what the series means and what they can do to support the provision of such quality services in their health system and facilities. There have already been quite a lot of requests for support and even accreditation of facilities to this new standard of care. What I hope most for the future is that women will understand what we're talking about and start demanding this kind of care for themselves and their families, friends, colleagues. Without the voices of women, the effort to improve maternal and newborn care will remain in the realm of the health care providers and will not be half as effective.

What are your plans for the future Petra? In the near future we're working towards inclusion of the messages and the framework from the series on midwifery, to be taken up and linked with the work on reducing maternal and newborn mortality world wide that is currently being pushed by the UN and its partners in large initiatives such as the Every Newborn Action Plan, Ending Preventable Maternal Mortality and the discussions about the post 2015 sustainable development agenda. But this series is not written for low and middle income countries only. It is as important for high income countries where overmedicalisation threatens normal pregnancy and childbirth and where midwifery is under pressure.

Petra, this work gives us hope for the future, and is a pivotal element of the momentum for radical change. Women and their children will benefit as a result of the recommendations, when they are appreciated and implemented. Women and families, together with midwives and all maternity care workers around the world are thankful for the expertise, time and energy you and your esteemed colleagues have given to addressing the issues that they see, hear, feel and suffer from on a daily basis.

And now we must speak out.

Petra's email address is: petra.tenhoope@integrare.es

Find Petra on Twitter at: @Ptenh

'Keep fear out of the birth room': an interview with Professor Hannah Dahlen

When I first heard Hannah Dahlen speak, it was in Grange-over-Sands, England, at the Normal Birth conference. Hannah gave a talk on the 'Juggernaught of Intervention', describing the potential consequences of unnecessary medical intervention in childbirth,  and  I was hooked. Each of Hannah's words rang true to me, I was, and still am, concerned about the ever increasing focus on 'risk' in maternity services, and the impact this is having on childbearing women and those caring for them.    Since then I have followed Hannah's brilliant work, via academic publications, with enormous interest. After the success of interviewing Prof Soo Downe OBE and Dr Helen Ball, I asked Hannah if she would be willing to participate too. I am thrilled that she said yes! Hello (or G’day!) Hannah! Thank you for agreeing to be interviewed... could you introduce yourself, please?

Hi Sheena, my name is Hannah Dahlen and I have been a midwife for nearly 25 years. I am currently the Professor of Midwifery at the University of Western Sydney, which is in NSW, Australia. I am also a practising midwife and I work with five other lovely midwives (Robyn, Jane, Janine, Emma and Mel) in the largest private group practice in NSW, called Midwives@Sydney and Beyond. I provide continuity of care for women throughout pregnancy, labour and birth and for six weeks following the birth. Around 90% of our women give birth at home. I am also the national media spokesperson for the Australian College of Midwives, which means I can be woken up as early as 5am to tiptoe through political landmines as I try and represent midwives in the best possible light. Once I did a radio interview at 4am and had a very funny time talking to truckies about birth, as apparently they are the only ones awake at that time. I am also on the executive committee of the NSW branch of the Australian College of Midwives and I have held this position for 17 years.

When did you realise you wanted to be a midwife? 

I don’t remember realising that I wanted to be a midwife because I can’t remember ever wanting to be anything else. My mum was a midwife and I grew up Yemen, where I was also born. My earliest memories were being cordoned off in a playpen in the corner of the clinic with a kidney dish and tongue depressor to play with as my mum worked. I also remember being sat on a tin in a backpack so I could see the countryside as mum and dad trekked into the villages to vaccinate people. Because I was so blond and fair skinned and had vivid blue eyes the Yemeni people found me fascinating and my hair was always being pulled to see if it was attached to my head. When I squawked in protest they concluded I must be a wizened up old woman with white hair. But of course there was a moment that I knew without a doubt the kind of midwife I would be when I was 12 years of age. My next door neighbour gave birth to her third child and I helped the local midwife catch the baby. When my neighbour saw it was another girl she turned her head away and said , ‘take it away.’ She feared that her husband would divorce her or take a second wife as she had not produced the much valued son yet. I remember carrying this perfect little girl, which they named Hannah after me, to the window as the dawn was breaking and the minarets began their melodic calls to prayer. I remember as girl on the brink of womanhood feeling both spellbound by the miracle I had witnessed and outraged that girls should have less value than boys. I knew then that you could not be a midwife without fighting for women’s rights and that was when I think the political passion I consider inextricable from the job of midwifery was born. I believe if you are apathetic about women’s rights then you are not cut out to be a midwife and if you are frightened to be political then choose another career.

What does a typical day in your working life look like?

