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

How do health professionals use social media?

 

In preparation for an article I am writing for a midwifery journal, I decided to conduct a short survey to ascertain why health care workers use social media in a professional capacity.  The survey ran from 10/4/14 until 27/4/14, and was disseminated via Twitter and Facebook.

321 individuals responded, and the brief results are outlined below. The full article will be published in June edition of MIDIRS as the Hot Topic, authors Sheena Byrom and Anna Byrom

The questions asked were:

1. Do you use social media for professional reasons?

2. Please indicate your profession

3. In what country do you currently reside in?

Respondents were from Australia, Brazil, Canada, England, Ireland, Netherlands, New Zealand, Northern Ireland, Scotland, Spain, Switzerland, USA, UK, Wales.

4. Which social media network do you prefer?

5. How often to you log into social networks?

6. If Facebook is your preferred network, what are the benefits to your professional role?

These included widely used, networking, sharing, support, with a significant amount using private communication through closed groups. Even though the question wasn't asked, several respondents mentioned the fear of  recrimination.

'Posting information to my audience, getting them involved by comments. They get to know me and recommendations come from being known' Participant 2

7. If Twitter is your preferred network, what are the benefits to your professional role?

Benefits included fast responses, more professional than Facebook, access to wide network of individuals and groups,  connecting with other professionals, flattened hierarchy (access to leading professionals), support, sharing, global contacts, easy to use.

'Enables conversation - debate - information and knowledge exchange- encourages active student engagement - modelling professionalism - relationship building and networking' Participant 161

8. Please rank the benefits of your social media use

9. Please give examples of how social media has helped you in your professional role.

The responses further elaborated on the above factors,

'Connecting with health professional who have enabled me to reflect and learn Increasing my professionalism Enabling me to have a voice and communicate my value' Participant 98

'It helped launching CenteringPregnancy in the Netherlands! Connections with obstetrians outside my area. Enlarged my view on midwives, emancipation, women, public health etc' Participant 107

I would like to sincerely thank all those who participated in the survey.

Help to connect more midwives around the world (and be a ‘Twitter Buddy!’)

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19th March 2017

This is an update of a post written three years ago - prior to the ICM in Prague. It was an attempt to connect midwives all around the world - and we're still on the journey! As the next Congress approaches, shall we aim to double the numbers? Let's try! Please read instructions below - and if you want suggestions on who to follow, check out the list on names - all linked. 

With the International Day of the Midwife imminent, and the countdown to the International Confederation of Midwives 30th Triennial Congress (ICM) from 1-5th June, I want to try to engage with midwives around the world, to encourage and support them to connect through Twitter. I started ‘tweeting’ approximately 18 months ago, and I haven’t looked back. Here’s a glimpse of what Twitter does for me.

Nurses and midwives are generally reluctant to use Twitter. Not Facebook, just Twitter. Yet those using it can’t imagine life without it-Twitter has opened so many doors for them, and offered oodles of support. @WeNurses founder and social media expert Teresa Chinn @AgencyNurse is also a registered nurse, and offers thoughts on her blog why nurses and midwives SHOULD engage with Twitter , and some of the reasons why they don’t!  If you are worried about using social media professionally, then listen to this podcast by Dean Royles @NHSE_Dean  CEO of NHS Employers, as he slays some of the myths.

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IF YOU WOULD LIKE TO JOIN TWITTER, JOIN UP HERE. If you are going to ICM in June, and considering using Twitter, please do so BEFORE you leave home. It will be much easier! If you are a health organisation, and you would like to know more about using Facebook or Twitter, check out Social Media toolkit for the NHS. I have facilitated a midwives chat space for 12 months…@WeMidwives (part of @WeNurses) has gone from zero to 3,133 followers, many from around the world. And now it’s time to really try and engage with more! SO….. Would you be a Twitter Buddy? At the ICM I am charged with sharing the event’s highlights through Twitter and other social media platforms, and I will be producing Storify updates each day. I will also be delivering workshops on using social media, but this won’t include ‘how to’. For that, I need 'Twitter Buddies". Twitter Buddy If you are going to ICM in person or joining LIVEonline streaming, or you are planning to tweet during ICM using #ICMLIVE then read on! I am building a team of  midwife and student midwife 'Twitter Buddies' on the recommendation of social media expert @VictoriaBetton.  If you would like to help spread the advantages of Twitter by sharing your skill with least one other person during ICM week (1-5th June), then I'd love you to be part of the project! Here is the simple plan:

1. If you want to be a Twitter Buddy let me know, via Twitter, using #TwitterBuddy. I'll then add your name below!
2. During ICM week connect and sit with an interested midwife colleague, and show her/him how to use Twitter on a 121 basis. Aim for at least one midwife recruit per day!
3. Tweet me the Twitter handles of the new midwife Tweeters, and at the end of the week the results will be collated.
4. The Twitter Buddy who launches the most midwives on a new Twitter journey will be announced the week after the conference!
5. Direct your Twitter recruit to this blog post for encouragement.

ANOTHER REMINDER IF YOU WOULD LIKE TO JOIN TWITTER, JOIN UP HERE.  If you are going to ICM in June, and considering using Twitter, please do so BEFORE you leave home. It will be much easier!  COME AND JOIN IN THE CONVERSATION And HOT OFF THE PRESS, my daughter Anna Byrom and I have written our first article together. It's about social media, so you may find it interesting! Here it is

 CONFIRMED TWITTER BUDDIES!

1. Anna Byrom @acbmidwife  
2. Shawn Walker @SisterShawnRM
3. Simone Valk @sljvalk
4. @linsyrjls
5. @llisa01
6. Jane Morrow @MorrowJane
7. Cassie McNamara @MamaConference
8. Carmel McCalmont @UHCW_Midwife
9. Jenny Clarke @JennyTheM
10. Nalonya vd Laan @nalonya
11. Sarah Johnson @sarahjohnson222
12. Elly Copp @EleanorCopp
13. Tracey Cooper @drtraceyt
14. Amanda Firth @LaughingMrsM
15. Heather Franklin @Twidmife
16. Midwife Supervision @midwiferyWAHT
17. Lola the E-Midwife Lola_emidwife
18. Carolyn Hastie @CarolynHastie
19. Sara Bayes @SaraBayes
20. Alison Brodrick @AliBrodrick
21. Lizzie Bee @Li33ieBee
22. Pam Wild @pamoneuk
23. @Dashing_d_leo
24. Claire Fryer-Croxall @ClaireCroxall
25. Hana Ruth Abel @Hana_Studentmid
26. Ali Searle @alisearle
27. Karen Yates @karenyatesjcu
28. Lyn Ward @linward
29. Nicky @twixynicky1
30. Anita Fleming @AnitaFleming7
31. Lorna @berrybird71
32. Trudy Brock @TrudyBrock1
33. Geraldine Butcher @gbutcher17
34. NHS Midwife @midwife_foz
35. Anjuli Lord @anjulilord
36. Linda Wylie @uwslindawylie
37. Janet Fyle @consideredview
38. Joanne Camac @CamacJoanne  
39. Jane @Midwife2b0514
40. Claire Omand @clarabell080
41. Mary Stewart @midwife_mary
42. Francesca @Francesca343
43. Hannah Bowater @funking-nora
44. Sarah Johnson @sarahjohnson222
45. Kathryn Ashton @KathrynAshton1
46. Birthing Instincts @birthinstincts
47. Dawn Gilkes  @dawnmidwife
48. Debby Gould @DebbyGould
49. Sarah @sarah_pallett
50. Laura Fyall @LauraFyall
51. Tracey Hunter (need link)
52. Alison Taylor (need link)
53. Elsie b @LesleyBland
54. Alison Power @alisonpower31
55. Aku Bidan, Kamu? @BidanBidanku
56. Linda Ball @BallLinn
57. MaggieMoo @MaggieBakesBuns
58. Mhairi @Stmwmhairi
59. Kate @Dottymom
60. Jude @beetrooter
61. Kylie @smileyhudders
62. Lillian Bondo @LillianBondo
63. Mitra Kadarish @mee_tra
64. Annabel Nicholas @annienicholas68
65. Jenny Clarke @JennyTheM
66. Jacque Gerrard @JacqueGRCM
67. Kelly Stadelbaur @KellyStadelbaur
68. Brigid McConville @Brigid_McC
69. Natalie Buschman @Birthsandmore
70. Jayne Case @jaynecase8
71. Sarah Stewart @SarahStewart
72. Beth McRae @outbackmidwife1
73. M. Michel-Schuldt @emma_von_mumm
74. Vanessa Shand @vshand
75. Julie Wray @JuWray
76. Hari Ani @hunnyhunnymuch
77. Soffa Abdillah @soffa_abdillah
78. Fardila Elba @elba_cholia
79. Kerry Spencer @miffymoffit
80. Macavity @elusivesarah
81. Marjolein Gravendeel @MGravendeel
82. Wendy Warrington @wendywarringto1
83. Nicolette Peel @NicolettePeel
84. Hannah Harvey @hannahharv13
85. Helen Young @helenyoungmw
86. Ashleigh @ashleey_latham
87. Linda Bryceland @LyndaBryceland
88. Claire Macdiarmid @Mcdaddymacswife
89. Janie @janiealalawi
90. Sophie @sophieinpariss
91. Leigh @Leighree
92. Laura Williams @Laura4_x
93. NHS Midwife @NHSmidwife
94. Maria Anderson @MariaAnderson17
95. Louise Randall @LouiseAJRandall
96. Mary Ross-Davie @MaryRossDavie
97. Ans Luyben @luybenans
98. Roa @Roretta
99. Inisial Z @zidemanjaya
100. Jupuut @juliaputriutami
101. Berty @me_b3rty
102. Mel @Mel_meilina
103. Qorin @QorinDias
104. Yennita Maharani @nypinyip
105. Michelle Anderson @michellemidirs
106. Cathy Ashwin @CathyAshwin
107. Jane Pilston @janepilston
108. Kookie Salt @kookie31
109. Joanna Lake @JoLake87
110. Hannah Telford @TelfordHannah
111. Mahasiswa Kebidanan @Mahasiswa_Bidan
112. Sisilh @Hilmasilsil
113. Indira A U_tami @indie_utami
114. Ikka Zullianti @ikkazz
115. Nicola Wenlock @wenlock_nicola
116. Charlene Cole @CharleneSTMW
117. Deirdre Munro @DeirdreMunro
118. Sally Goodwin @Sally5881
119. Sam Halliwell @stmwsam01
120. Ellie Baggott @ElzieBag
121. Sami Joyce @sj_studentmiddy
122. Louise Webster @louise_ann_StMw
123. Lindsay Hill @pixhill
124. Clare Morris @Clarsey
125. Lina Duncan @MumbaiMidwife

Obstetric violence and humanized birth in Brazil

Student Midwife Oli Armshaw @olvinda has written another post for my blog. With others, we have been corresponding by email over the past few days, following the horrific revelation below.  

With sadness and horror I read about Adelir Carmen Lemos de Goés, a 29 year old pregnant woman, in Torres, Rio Grande do Sul, Brazil, being forced by the authorities to have a caesarean, on 1 April.

On 31 March, she had a scan and was examined by a doctor, who said she needed an immediate caesarean as she had already had two previous caesareans, the baby was breech and her pregnancy was 42 weeks.

Adelir, saying she would prefer a VBAC (vaginal birth after caesarean) in the hospital -although there was no staff to support her choice, signed a document taking responsibility for her decision and went home to await labour, with her doula, Stephany Hendz. In the middle of the night, when Adelir was already in established labour, armed police and medical personnel arrived in two military police cars and an ambulance, to force her to Hospital Nossa Senhora dos Navegantes, for a caesarean. In the name of risk to the unborn baby, the doctor had asked judge Liniane Maria Mog da Silva, to issue an injunction to bring her in for caesarean section. She was submitted to surgery by force, against her will. Yesterday, the result of her ultrasound scan circulated on Facebook, showing a gestational age of 40 weeks.

Brazil’s major press, including Globo G1, reported the story on 2April, which you can see here and also translated here.   According to Adelir, "Two military police cars came and an ambulance to take us from our house. I was very anxious. I was all but handcuffed," she said, alleging verbal abuse by police.

Here, you can see Adelir speaking about the terrifying experience of police arriving at her house when she was in established labour, contracting every 5 minutes, and being forced to hospital for surgery. You don’t need to understand Portuguese to see how she feels.

The response in Brazil has been mixed: Most Brazilians do not sympathize with Adelir, the outraged birth activists or the ‘crazy feminists’, who support a mother’s right to make her own choices about birth and risk. But there is a strong, groundswell movement for the humanization of birth, fronted by ReHuNa (League for the Humanization of Childbirth), which considers this brutal incident to be an unacceptable breach of human rights, and is demanding that the Justice Department take action to address it. Peaceful protest demonstrations are being staged on 11 April in São Paulo, Rio de Janeiro, Torres, Belem and across the world at all Brazilian embassies. The UK embassy of Brazil is at 16 Cockspur St, London SW1Y 5BL. For more information please visit: weareadelir.blogspot.co.uk

Birth activists have started a petition on Avaaz, which you can sign here, to oppose the infringement on civil liberty, and extreme technical incompetence of doctors and government. They claim the incident not only breaches the Code of Medical Ethics, but goes against basic evidence: “Labour is a safe and appropriate choice for most women who have had one or more previous caesareans” and “pelvic planned vaginal delivery of breech babies may be reasonable under the guidelines of hospital protocols.” (ACOG Bulletin for clinical practice No. 115, 2010). You can read a full translation of the Avaaz petition here.

A formal complaint has been lodged at the Secretariat of Justice and Human Rights of the Presidency of the Republic by Artemis, a Brazilian NGO promoting women's autonomy and the prevention and eradication of all forms of violence against women. Here, you can see their letters on Ligia Moreiras Sena’s blog. @birthrightsorg have responded with this excellent blog on obstetric violence and use of ‘risk’ to legally justify treating women’s bodies “as public objects subject to the whims of the medical profession backed by the coercive power of the state” (Birthrights, 2014). Read also @KathiValeii’s powerful and passionate blog, ‘The war on women just got bloody brutal’ at Birthanarchy.

As Daphne Rattner, president of ReHuNa points out, this incident has occurred in the week that Brazilians are counting fifty years since the military coup d’etat in 1964, making it all the more grimly poignant that armed police were involved in forcing Adelir to hospital for unwanted surgery. It has Brazilians wondering who will be next to be dragged away by police, and if Adelir or her husband, Emerson, had resisted or reacted, would they have been shot?

Thanks to The Iolanthe Midwifery Trust, I’m going to Brazil for an elective midwifery placement at Hopsital Sofia Feldman, a beacon for the humanized model of care in Brazil, and attend the 9^th Normal Labour and Birth Conference. It’s going to be an incredible journey back to Brazil, the country I adore. I anticipate learning a lot from the brilliant midwives there, who are committed to supporting women to birth their babies where, how, with whom, and when they want; and fighting for an end to obstetric violence of all kinds.

“Humanized Birth”, as Elis Almeida puts it so powerfully in her blog Parto Humanizado no SUS, (translated here) “contrary to what most people think, is not background music and/or low light at birth, but a set of actions aimed at a satisfying birth experience, in which the woman and the baby are the protagonists, where attention and care are fully focused on the mother and baby dyad, and not on the doctor and institution”. A bill was passed by the government on 25 September 2013 legislating for humanized conditions at birth, but ‘what’, asks Almeida, ‘is the point of having a law if it is not supported and enforced by existing policies and practices?’

I trust that Adelir’s case will mark a turning point, a pivotal moment in the ongoing fight against obstetric violence, and catalyse lucidity and urgent action to humanize childbirth in Brazil.

Oli Armshaw @olvinda, April 2014 #NOobstetricviolence

Oli Armshaw @olvinda, April 2014

C/S Photo source

Born to Safe Hands: with a few battle cries

Two exceptional midwives from Bolton, in NW England, decided to plan a conference after being inspired whilst attending MAMA conference in 2013. Joanne Camac and Annabel Nicholas wanted to hold an event to celebrate birth centres, and chose the name ‘Born to Safe Hands’  from their family experience/visitors book.  Jo told me 'a lovely family that Annabel and I looked after wrote this and we felt it was just perfect for our conference'.  So they set about inviting potential speakers, collaborators, film makers and researching venues. Last week the conference happened. From the moment I arrived, I knew I was part of something special. The wonderful Oli Armshaw (@Olvinda), a student midwife from the University of the West of England attended (see photo below), and has written a superb reflection of the day.

When Sheena asked me to write a reflection on Friday’s Born to Safe Hands conference, I did what I always do, which is, a) instantly say yes without considering how on earth I’ll lever it in around family/full time placement/exam revision and, b) consult Twitter – and there it was, the whole marvelous day to be relived, one #B2SH tweet at a time!

On 28^th March 2014, 180 midwives, mothers and a few doctors converged on the home of Bolton Wanderers football club for Born to Safe Hands: a conference to celebrate birth centres, beautifully brought to life by Bolton Birth Centre midwives, Joanne Camac and Annabel Nicholas. I’m still buzzing from the vibrantly positive atmosphere and sense of building a community, a living network - not just within the walls of the Reebok stadium conference room, but as far afield as Perth, Rio de Janeiro, Edinburgh, wherever Twitter stretches. The midwifery ecosystem keeps growing, inspiring us to keep up the fight for women’s rights to informed choice and dignity in childbirth, and to keep looking for ways to be ‘with woman’ - for all women, not just those who fit admission criteria.

Certain battle cries stood out from the day:

‘Put on your leadership hat and fight for women!’ Cathy Warwick incited every single midwife to be innovative, imaginative and creative about the woman-centred agenda, do research, challenge practice and use emerging evidence. As we all know, it’s not just the birth rate putting midwifery under pressure, but the complexity of the women we are looking after, and we need to keep this complexity in perspective, as it’s not always a problem. Cathy highlighted the need to adapt our care and policies to the over 40s mothers, who are the most rapidly increasing group, and to learn from each other about keeping the numbers up for birth centres and freestanding midwifery units.

‘Why can’t labour wards look like birth centres?’ Denis Walsh demanded, as he enthused about normalizing birth for older mothers, women with high BMIs and other complexities. He calls for a change in how we assess risk, and to make the point that change can and does happen, told us about the ACOG’s game changing revised active labour thresholds: “Cervical dilation of 6 cm should be considered the threshold for the active phase of most women in labor. Thus, before 6 cm of dilation is achieved, standards of active phase progress should not be applied.” and “A prolonged latent phase (eg, greater than 20 hours in nulliparous women and greater than 14 hours in multiparous women) should not be an indication for cesarean delivery.”

‘It’s the baby’s blood anyway!’ cried obstetrician, David Hutchon confronting the misnomer ‘placental transfusion’. No one can still be in the dark about the benefits of timely cord clamping to prevent neonatal hypovolaemia, though third stage practice is slow to change.

‘Love or fear?’ Soo Downe, made it very simple, binary even: Love or fear. Which one are we working from? Which drives our decisions and actions? I enjoyed her every word about belief and salutogenesis: the fundamental belief that birth is salutogenic – ie seen from a perspective of wellness.

To illustrate the effects of being watched, and the power of belief, Soo showed us this chilling image of Jeremy Bentham’s Panoptican penitentiary (1791). The concept of the design is to allow a single watchman to observe (-opticon) all (pan-) inmates of an institution without them being able to tell whether they are being watched or not. Although it is physically impossible for the single watchman to observe all cells at once, the fact that the inmates cannot know when they are being watched means that all inmates must act as though they are watched at all times, effectively controlling their own behaviour constantly. It reminded me of the main office on delivery suite where 8 women’s CTG traces can be viewed at once on a huge screen – not exactly the ‘private, safe and unobserved’ conditions recommended by Dr Sarah Buckley as the optimum environment for undisturbed, physiological birth.