Gosh, I have no typical day, as that sounds too much like the definition of boredom. My life is often very eclectic and unpredictable. I get to work about 9am after putting my youngest daughter on the school bus and then I might be doing several things, such as teaching, undertaking research, going to meetings, answering telephone calls from journalists or the women I care for. I have lots of wonderful PhD, Masters and Honours students who give me such delight, as I love growing the future of our profession, and they are indeed the future. I might end my day with a postnatal or antenatal visit in a woman’s home, and if I get called to a birth it is usually at night. I have only had to get someone to fill in for me once in the past four years of being on call because a woman gave birth when I had a lecture on. Once back home I do what all mothers do: get the dinner on, nag about homework, listen to stories of the day and hopefully collapse on the lounge to watch Call the Midwife with my daughters, or Modern Family, which is another favourite.

I am a great advocate of your work on how the ‘risk agenda’ is influencing maternity care. Can you tell us why this is so important to you?

Fear is ruining birth and we have to stop the fear. When I am asked what I do as a midwife I say my job is to keep fear out of the room. I knit at birth now and work very hard to keep fear at bay in my own practice. I left the hospital system after 20 years of practice because I recognised I had become undone by the fear that was manufactured around me and I was no longer providing women with the best care. Now that I work in private practice and out of the system, supporting women mostly to give birth at home, I have re-found my faith in birth and realise it is not birth that is dangerous, it is us! I love working with midwives on how to put risk in perspective and manage the fear that is so endemic in our maternity systems. We need to make friends with fear and work out when it is protecting us and when it is destroying us. We also need to stop blaming women for their fear as I think the models of care, attitudes and language of health professionals are most to blame. I love watching women give birth without fear now, surrounded by love and trust. Women are so amazing and we are so lucky to share this magic journey with them and their partners and families.

We have a situation where maternity services are focused on risk reduction, and yet outcomes aren’t improving. What do you think the answer is?   

Get women and midwives out of the hospital. Move back to primary health care, community based models. Give every woman a known midwife and make relationship based care the priority. I often say to my students the largest organ involved in childbirth is the brain not the uterus. If you want the uterus to function well then start working with the brain. Value women and value birth. Base practice on evidence and make health services accountable to the evidence and provide cost effective care. In Australia we have been calling for private obstetricians to make their caesarean rates public so women know when they are cared for by a doctor with a 90% caesarean section rate. In my country I think this would have a big impact on our caesarean section rate which is nearly double in the private sector. Lastly, and most importantly, if women are to trust in themselves and birth then surely those caring for them need to trust in women and birth.

What other areas of maternity care are you interested in?

Just about everything, this is my problem. My mother always said the worst thing you can do with Hannah is make her bored. I can promise you one thing there is nothing about being a midwife that is boring. I say my job is perfect because I combine teaching, research, clinical practice and politics together. I would hate not to believe in what I do and I really, really do believe in the amazing job midwives do. I would love to see my colleagues hold their heads up high and say ‘I have the most amazing job in the world’, after all we usher in the future! I really love history as well, as I am convinced that the past has much to teach us and some really good midwifery practices happened in the past. This is why I chose to undertake a randomised controlled trial looking at the effect of perineal warm packs in second stage for my PhD, as it was branded an ‘old wives tale’ with no evidence to support it. This so called ‘old wives tale’ is now Level 1 evidence. It does give me a thrill that amidst all the ‘machines that go ping’ a midwife can hold her head high as she walks down the corridor with a bowl of steaming water and flannel to give a woman in second stage comfort. I am also very interested in how birth is shaping society and founded the group EPIIC (Epigenetic impact of Childbirth) with Professors Soo Downe (UCLAN) and Holly Powell Kenney (Yale) in 2011. I think this is where we need to really channel our energy in the future. If the way we are born is re-shaping society, which is increasingly looking likely, then we need to urgently get the message out before it is too late.

What are your plans for the future Hannah?

I never think about the future and I never really have. I never thought I would do a PhD - I kind of fell into that. I never thought I would be a professor and that just seemed to happen. I believe in doing what I love and believing in what I do and whatever eventuates usually is a good thing. But most important of all you sleep well at night when you adhere to this philosophy - that is if the phone doesn’t ring to call you to a birth of course. Best of all I can honestly say I have no regrets. Every part of my life, even the sorrows and mistakes have made me who I am and provided me with such valuable lessons.

And lastly, what inspires and motivates you to be proactive what you do?

Women’s rights motivate me and making the world a better place.   None of us should come into this world and leave again without making the world a better place. Until we do right by women and recognise, value and facilitate their amazing role in society then everything we do will be incomplete. The hand that rocks the cradle does rule the world whether the world is willing to acknowledge it or not. When every girl baby is born into the arms of parents who want her as much as they want their sons then we will be on the way to bright and certain future. In many ways I feel today that I am still that 12 year old girl standing by the window in the dawn light gazing at that perfect little girl, spellbound and outraged but always full of hope that we are on the way to a brighter future.

Hannah, thank you SO much for taking time to tell us more about yourself! It's such an honour having your input into my blog….I am thrilled!

You can follow Hannah on Twitter:  @hannahdahlen

And her website: http://www.uws.edu.au/fach/fach/key_people/associate_professor_hannah_dahlen

Photograph by Holly Priddis