Sheena Byrom’s whizzy Prezi explored the pitfalls of using guidelines-policies-protocols interchangeably, and linked the importance of supporting women to make autonomous decisions with human rights and the dignity agenda. @SagefemmmeSB is a massive advocate of Twitter, as her ‘I love you Twitter!’ video shows, eulogizing about the potential for getting and giving support; sharing ideas and news; building relationships, communities, networks and social capital; influencing change; starting or engaging in debate about practice. She implores all midwives to adopt Twitter, to respond to evidence and articles, to challenge what’s being said, to question and connect with each other. Bring the birth revolution!

‘Is hospital birth a riskier choice for healthy women and babies?’ It was the first time I’d heard Mary Stewart speak and I loved her ‘coming clean’ as a passionate advocate of homebirth. She tackled the knotty concept of risk, swapping the word risk for chance, when talking about out of obstetric unit (OU) birth and transfers to OU from home. Mary urged us to be responsible when talking to women about place of birth, providing balanced information about planned hospital birth as well as planned home birth.

What I found most stimulating about Born to Safe Hands, was the social bonding, and positive community building of it all, which Lesley Choucri, director of midwifery at Salford University, related to Cooperider’s work on ‘unleashing the positive revolution of conversations’. Thanks to Twitter, the potential reach of the normal birth conversation at Born to Safe Hands stretches way beyond the immediate 180 people present in the room. In fact, Twitter stats  suggested that 123,228 unique users saw #B2SH and the number of impacts was over 2 million, i.e. the potential number of times someone could have seen #B2SH. This is very exciting.

Born to Safe Hands really was a celebration of the inspiring woman-led work going on in birth centres around the country - an antidote to fear and feeling disheartened, that we are losing our grip as birth becomes ever more medicalized, as women become more complex, and less curious and trusting of our bodies. Born to Safe Hands has revived my vigour and clarity about how to develop and nurture the new midwifery and bring to life the benefits of being truly ‘with woman’, for all women - the benefits of which span generations.

Oli Armshaw @olvinda

THANK YOU OLI!

A Storify from the conference is here, and a selection of comments:

‘best study day ever! Thank you – it’s been wonderful’

‘Best conference I’ve been to in years (and I go to a lot!). Well done. Make it annual! Make available on DVD for sale!’

‘Wonderful, wonderful day, loads of evidence and positive stories to take into my practice, thank you so much for organising’

‘Had a fabulous time, brilliant speakers. Feel ready to return fully invigorated’

‘Lovely to her what committed, expert birth centre midwives are doing in Bolton and around the UK’

‘More than exceeded my expectations, totally fantastic day, will look forward to the next one’

‘I came today to be uplifted and inspired as my unit feels very negative and de-motivated. I feel much more confident, have learnt something and feel so inspired and enthusiastic’

So Annabel and Jo, we hope you will start to plan next year's conference soon, and make it a annual event. As Jacque Gerrard said 'This could be the North West's answer to MAMA!'

We are NOT using the evidence: it’s time to change

 

I am posting this on #NHSChangeDay 2014.

I pledge to continue to make the case for change in maternity services, until ears listen.

Recently, my lovely Italian midwife friend who is a Doctoral student in England, told me of her confusion. ‘What I can’t understand’, she began ‘is why practice in maternity services in UK remains unchallenged when you have so many esteemed academics and the some of best research evidence in the world? She made me think.

Last week I was invited to present evidence related to continuity of care and choice in place of birth at one of the Personalised Maternity Care stakeholder events, in Leeds. The events are being held around the country, and are hosted by NHS Health Education England in response to a request from the Permanent Secretary for Health, Dr Dan Poulter. Dr Poulter wants to explore the ambitions for future Maternity Services and what such services might look like by 2022.

You can read info via the tweets here.

So on finding the evidence it became very apparent-we certainly aren’t using it.

Here are my slides.  I decided to share them widely to enable discussion and hopefully receive comments and ideas from readers to help inform the Minister.

Slide 1: There is an abundance of policy, guidance and results of surveys directing maternity services, which is largely being ignored. This is alarming, though not surprising. Yet let us consider: why was the Peel Report (Ministry of Health 1970) directing 100% hospital ‘deliveries’ given urgent attention, and fully implemented WITHOUT  evidence presented or women’s opinions to back it up?

Slide 2: We are not using latest research evidence, and according to the National Audit Office report (NAO) and the Public Accounts Committee report  (PAC) there is no measuring or reporting progress, no data, no assurance of value for money, and huge variations in cost, quality, safety and outcomes. In addition, women and families are reporting dissatisfaction with their care (Birthrights, CQC, Women's Institute), few women are receiving continuity, and choice in pace of birth (NAO, BirthChoice UK). Furthermore, stillbirth rates in England are highest in UK, and litigation costs increasing.

Slide 3: Margaret Hodge MP spells it out for you to read. Maragert chairs the PAC, and her observations are, I believe, a true reflection of maternity services in England today.

Slide 4 and 5: Reality for midwives. Desperation which often leads to leaving the profession, and for those can’t leave, numbness which increases risk of substandard care. There is a link to another post on this blog, where many comments have been made.

Slide 6: The NHS Mandate gives some direction for the future. Named midwife. What does that mean? The NHS England definition is 'a midwife who co-ordinates all the care and delivers some of the care' .   Continuity of care is another misused phrase, but if continuity is good, surely there would be improved responses to ‘mental health concerns’.

Slide 7: Highlights the main references for the research evidence for continuity of care

Slide 8: Reveals some of what this evidence tells us. How can we not take notice?

Slide 9: Did you know that the National Service Framework for children, young people and maternity services was still the current directive for maternity services?  And it states that every woman should be able ‘to choose the most appropriate place and professional during childbirth’

Slide 10, 11 & 12 : The evidence for choice in place of birth has NEVER been so strong as it is now, for women with no or expected complications. These are the key findings of the Birthplace Study but in general it tells us:

-Giving birth is generally very safe

-Midwifery units appear to be safe for the baby and offer benefits for the mother

-For women having a second or subsequent baby, home births and midwifery unit births appear to be safe for the baby and offer benefits for the mother

-For women having a first baby, a planned home birth increases the risk for the baby (this is very small- four more babies in every thousand births had a poor outcome as a result of a planned home birth in first pregnancies).

-Women planning to give birth in a midwifery unit experienced substantially less medical intervention than those in an obstetric unit.

For women having a second or subsequent baby, home births and midwifery unit births appear to be safe for the baby and offer benefits for the mother

 For multiparous women, there were no significant differences in adverse perinatal outcomes

between planned home births or midwifery unit births and planned births in obstetric units.

 For multiparous women, birth in a non‐obstetric unit setting significantly and substantially reduced the odds of having an intrapartum caesarean section, instrumental delivery or episiotomy.

Important points I would like to make here, for those working closely with expectant parents:

Do you mention the above evidence when talking to women about their choices? I expect most will remember to mention the small risk for first time mothers wishing to birth at home. But do you advise women about the potential increased risk of unnecessary  medical intervention?

How do you make evidence accessible for parents? How do you deliver the evidence, do you know what it says? This is a brilliant article on how to share evidence based information. It’s a must read.

Slide 13: Is self-explanatory. Note the decrease in obstetric units (OU) and increase in alongside midwifery led units (MLU). This coincides with the number of amalgamated Trusts, and the aforesaid NSF. There is only a slight increase in the number of freestanding midwifery units (FMU), probably due to closures corresponding with others opening.  The slide informs us that very few women have the full choice guarantee as proposed in the NSF in 2004.

Slide 14: Because of the above, the slide shows that most women (87%) give birth in an OU.

Slide 15: Two recent media articles demonstrating ongoing constraints of providing home birth and birth centre births, yet the evidence is clear that women choosing to birth in these venues are there less to endure unnecessary interventions, and the service is more cost effective.  Does that make sense?

Slide 16: The best estimate of women eligible to have their baby in a non OU setting (low risk) is 50%, although WHO estimate this should be between 70-80%.   Taking 50% of 2012 birth rate (700,000) = 350,000  and deducting 89,000 women who actually had midwife led births in non OU setting, leaves us with the shocking figure of 261,000 women and babies who, according to Birthplace Study, are potentially exposed to unnecessary medical intervention.

This is unacceptable. Yet it remains silent, unspoken, when the small risk of home birth is magnified out of proportion. In addition to the human cost in terms of morbidity, there are financial implications, and pressures on the workforce. So now we have the evidence, and things MUST to change.

Slide 17: Some of the effects of the previous slide, in terms of mode of birth, and maternal feelings. Diagrams taken from the Dignity Survey 2013.

Slide 18: The potential consequences of current maternity service provision.

Slide 19: What Personalised Maternity Care should look like, including flexible use of clinical guidelines, to support women’s choices.

Slide 20: Relevant and important recommendations from the Public Accounts Committee.

The following slides give and example of maternity services in East Lancashire, where I worked for 35 years. I have highlighted these award-winning services to demonstrate how choice and continuity can be achieved. The service is situated in one of the most socially deprived Local Authorities in England, and has undergone a significant reconfiguration in 2013. With 30% of 6,700 births per year in the three birth centres (2 FMUs and 1 AMU), they are maximizing opportunity for women and staff, with excellent results.  The slides demonstrate financial gain from the model of care, and how mothers, midwives and managers feel about the service.  The key factors of success for the model in East Lancashire are:

-Model of care: midwives work in the community AND the birth centre, providing continuity and accurate and positive information sharing about place of birth

-Collaboration: obstetricians, midwives, neonatoligists, service uses, auxiliary staff support each other, and work together to ensure the woman and her family are supported.

-Leadership: the service has strong midwifery leadership at all levels.

The last slide is of my newest granddaughter, Myla. When Myla is of age to have children of her own, I want her to know that the evidence we now have was used well, to give her the best chance ever to have a positive experience and healthy baby.

Please leave your comments. We musn’t give up.

Table: Dodwell and Newburn (2010) 

Reference:

Ministry of Health (1970) Domiciliary Midwifery and Maternity Bed Needs: the Report of the Standing Maternity and Midwifery Advisory Committee (Sub-committee Chairman J. Peel), HMSO, London

Photographs used in slides are owned by Sheena Byrom and East Lancashire Hospitals Trust

We need more midwife Care Makers! Check out what Liverpool students did!

I received an email today from the Royal College of Midwives, asking me to post this wonderful news item on my blog. And I was delighted to, for many reasons.

As I regularly use Twitter and connect with nurses and midwives at all levels, I read about the massive impact the Compassion in Practice strategy is having on the NHS…both at the bedside and on social media. I've been enthused by the role of Care Makers, and have been trying to encourage more midwives to join. So if you are a student midwife, or a midwife, this may encourage you!

Care Makers are health and social care staff (student and qualified) who act as ambassadors for the 6Cs. They are selected for demonstrating a commitment to spreading the word about Compassion in Practice across the NHS. Care Makers create a unique link between national policy and strategy to staff working with patients. The aim is to capture the ‘spirit’ of London 2012, learning from the way Games Makers were recruited, trained and valued and  instilling the spirit of energy and enthusiasm they created.

This January five Liverpool John Moores Midwifery Students represented their University at a Nursing and Midwifery Celebration Event at Liverpool Women's Hospital. These students (pictured above) volunteered as Caremakers at the event, which showcased services at Liverpool Women's Hospital. The day was a huge success, with notable external speakers, stakeholders, staff and service users in attendance. Nursing and Midwifery workforce also got the opportunity to make a commitment to their patients in part of the new strategy at the Women's titled "Our Promise to Patients".

Three of the students also represented the University and Trust as Student Quality Ambassadors - a new role developed in the North West of England for students to champion and highlight good practice and challenge areas needing development in the practice areas of their placements. Student Midwife Ela Yuregir said "Having just started my Midwifery training I am keen to get involved in the sphere of Midwifery both at a local and regional level which is why I chose to become an SQA at The Women's Hospital. Events like this one really inspire me as I can see the staff here are so passionate about the women they care for, and it's great to see the Hospital are so pro-active in acknowledging and improving their great standard of care" Student Clare Bratherton comments on her experience taking part in the "Me Effect" video launched at the event: "I was really proud to be asked by Liverpool Women's hospital to represent LJMU by taking part in  video.  It highlights the impact that every individual has on patient experience and care.  The nursing and midwifery celebration day saw the launch of this and to be present as a Caremaker was a real privilege." Tisian Lysnkey-Wylkie explains how the event highlighted to her the passion that her mentors still have "As a student midwife in the middle of my training it's great to be part of an event and see my mentors keen to engage in the trust they work for, and be proud to work at LWH. That to me shows that they are still motivated and passionate about midwifery and include themselves in progressing to provide better maternity care for our women. I am proud to be a student learning in a trust that is so dedicated to women's health and look forward to the rest of my training here. As an SQA it's part of my role to highlight good practice an developments that benefit those in the NHS, at a time when midwives are under pressure celebration days are needed to show the appreciation that midwives deserve, more events should be done to acknowledge their hard work" The event was a great success overall and the students hope that their roles as both Care Makers and SQAs will inspire current and future JMU Midwifery Students to get involved with their local trusts.

WOW! What incredibly motivated and passionate student midwives…well done to all of you for representing your organisations, the NW of England, and MIDWIFERY! Thank you!

So come on fellow midwives…join the crew! 

EXCLUSIVE INTERVIEW-Toni and Alex changing the world

Toni Harman and her partner Alex became known to me when I saw a short clip of one of their outstanding videos, on a social media channel. This was several years ago, and since then I have stayed in close contact with them, assisting and supporting them whenever I can. To say that they took the birthing world by storm is an understatement. This unique partnership has given birth activists the voice they needed, and their expertise in documentary film making means we now how a powerful medium to share knowledge to more people.

As Toni and Alex have just launched their exciting new campaign MicroBirth, I asked Toni if I could interview her for my blog (and she agreed!)

Hi Toni, thanks for agreeing to answering my questions, hope you have fun! Can you tell us a bit about yourselves in a nutshell?

 Toni: Thanks Sheena for inviting us to do this! 

Alex and I met at London Film School 20 years ago, (back then it was called the London International Film School). After we graduated, we formed a company called Alto Films and started making films together. We made documentaries, short films and even a psychological thriller feature film. Then six years ago, we had a baby. And that changed everything.

We started making films about birth. We made a documentary about doulas called DOULA! then we started looking into the bigger picture of childbirth.

Three years later, we've travelled 35,000 miles and interviewed over 150 world leading experts - amongst them, academics, lawyers, scientists, midwives, obstetricians, psychologists and anthropologists. We've released short videos on our One World Birth website and started building a community of people on Facebook.

In 2012 we released FREEDOM FOR BIRTH, a 60 minute documentary that exposed human rights abuses around the world, particularly highlighting the story of the imprisoned Hungarian midwife Agnes Gereb.

In December 2012, we started looking at possible subjects for our next documentary. We started researching the science around birth and the more we read, the more “levels” we seemed to uncover. It was fascinating but also, deeply troubling. So in the summer of 2013, we started filming, first in the UK and then we flew out to the United States and Canada. What we learned shocked us to the core - we realised this film had the potential to change everything. And so MICROBIRTH was born.

ONE WORLD BIRTH is a now well known name globally, and FREEDOM FOR BIRTH  is a huge success. What impact do you think you and the campaign has had so far ?

Toni: That's very kind of you to say. I think ONE WORLD BIRTH is perhaps well-known in the birth world, but outside the birth world, I don't think many people have heard of it.

Same goes for FREEDOM FOR BIRTH - I am really proud of its “success” in terms of the number of people in the birth world who have seen it, or at least have heard about the film. With the premiere launch, we had over 100,000 people see the film at over 1,000 screenings in 50 countries in 17 languages - all on one day.

 And I'm very proud that the film has played a part in starting to change maternity policies worldwide so that the rights of birthing women are respected. But realistically, outside the birth world, I'm not sure how many of the “mainstream population” have heard about it or know about the issues.

Unfortunately, women's rights in childbirth are still being abused every day all around the world - many expectant women are not being given full informed consent, home birth attended by midwives is not available as a supported choice in many parts of the world and indeed, in the past year, many more midwives have been criminally prosecuted for supporting women giving birth at home. I remain optimistic that change will happen so that all women's choices are fully respected everywhere around the world and I am excited by the potential of the formation of Human Rights in Childbirth and Birthrights as organisations that will help further the cause.

 I am so excited about your new project MICROBIRTH -do tell us about it please, and a something about the inspiration behind it?

 

Toni: MICROBIRTH is our new feature-length documentary asking if medical interventions in childbirth could be damaging the long-term health of our children and have repercussions for the whole of our species.

We wanted to make a film that looks at birth in a whole new way, through the lens of a microscope. This has never been done before and we believe the science the film is revealing is the missing piece of the jigsaw. This could change birth around the world, forever.

The film explores the latest scientific developments in the fields of microbiology, physiology and epigenetics.

Some scientists are starting to question if there is a link between medical interventions in childbirth (specifically use of synthetic oxytocin, antibiotics, C-section and formula feeding) with an increased risk of our children developing non-communicable disease later in life.

Non-communicable diseases include heart disease, asthma and other respiratory diseases, diabetes, autoimmune diseases, some cancers and mental health disorders. They are already at epidemic proportions around the world and are the world's no. 1 killer. But these diseases are on the rise. It is predicted that the cost of non-communicable disease could bankrupt world healthcare systems by the year 2030, an event that could have catastrophic consequences for mankind....

The campaign's 9 minute pitch video features some of the scientists we have filmed and explains a bit of the science of the microbiome. The film also tells more about the event that we've been describing as “global warming for the species”:

What are your plans for this campaign?

Toni: We need to raise $100,000 to complete filming and to get the film seen around the world. So we've launched an Indiegogo campaign to help us raise the funds we need. If we can raise enough money, then we want to film at the Human Microbiome Project in New York, the United Nations, the World Economic Forum and the World Health Organization as well as filming the top people at leading obstetric organisations to hear their view about the potential long-term consequences of medical interventions in childbirth.

The most exciting part of this project is how we want to release the film. Just like we did with FREEDOM FOR BIRTH, we want to have thousands of premiere screenings of MICROBIRTH held all around the world on one single day. We want to create a global simultaneous event with screenings in every community, in every country so that we can grab the attention of the global media and we can grab the attention of decision-makers including our Presidents and Prime Ministers. It sounds ambitious, but we truly believe that if we can do this, especially if we have the the support of strong-minded, strong-willed individuals committed to making change happen.

In terms of what we want this film to achieve, we want to raise awareness that there could be long-term consequences arising from the medicalised way we are giving birth today, both for our children and for our whole species. We want to get everyone talking about this and taking this issue extremely seriously for the future of humanity could be at stake. And we would love to see much more scientific research looking at the potential long-term consequences of medical interventions in childbirth, before it is too late.

 What’s the most important thing you have learnt since beginning this amazing journey of campaigning for better childbirth?

Toni: We've been very fortunate in being able to film interviews with over 150 experts across so many different fields.

But I think there's two pivotal moments in our journey so far.  The first birth I filmed completely changed my world view. It was four years ago and it was a home water birth in the UK with the mother and father supported by a doula and two wonderful midwives (it was the first birth featured in our DOULA! Film). It was a completely physiological labour, birth and 3rd stage with no pharmacological pain relief, not even gas and air.  The labour and birth was the most beautiful, amazing, calm, wonderful, inspiring thing I have ever seen. It was perfect. I saw with my own eyes what birth could be like. I know some women might not want a home birth. And some women might want or need pain relief and other medical interventions. But the beauty of that moment, well, it was simply life-changing.

The second pivotal moment was last summer when we were filming for MICROBIRTH. We filmed a Professor of Immunotoxiciology at Cornell University. He told us exactly why and how interventions in childbirth could be damaging the long-term health of our children with implications for the whole of mankind. We had huge goose-bumps. I still have them now as I remember that moment.

If I had a magic wand, and could grant one wish to ensure all women had a positive birth experience, what would you ask for?

Toni: After we made FREEDOM FOR BIRTH my hope was that every woman on the planet has the best possible birth wherever, however and with whom she chooses to give birth. I hope that all women are fully informed about their birth choices and that these choices are fully respected by every healthcare provider.

But now with MICROBIRTH, I have one more wish. That every expectant mother and healthcare provider is fully informed about the importance of seeding the baby's microbiome with the mother's own bacteria. That even if a mother needs to have a C-section, that she is still fully supported with immediate skin-to-skin contact and with breastfeeding. It sounds a technical, scientific wish, but if this was possible on a planet-wide basis, I believe that this could make a significant difference to the future health of mankind.

And lastly, what drives you both, as a couple, to stay motivated and passionate about your work in this area?

Toni: When we were at film school, we were told to never make a film unless you felt that it had the power to change the world. So every film we make, we honestly do set out to change the world. That's what drives us forward. That's what motivates us. The thought that we can use our skills as filmmakers to make a significant difference to the world.

With MICROBIRTH, we think this could be a game-changer. This could be THE ONE. We feel that this is the most important film we will ever make. But to get it finished and seen around the world for maximum impact, we need everyone's support - not just financially in terms of contributions to our fund-raising campaign, but in sharing links and in spreading awareness, both now and when the finished film is released this September.

Thanks Sheena for asking me to do this. It was fun!

It's 2014. Time to listen, and hear what midwives say

Earlier this month a health correspondent from The Independent contacted me via Twitter to ask me if I would be willing to comment on this article, written the day before.

The piece quoted the words of a very honest and courageous midwife, and I applaud her. I don’t usually like commentaries which could potential cause fear amongst women who use our maternity services…and I am always wary of journalists, for this very reason. However this article is very accurate, and I am sure 80% of midwives would agree with what is written.

I wrote about these issues here.

The RCM are continuously campaigning for more midwives, and although NHS England have published a staffing strategy placing onus on Trusts to ensure safe standards in terms of capacity and capability http://www.england.nhs.uk/2013/11/19/staff-guidance/, there aren’t enough midwives to fill posts. Support staff are crucial, as often midwives are doing non midwifery tasks, but often organisations can't afford them either. We are constantly reminded that there are increased pressures within maternity services due to an increasing birth rate and complexities of those using the service, but external and internal reviews of NHS organisations and departments, and risk management agendas (including processes relating to CNST) are adding to the strain through increased bureaucracy and fear.

It seems some midwives possess professional resilience to pressure and adversity in the workplace, managing to stay positive and motivated despite the increasing demands placed upon them (Hunter and Warren 2013). . One of the themes from this study findings was ‘building resilience’, where participants demonstrated the development of strategies to help themselves and others to cope. So where do student midwives and midwives get the support from, to help them to cope on a daily basis? Do they know whom these ‘resilient midwives’ are, to help them to build coping mechanism for preservation? Sometimes sharing a crisis moment with a work colleague or supervisor of midwives does the trick, and support is there and continues. But there are times when practitioners fail to share feelings for many reasons, including time, confidentiality, and confidence.

I had specific colleagues that I turned to in stressful times or moments of crisis, and I knew the things I could do to help me re-focus and keep things in perspective. In the early 1990s I had read Caroline Flint’s book, ‘Sensitive Midwifery’ (Flint 1991), and I loved and used the suggestions Caroline gave to midwives on self-care. I think they helped me.

I have written a short piece in February's edition of Practising Midwife, about how social media and online resources can help practitioners to stay in touch with like minded individuals and to glean tips to try to stay positive at work. And later this month I have written a @wemidwives chat to share ideas with nurses, midwives and students. Join in if you can!

In the meantime, these were my suggestions to the journalist, about how we can try to help midwives and improve maternity care:

The Government needs to hear and act in terms of resourcing increased midwife numbers. The problem will not go away. Choice, continuity of care and carer and the sustainability of independent midwifery are all crucial issues that need urgent attention, BUT WE NEED MORE MIDWIVES.

For maternity services, there needs to be a shift of focus on wellbeing instead of illness, and kindness and compassion instead of punitive culture where fear and blame prevails. The latter adds extra burden on an already pressured service. Although midwives are leaving due to increased stress at work, there are many who can’t, and they need to be valued and cared for.

We need an invigorated focus on reducing unnecessary medical intervention during childbirth, mainly because there is emerging evidence that the consequences are potentially catastrophic.

What are your thoughts?

Reference:

Flint C (1991) Sensitive Midwifery Butterworth-Heinemann Ltd London

What happened to my blog! Thanks to all readers in 2013

The WordPress.com stats helper monkeys prepared a 2013 annual report for this blog.

Here's an excerpt:

The concert hall at the Sydney Opera House holds 2,700 people. This blog was viewed about 46,000 times in 2013. 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.

England needs more midwives: but legal services are fine

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I was interviewed on Radio 5 Live yesterday, in relation to the news coverage of the National Audit Office revelations of maternity care.  The report confirmed the fact that England IS short of midwives, and revealed that the NHS spends nearly £700 on clinical negligence cover for each live birth in England. I wonder how many times audits and reports will confirm what we midwives have known and shouted about for years, and how long the message will continue to fall on deaf ears.

The Royal College of Midwives,  National Childbirth Trust, AIMS,  Women’s Institute and other organisations have campaigned long and hard for more midwives, needed urgently for the rising birth rate and increasing complexity in caring for mothers and babies. But there is something else going on here. The financial implications of England’s current negligence insurance scheme (Clinical Negligence Schemes for Trusts) mentioned above are bad enough, but associated processes also significantly increases the workload of maternity care staff, and adds to the growing culture of fear in maternity services.

In an attempt to increase safety through implementing standards of compliance, activity related to the scheme potentially increases risk by putting extra pressure of individual members of staff. ‘Tick box’ activity, extra form filling, and duplication of records add to the human cost and potential for mistakes. In many organisations midwives are taken out of generic posts to work as ‘risk midwives’ or governance leads. Usually these midwives are highly competent clinically, and their absence in the clinical area is missed-adding to the risk.

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However, an important impact of our legal system is related to practitioner's fear of recrimination, and fear of litigation. Defensive practice or ‘covering your back’ ‘just in case’ is a recognised symptom of fear of litigation-and subsequent over treatment increases the risk of iatrogenic harm.  The increased and often duplicated recording of information becomes the focus of ‘care’, as practitioners complete patient records which are audited for insurance purposes. What the carer writes becomes more important than what she/he does, and women and families increasingly experience this distraction negatively.

The medical negligence solicitor who took part in the radio programme with me yesterday, said midwives and doctors need to increase their skills, and he suggested that England’s medical negligence processes were the envy of the world. I have a different opinion. Ensuring safety through appropriate skills is crucial, and whilst mistakes will happen, there is no excuse and we should continually aim to learn from mistakes,  and work on improving services. Along with others, I believe improvements will only come if NHS workers are sufficient in number to have time to care, and that they are supported and nurtured enough to feel safe themselves. Where fear prevails and defensive practice in normal, women and families will continue to suffer. Radical but carefully planned changes are needed. Malpractice claims are rising, and there is little evidence that safety is improving, despite the laborious and bureaucratic systems and process imposed in the name of such. Our negligence claims insurance schemes aren’t working, and midwives are on their knees. Even though politician Dan Poulter is an obstetrician by profession, his responses to the NAO report reveal limited insight into the detail underpinning the facts that matter. We’ve said it before many times. If we don’t get it right for mothers and babies at the beginning of life, the impact can last a lifetime.

Childbirth has far reaching public health implications. This specilist medical negligence solicitor reveals the fact that many of the claims she sees are the result of pressures within the maternity systems, and calls for more resources to be invested.  Maybe it’s time to revisit a no-fault compensation scheme, the attempt in 2003 was never taken forward. Scotland has pursued this in light of the success in other countries.

Whatever we do, we can’t continue in the same vein. I would love to know your thoughts.

Lively interview with student midwife Liz!

Well, as with many other inspirational student midwives, I 'met' Liz via Twitter. Her name appeared regularly, on midwifery debates and forums, and her enthusiasm and drive attracted my attention. I think the calibre of student midwives is getting better and better; women (and men!) entering our profession are kind, compassionate and quite dynamic.

So, here's Liz Blamire!

Hi Liz, many thanks indeed for agreeing to be interviewed for my blog! I am delighted...would you like to start by introducing yourself?

I am a third year student midwife at Anglia Ruskin University. I am also a wife and mother of two children aged 10 and 12. I am 36 years old and I love to read and I like fast cars!

Great! Can you tell us about why you decided to become a midwife, and what influenced your decision?

When pregnant with my daughter I discovered the world of pregnancy, labour and birth and the political aspect appealed to me. I had home water births and for me, birthing was very much about womanhood, body awareness and feminine power. I felt incredibly in touch with myself. In my subsequent voluntary work with NCT I met many women for whom the experience was very different, with disempowerment, loss of control and a ‘grin and bear it’ experience being common themes. It was largely the influence of my husband – “don’t just moan about it, get in on the inside and change it!” – that pushed me to apply. In fact, I had a place to start the Midwifery BSc in 2005 and I ultimately declined the place as the children were so young and my husband was starting his own business. In retrospect I probably would not have made it through the course back then. Instead I started in March 2011 – again because of my husband, who said “you are going to be a midwife now” when I had all but forgotten about the dream.

What are the things you enjoy most as a student midwife Liz?

The best part of being a student midwife is the amazing rapport you can build with women. Women surprise me everyday, with their strength, character and sense of humour. We get to take part in the most intimate and transformative journey that most women go through. What can beat that?

And what things would you change, if you could?

How long have you got?! This is actually a very difficult question as my experience has been overwhelmingly positive although I know that many student midwives struggle with various aspects of the training. The hardest things for me have revolved around getting the work / life balance right. The work of the midwife is emotionally draining and sometimes I feel like I need the equivalent amount of quiet, contemplative time to heal myself. So it can be incredibly hard to finish a 12.5 hour shift and then know that when you get home you need to strongly encourage the children to do their homework and clean out the hamsters! Or deal with a family problem such as friendship fall outs at school and upset 12 year old girls, or just be nice to your husband…

Mentorship is very important to student midwives, and I understand why. We hear different accounts from students about their mentors -some good, and some not so good.  Can you think about the best mentor you have had, and tell us what her qualities are that make her stand out?

Hand on heart every mentor I have had has been incredibly good. The qualities I appreciate most are the qualities I try and embody in my own midwifery practice and I see the mentor-student relationship as very similar to the midwife-mother relationship. To be supportive, nurturing and always act with integrity. To enable hopes and targets to be realised, even if that means you have to be pushed slightly out of your comfort zone. To have a mutual respect for and learn from each other.

I know that you are involved in extra activity, such as your work with the Royal College of Midwives. Can you tell us about that and anything else you do outside your regular training?

You are right I am the (outgoing) chair of the Student Midwives Forum at the RCM. I am also on the Steering Group of the Association of Radical Midwives. In that role I am hosting an amazing (if I do say so myself) meeting in Northamptonshire on December 7th 2013. 

Obviously I try and get out and about with my children, usually involving a long walk in a country park and a sneaky lunch out somewhere! I used to spend a lot of time attending motorsport events and I am actually the co-owner (with my husband) of a company that tunes performance cars, although I have only been to two events this year. My motorsport life sometimes seems like a world away from midwifery and yet, those old friends are all incredibly supportive and love to hear about birth and stuff even when twirling a spanner over an engine bay!

What are your long term plans?

I absolutely want to work in a low risk setting. Either a stand alone midwifery led unit, or as a caseload midwife. I would also like to undertake postgraduate study and dream of being a Professor of Midwifery (probably clinical) one day. Most of all though, I want to continue to enjoy the profession and keep my passion burning and make a difference to as many women as possible.

What advice would you give to someone who would like to become a midwife?

Find out as much as you can about midwifery, the good and bad bits. Try and meet different kinds of midwives. If you still want to do it and think you can, the only way you will fully know is to try it.

Many thanks Liz, you obviously made the right choice, as your passion shines through in your words. I am sure already you are making an enormous difference to women and families you care for. 

Liz can be contacted via Twitter :  @Li33ieBee

The right to choose home birth: a debate in the UK

I am always alarmed, though not surprised, to see press articles such as this questioning the ‘rights’ of women requesting a home birth.  Over a period of 35 years as a midwife, I have cared for scores women who have given birth at home, and those occasions have been some of the most rewarding moments in my career.  We now have clear evidence that home birth is cost effective and safe.

My district nursing sister (who had her babies at home) tells me that when loved ones wish to die at home, the request is always respected. Services are mobilised to ensure those precious end of life moments are as comfortable as possible. To me, this is fundamental stuff, and choice at the beginning and end of life should have equal priority.  Yet in the above article, lawyer Barbara Hewson is quoted as stating that ‘mother’s don’t have a right to choose a home birth’.

I noticed that the Royal College of Midwives is debating this very issue at their forthcoming conference in November.

I was surprised that an obstetrician is speaking on the topic, and we are to hear perspectives from a panel made up of a lawyer, an obstetrician and a journalist. But where’s the midwife? Isn’t the midwife the one who facilitates home birth?

So I thought I would ask some questions to a similar panel, but to include a midwife, to get a debate going…please add your comments and experiences at the end of the post, and add to the conversation.

 The panel:

Professor Soo Downe OBE (Midwife)

Elizabeth Prochaska (Lawyer-Public Law and Human Rights)

Milli Hill (Journalist-Mother-Doula)

First of all, what do you think about the newspaper article, and Barbara Hewson’s stance on the matter?

SD: I was rather surprised to see the statement that women don’t have a right to a home birth in the UK. As far as I understand it, the Midwives Act 1902 gives women this right, by virtue of the fact that the midwife must attend a woman in labour if called. So, at the extreme, whatever clinical or social situation she is in, a woman in labour at home can call a midwife to her. Obviously, it is much better if this doesn’t happen at the last minute, and if this right to be attended in labour is translated into a an obligation for the maternity services to provide good antenatal care and planned support for the labour, the home birth right-or-not debate becomes a red herring.

The debate also sets up women in opposition to the fetus, and the midwife as having more obligations to her employer than to her Code of Practice and professional moral standards. Both of these developments are very sinister, and both should be resisted.

MH: Although my first reaction to the newspaper article was negative, on reflection I think the article is interesting.  To me it looks like an editor has given it a very attention seeking headline and chosen a particularly provocative sub heading (sometimes called the ‘sell’), which sadly complies to the popular notion that home birth is dangerous and probably shouldn’t be allowed.

However, the article is not really saying that birth is dangerous – Barbara Hewson balances this statement with the fact that birth can equally go wrong in hospital and that the litigation culture is probably causing unnecessary interventions. Nor is Hewson saying that ‘mothers don’t have the right to a home birth’ – although she is unpicking from the legal angle the question ‘what are mother’s rights when it comes to home birth’ – a subtle difference that the editor perhaps ignored in their search for traffic.

As a mother who has birthed at home twice (once last month!), the article made me very uneasy. When you put it alongside the current situation in Ireland highlighted by the recent case of Aja Teehan – and the current situation for Independent Midwives in the UK – and a similar struggle to save home birth in France - which I understand is also happening in South Africa… and then read details of the RCM conference debate - it really starts to feel almost like a backlash against the movement to reclaim birth.

Home birth – for me – was the place where I felt safest from unnecessary intervention – and I speak as someone who experienced an episiotomy and forceps delivery in hospital for my first birth, purely because the clock dictated I could not have any more time, although myself and baby were well.

In my two home births I have experienced how birth proceeds so normally in a safe and loving environment, and how wonderfully empowering it can be to birth your baby yourself, with nobody taking control or telling you what to do. I wonder why there is such an energy across the western world that seems determined to prevent women birthing like this? Is it really all about safety?

EP: Lawyers often have different views on the right interpretation of the law and there are rarely clear-cut answers to legal questions, especially when the question hasn’t been considered by a court. Nevertheless, when a lawyer purports to explain the law (rather than give their own opinion about it), it is incumbent on them to give a clear and balanced account. It is a shame that the headline to the article suggested that there is no ‘right’ to home birth, as this is not an accurate reflection of the law, and did not reflect the nuance of the article.

What are the mother’s legal rights to a have a home birth, and does it make a difference ‘if things go wrong?’

SD: Even in the very rare situations where the choice a woman makes for place of birth might lead to a very real risk to the baby, there is still no legal grounds for denying her her autonomy, as far as I’m aware. Consider, for example, the case of two identical twins. One is terminally ill with kidney failure, and his twin is the only possible donor match. However, for reasons best known to himself, the healthy twin refuses to donate his kidney to save his brother. Is there any conceivable situation when it would be legally and morally acceptable for the healthy brother to be taken against his will to hospital, subjected to necessary drug treatment to prepare him for surgery, be operated on against his will, and have his kidney removed, for the sake of the brother, however much we may struggle to understand the rationale for his refusal?

Why is it different for women who are refusing to go to hospital for the sake of their baby?

MH: Since learning about the case of Ternovsky vs Hungary at the European Court of Human Rights, I have been under the impression that women have a human right to give birth wherever they wish.

What Barbara Hewson seems to be saying is worrying – essentially that, although women may have the ‘right’ to give birth where they like, the state does not have an obligation to provide them with care in any setting, if this is not practical or they deem the birth to be too risky. This is exactly what has just happened to Aja Teehan, and it seems we are only a whisker away from a similar situation in the UK – the whisker being, as Hewson points out, that the NMC states that midwives have a duty of care to attend a woman no matter what.

Some women who are aware of this will currently insist on attendance by a midwife at home even if their local hospital states that they do not have enough staff to provide one.

But it would only take a small change – an insurance issue, for example – for us to be in a situation where it was impractical or even illegal for a midwife to attend a woman at home regardless of their employer’s wishes.

‘Things going wrong’, insurance, and the desire to minimize or even eliminate risk seem to be at the heart of the issue. Having had two ‘uninsured’ home births with Independent Midwives, I think it’s worth reminding ourselves that insurance only pays out in the case of negligence, and that ‘things going wrong’ in birth does not necessarily mean someone was to blame or that we would have been safer in hospital. I also feel that myself and my partner were capable of assessing any risks involved in home birth – exercising our autonomy as we did so, and being prepared to take responsibility for our decision no matter what happened.

Perhaps the most controversial aspect of Hewson’s piece is that she implies that mothers (and fathers) of unborn children may not be the best people to decide where their baby is born. She talks about births at home against medical advice that had tragic consequences. And she finishes by saying that insisting on having a midwife attend you at home against their employer’s wishes may not be ‘wise’.

This, too, is at the crux of the debate – who should decide where a baby is born? Of course, my view is that it should always be the mother, and that she can absolutely be trusted to make the right decision about this. However, this view is not shared by everybody – many still subscribe to a ‘doctor knows best’ attitude and are reluctant to examine the actual facts and figures that underpin medical advice and decisions. As Labour party Counsellor Ronan McManus tweeted in response to AIMS Ireland, “allowing someone untrained and emotionally involved to interpret the evidence is a dangerous trend.”

This breathtakingly misogynistic view sums up the problem that many people have with home birth – it puts the power and autonomy back into the hands of the mother, which is ‘dangerous’.

The voice of a home birth mother – or any mother – also seems conspicuous by its absence at the RCM debate?

Again I’m wondering – is the current backlash against home birth part of a drive towards safer births and better outcomes? Or does it contain an undercurrent of an age-old desire to limit or destroy the power of the birthing woman?

EP: We need to start from the basic premise that women are the best and only judge of where they give birth. If we start to question their capacity to make that decision, we undermine centuries of hard-won legal autonomy and we wouldn’t be far from advocating forced c-sections, which Barbara Hewson was instrumental in prohibiting in the 1990s.

The simple legal answer to the question whether a woman has a right to give birth at home is: yes, of course. She has a right to make choices about the circumstances in which she gives birth, including where the birth takes place. This is uncontroversial as a matter of English common law (which respects autonomous decision-making) and under Article 8 of the European Convention on Human Rights (which protects the right to private life and associated right to physical integrity).

A woman cannot be compelled to accept hospital services and she may give birth where she chooses. The real issue is whether this ‘negative’ right translates into a positive right to midwifery assistance at home. The European Court has recognised that the state is required to take steps to enable this positive right, but there will be acceptable limitations that can be placed on it. Barbara Hewson’s article dealt with those potential limitations. She suggested that staffing shortages might be one such limitation. In the absence of a case determining this point, we can only say that there may well be circumstances in which staffing issues would justify a limited service and cases when they would not. There isn’t a blanket rule when it comes to factual conditions that justify limitations on rights. Certainly, government and NMC policy mandating attendance of midwives at home would inform the court’s assessment of hospital decision-making about home birth.

You can read more about the debate on the Birthrights website: www.birthrights.org.uk

How can we ensure that the balance is right, with respect of what the woman wants, and what the care-giver wants and is able to provide, ensuring safe, high quality care?

 EP: The question of service-provision isn’t really about balance, it’s more about what women can reasonably expect from their maternity services. Clinical Commissioning Groups (CCG's) in England and Health Boards in Scotland and Wales are under an obligation to provide services to meet local needs. Women invariably need to be provided with a variety of options for maternity services, including home birth. CCGs and Health Boards are also under an obligation to have regard to government policy on maternity choices, which requires them to make home birth available as a choice in all areas. In essence, women can expect to be provided with home birth services and should hold their local decision-makers to account if they are not provided, or are unreliable.

Do you think the issue of choice in place of birth influences the relationship between mother and midwife, and if so, why?

SD: Good maternity services = skilled and compassionate care in an authentic relationship with the woman. And this includes a stop to the quibbling about facilitating home birth for women, especially when the evidence says it is the most economic and safest place for most low risk women and babies to be;  and a turn towards providing the best possible care for women and babies in the place that suits them best.

EP: All the evidence suggests that choice of place of birth can have a profound effect on women’s experience of their birth experience, measured not only in improved clinical outcomes (and consequent public health savings) but also in terms of long-term emotional consequences for the mother and child. Continuity of carer, generally only achieved when the mother chooses a home birth, has a particularly positive effect for women, presumably because women build a trusting relationship with their midwife that enables better care and support. It is no surprise that the Department of Health seeks to promote home birth as a result.

If you have anything else to add….

MH: I don’t think the question should ever be asked, “Do mothers have the right to give birth at home?”, or, “Do women have the right to give birth where, how and with whom they choose?”. A woman’s right to have her baby where and how she chooses seems so fundamental to me and it feels wrong and dangerous to even question that basic right.

However, there are questions about the practicality of home birth in such times of midwife shortages, insurance issues etc, that are worth asking. Why are the RCM, for example, not debating ‘How can we encourage home birth to increase and flourish in the current climate?’, that would seem to make more sense.

We would like to know your thoughts, to start the debate...

More about the contributors

Milli Hill:

Founder Positive Birth Movement Twitter: ‪@birthpositive

Editor Water Birth: stories to inspire and inform Twitter ‪@waterbirthbook

Birth Columnist for Best Mag Daily ‪@BestMagDaily

Blog: the-mule.com Twitter @Millihill

Elizabeth Prochaska:   

Lawyer, Matrix Chambers 

Founder: Birthrights Twitter @birthrightsorg

Professor Soo Downe OBE

Professor of Midwifery University of Central Lancashire 

Previous post interviewing Soo Downe

Dear Mum and Dad

Dear Mum and Dad,

Guess what? Next week Paul and I are going to Bermuda. It's our turn-the last ones in our family-to visit this island of paradise. And what really excites me the most is that we're hopefully going to retrace some of your steps, and see the things you saw for the first time, decades ago.

Our sister Sue (and John) have so generously invited us to stay with them in their apartment. Do you remember when the suggestion was made for you to go in the early 1970’s? Whilst we have been fortunate enough to  have visited many far flung places around the world, you had never ventured further than Blackpool for family holidays, in England. Outside England I think there was only an odd trip to Dad's homeland, Ireland, and one holiday in the Isle of Man.

Because I can't ask either of you, I wonder what did you feel like when the time came for you to go? I vaguely remember the excitement at home. You had never been on an aeroplane before, and I can imagine you thought that going to Bermuda was as remarkable as flying to the moon.  Sue and then boyfriend John gave you an experience of a lifetime, and you returned full of exciting tales about your adventure. With the help of music cassette tapes, you described the unique sound of the steel bands and calypso songs such as 'yellow bird'. 

When your photos were developed you showed us images of vibrant, colourful fish,  even more colourful cocktail drinks, turquoise sea, and blindingly sunny skies. I remember you telling us about eating 'brunch'.  Like you, we'd never heard of the word. With gawping mouths we tried to imagine (but how could we?) the banquet style breakfast-come-lunch, with delight!

Being working class through and through, I’m sure you never dreamed of being in a position where you would visit anywhere as remotely exotic or as far away as Bermuda.  I wonder if you really knew where the island was in the world? Oh Jim and Kathleen, you didn't know what was to come when you got home.

So sadly, eight years later, you died Dad, and left us. Too, too young. And there was more ill health and further sadness in store for the whole family.

But we'll be thinking of you both as we step off the plane next week, and I'll be humming the song you played non stop on your return- Bermuda is Another World

Loving you always, Sheena xx

Guest post: an interview with Professor Soo Downe OBE

Added comment - March 2019

Professor Soo downe obe

During my career I have been inspired by, and aspired to be like, several midwives.

Professor Soo Downe is one of those, and I was incredibly fortunate to work closely with her during my role as a consultant midwife. Soo gave me confidence in my academic ability, and she fostered in me a sense of self worth. I remember hearing her giving a talk to several hundred midwives, and mentioning the work we did at East Lancashire Hospitals maternity service. I couldn't believe it. She really thought we were doing great things as a maternity unit, and it gave us a much needed confidence boost. Soo Downe is a transformational leader, and shares her knowledge and skills for the greater good, and not to receive accolade or to gain power. I was delighted that she 'agreed' to do this guest post, because I know that every nano second in her day (and night) is taken up with family and work. I hope you enjoy this small glimpse into Soo's amazing midwifery world.

Hi Soo, thanks for agreeing to chat to me here! Could you introduce yourself?

Hello my name is Soo Downe, I am a midwife and I qualified  in 1985. At the moment I’m working as Professor of  Midwifery studies at the University Central Lancashire in the Research in Childbirth and Health (ReaCH) team. Our main area of research is around the nature and consequences of normal childbirth.

When did you first become interested in becoming a midwife?

When I was at university in the late 1970’s, I had no intention of being a midwife at all. I was studying English literature and language, and beginning to wonder what to do with my life when all the years studying finally came to an end. In the middle of my degree studies, I found myself working at a maternity mission station in Bophuthatswana, which was a homeland in South Africa, at the time when the country was still suffering under apartheid. There was a long chain of events that led to me being there that is not worth going into, but the most important thing is I found myself watching women having babies quietly, peacefully with the loving support of the midwife nuns who were working there, with minimal resources, and, on reflection, no interventions that I can remember.

The labouring women were apparently completely unfazed by what was going on, and completely engaged in their labours. It came to me that, if we can get childbirth right, we can get the world right. It felt like a kind of road to Damascus experience, even though I’m not particularly religious. Having finished my 4 weeks in Africa, I came back and to finish my university studies, after which I worked for some months as a healthcare assistant at Guys Hospital in London. This was because I knew that midwifery was very unlikely to be the same in the UK as it was in the middle of a homeland in South Africa. Despite the differences, I still loved what I could see of the profession, so I applied to St Thomas’s Hospital in London to do nursing, because at that time I didn't realise that you don't have to be a nurse to the midwife. However, having been accepted on the nursing program, I found out that there were, at the time, two places in the country where you could become a midwife without having a nursing qualification. So I immediately applied to Derby City Hospital and that's where I undertook my midwifery training. It was not at the level of a degree or even a diploma, it was just 3 years of midwifery theory, practice, and skills development, and it was the most difficult thing I’ve done; far harder than my academic qualifications, because it mattered so much to get right.

Once I qualified I worked for about more years on the labour ward at Derby City Hospital. The labour ward had about 5000 births a year, so it was very busy, with a fairly high rate of interventions, including the early adoption of routine fetal monitoring for all women. This raised a whole series of questions for me that started to push me towards undertaking research, to find out what the implications were of what was happening. By the time I left Derby city Hospital in the year 2000 to move into academia, I had been working in a joint clinical and research midwifery post for several years.

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

Sadly, I am no longer working clinically, so my working day now is much less hands-on.  I work in a team of about 12 people, and they are divided into 2 separate but related groups,  one which I lead (the Research in Childbirth and Health group, ReaCH) and the other which is led by Prof Fiona Dykes (the Maternal and Infant Nurture and Nutrition group, MAINN). Much of our day is spent on the computer. This includes responding to hundreds of e-mails that come from all over the world from students and collaborators and colleagues, who are networking, writing papers, writing bids, and generally discussing questions of research and practice. More specific activities might involve writing a presentation for a national or international conference, meeting with one or two Ph.D. students to talk over the work they’re doing, talking to local midwives and doctors about the areas of research that might interest them, meeting with service users who are involved in some of our studies to discuss information leaflets, or how to disseminate research findings to a wide audience.

It might also involve the more frustrating bureaucracy that is growing all the time in higher education, just as it is in the health sector, including filling in large numbers of administration forms. I also attend a range of meetings, catch up with the work of team members,  review papers that have been submitted to journals or bids that other researchers have submitted to funding committees, or teach and supervise undergraduate or postgraduate students. Occasionally we get a bit of space to write an academic paper, or a bid, and the day includes great excitement when were awarded finally one of our bids (on average, for most academics, only about 1:10 bids are successful), or when one of our papers is finally accepted for publication, or when one of our students is awarded their qualification after all their hard work, or when the media contact us to find out about the results of one of our studies which might be significant in practice or policy for the future.

Fairly often I visit colleagues overseas, to give keynote lectures or to talk about future research projects. Indeed one of the really rewarding and reinforcing factors in my work life is a number of countries I visit where women and midwives and doctors and other stakeholders are saying the same thing:  we really need to get physiological birth right.

As you can see, it is extremely hard to sum up a typical day in this job!

The main focus of your work in promoting and supporting the normal birth agenda, can you tell us why this is so important to you?

What has always fascinated me is the sense that the process of childbirth is far more than just getting a baby out. It is something that links us back through all our ancestors, and into the future, and we are all (mother, father, baby) irrevocably marked by it. It is also one of the few experiences left in society which, when undertaken physiologically, is ultimately unpredictable and uncontrollable and, as a consequence, deeply emotional. It takes all those who experience it authentically to the very edge of their capacity to cope, and it says to them, you can do this – and if you can do this, you can do anything. Getting it right is therefore profoundly important for the wellbeing of families, and for future generations. While I have always believed this intuitively, recent exciting evidence from epigenetics seems to suggest that there is biological evidence for the impact of labour and birth on way genes might be expressed for the child, and for their adulthood, and then their own children in the future. So, for all these reasons, the normal birth agenda is really important to me.

There are some individuals and pressure groups in England that would like to abolish to the term ‘Normal Birth’. What are your thoughts on this?

I really dont understand why we can talk about 'normal child development' and 'normal adjustment to school' or whatever else, and not about normal childbirth. I am the mother of a profoundly disabled child, but I dont object when people talk about the normal development of their or any other child - I dont feel that that makes me or Jessica (my daughter) somehow less because she is (clearly!) not developing normally, and never will, and I certainly dont think I have the right to deny other parents the joy in the normal achievements of their own child. Why do we think we have the right to deny women who have normal births the right to delight in this? 

I do tend to use the word physiological when Im writing about normal birth in the professional sense, but women routinely use the work 'normal' in terms of pregnancy and birth, around the world - and, indeed, in my experience very few other countries see any problems with it. It is part of the  international definition of a midwife. I honestly think we should resist this populist pressure to redefine a fundamental female biological process as something 'other' that cannot be talked about. The problem is not with normal pregnancy and birth, but with the systems we have set up that render it almost extinct, so that women think that the traumatic things that happen to them in labour are 'normal' birth (indeed, I have seen a USA blog where a woman says her 'natural' birth was barbaric and horrific and then we find out half way down the blog that her labour was induced). Of course women who experience this feel they have failed, and are traumatised - but this is not normal birth, and it is not they who have failed, but us who have failed them - and we need to own up to this and change it. 

The less we talk about what normal birth is, the more it will vanish. We need to say, loudly and clearly: unsupported, traumatic birth with unconsented proceedures and non-present staff (in all senses of the word) is NOT normal birth. Normal birth as we have always meant and defined it is the kind of birth that most women, with the right support and skilled, compassionate care can achieve - and for those women for whom this is not possible or desired, then the optimal birth experience is necessary for them as well. Once again, it isnt either-or but both-and.

Sometimes 'normal' or 'natural birth' advocates are criticised for 'encouraging unreal expectations' for childbearing women. What do you think about that?

I think the best parallel here is with the breastfeeding debate. The reason women found it so hard to succeed in breastfeeding in previous generations was because of the insistence of maternity organisations on profoundly non-physiological ways of managing breastfeeding. This meant that we had a whole generation of women who had ‘failed’ in breastfeeding, and so who could not help their daughters to do so; indeed, I suspect that some of them felt that, if their daughter did try to breastfeed, this was an implicit critique of their own ‘failure’. We are now in this situation with physiological labour and birth. We have a generation of grandmothers, and of friends of newly pregnant women, who cannot contemplate their daughter/friend having a baby without, for example an epidural. This has happened because we have created the circumstances in which it is very hard for women to have their babies without such technological help.

What makes the expectations for physiological labour and birth unreal is not women's innate capacity by large (although of course for some women and babies there will always be a need to intervene). Unreal expectations only exist because we have setup maternity services to make them unreal. Where we create circumstances in which women are able to trust those around them to give them space to labour spontaneously the vast majority will succeed in labouring spontaneously and positively and even joyfully.

Photo: sarah brown

What are your plans for the future Soo?

It would be great to finish all the projects that I’ve started and that I haven't yet had a chance to sort out or write-up!. However I think this is probably never going to happen – indeed, just getting to the bottom of my e-mail inbox would be a massive achievement, but again I don't expect to achieve this before I retire in about 10 years time!. More seriously, the major piece of work I want to start with colleagues including Holly Kennedy from the USA and Hannah Dahlen from Australia is to look at how what happens during labour and birth influences the well-being of mothers, babies,  partners and families into the future, in terms of the epigenetic make-up of the neonate, long-term noncommunicable disease, and perhaps more importantly even, to find out what is about labour and birth that might help things to go right in the future for the baby and the family (see link). For example how,  is it that some women with a difficult personal or family obstetric or medical history, or difficult social history, still manage to have very positive empowering life affirming birth and others do not.  How many situations that are currently treated as  pathological, such as long gestation or long labour, are actually physiological for some women and babies in certain family contexts?. Ultimately, can we use this information to make the allegedly unreal expectations that women have at the moment real expectations, by changing the maternity services globally, so that it maximises the potential for the best possible outcomes to mothers and babies in the future?

And lastly….what motivates you to continue to champion the cause?

All the factors above, I think! 

Aaaaa Thank you Soo, for this incredibly insightful interview. So many childbirth workers (and childbearing women) are grateful for your hard work, passion and dedication.

You can contact Soo at:

SDowne@uclan.ac.uk

Link to paper The EPIIC hypothesis: intrapartum effects on the neonatal epigenome and consequent health outcomes

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

My thoughts:

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

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

For childbearing women and partners

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

For midwives/doctors:

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

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

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

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

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

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

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

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

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

In response to Kirstie's radio programme:

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

And finally, a note for our Governmental Ministers

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

Photo credit 

Three babies and a party!

It’s been a busy and exciting couple of weeks. It started with the birth of our sixth grandchild on the 11^th of July, which was our other granddaughter’s Betsy’s 1^st birthday.  Then it’s been babies all the way.

Our youngest daughter Olivia gave birth to her second baby, Myla, after several weeks of being unwell. We heaved an audible sigh of sheer relief, as well as tears of joy, as we cast eyes on a beautiful and tiny angel face.  As Myla was born early by Caesarean section, she could've been fragile.  Instead she was alert and responsive, and healthy. Olivia had amazing maternity care, and we are incredibly lucky. Tender, compassionate midwives and a trusted, expert obstetrician Liz Martindale ensured that our girl and her baby were happy and safe. So many heartfelt and everlasting thanks to you all.

Then Prince George made his grand entrance, with such little fuss! As a midwife of more than 3 decades, I was delighted to see an unruffled, beautiful Duchess emerge from the Lindo Wing doors, hours after giving birth. Like many other midwives and birth supporters, the speculation on HOW baby George was born has been phenomenal. And of course it was speculation until today, when it emerged that Kate was attended by midwives, who facilitated the birth. And one of those midwives is an old friend of mine, and featured in my book, Catching Babies! I am so delighted that Kate had the normal, positive childbirth experience that she wanted.

And on the same day, Sonny Ray was born in water at Blackburn Birth Centre. There was a double significance to Sonny's birth, as I was the midwife who helped Amy (Sonny’s mummy) into the world 26 years previously, at a nearby birth centre (Bramley Meade). As Amy, Alex and Sonny are propelled to fame due to Royal 'links', I revel on how the world moves in mysterious ways, and the synergies and connections between people make life so intriguing and very wonderful.

My reflections of the three births in a nutshell:

Olivia needed medical assistance for her pregnancy and birth, and it was available, thank God. Although her choices were limited, she was able to make some, and therefore she had a wonderfully positive experience. I am so proud of her.

Amy was born into my hands, and 26 years later gave birth in a birth centre that I helped to develop. Amy didn’t need medical help, and whilst she had many choices, she believed in her body’s ability and made the perfect decision for her, her partner, and her baby.

And Kate chose (or did she?) to have her baby in hospital, with medical support on hand even though she didn’t need it, yet the Queen had her four children at home.

So, Myla, Sonny and George have one thing in common. They were born in the same month, and their parents are happy and healthy. I wonder what their lives will bring?

PS And lastly, I was at a very successful launch of the parent led 'Birth in East Lancs' website on Thursday evening…you can read about it here!