Birth and Death - saying goodbye to Pauline Quinn

I’m sitting in my kitchen, it’s 5 am and I’m wide awake. Thinking about the events of the past few months where I was more than privileged to be close to my dear friend and mentor, Pauline, in her final weeks of life. A midwife like me, Pauline was my manager for most of my career. When Pauline’s health deteriorated I became closer to her, spending precious time - moments where we talked about birth and death, and LOVE. I never thought I’d be in the sacred space between life and death, where the health of my role model was deteriorating. Caring intimately for her needs alongside her beautiful family - part of their ‘tag-team’, Jennifer said.

‘These moments are precious’ Pauline told me, breathlessly, on numerous occasions as the oxygen she needed streamed into her lungs. Closed eyes. Probably reflecting, I thought. My reflections of that time, spent with Pauline as she lay in bed waiting to die (as she wanted), are that she showed me HOW to die; I am now more certain than ever that, if possible. I would want be with my loved ones and to be able to talk openly about the right of passage that death is. If possible.

Yesterday was Pauline’s funeral. So many friends and family and colleagues who travelled miles to pay their last respects said their goodbyes to this strong, courageous woman. This woman who had a positive impact on the world in so many ways - we heard about these testimonies as we gathered close at the ceremony and then more at her wake.

I asked Brian, Pauline’s husband, and daughter Jennifer if I could say a few words about Pauline’s career. Here’s what I said…

 For Pauline

Thank you, Brian and Jennifer, for allowing me to say a few words about Pauline’s career, Pauline usually known as Mrs Quinn or PQ – what an honour it is for me and I’m more than grateful.

It’s really hard to know where to start. I worked with Pauline for most of my career, she was always my manager, firstly when she came to Bramley Meade in the1980s. My reflections of her work as a midwifery leader are reinforced by many who are here, and also worked alongside her – Pauline was a legend and her legacy lives on in the midwifery leaders who she inspired and influenced, passed down through each generation. East Lancs Hospitals maternity services are amongst the best in the country, if not world, and Pauline’s vision and dedication was the turning point for sure.

 Each midwife or colleague of Pauline’s in the room today will have their own memories of her. And what they will remember is that the progress she made was against a backdrop of a patriarchal culture in the NHS, challenging staff groups and over-powering hierarchies. What Pauline achieved through sheer determination and a passion for midwifery and woman-centred care was ground-breaking. Pauline was a natural innovator – before her time as they say. In today’s terms, she was a compassionate leader, and she didn’t know it.

So, what did Pauline do that made this difference, that made the team of judges approve the OBE nomination that we made for her? Pauline introduced practices to enhance the wellbeing of mothers and babies such as rooming in babies with mums at night, ‘allowing’ partners into the birth room, buying active birth equipment in the early 1980s that even now some services struggle to do. These things may seem small, but they were huge at the time and difficult to implement. I remember!

Pauline made significant strategic changes too, engaging with the research agenda with the University of Central Lancashire when it was unheard of – especially in Lancashire.  Pauline enthusiastically followed recommendations from national policy and in the early 1990’s she successfully implemented midwifery-led care and team midwifery, introducing continuity of midwifery care. Part of the plan was to close the maternity homes that were underused - an unpopular decision but it was important for Pauline to ensure equity across the service. Leading this agenda was an enormous task given the huge opposition from obstetricians and others, and because of this the Department of Health highlighted Blackburn maternity services as an exemplar of good practice in policy documents and even a film. At the same time Pauline introduced hand-held records, a huge change for everyone involved in providing care in maternity services – but she made it happen.

Another of the many quality programmes Pauline engaged with was the UNICEF Baby Friendly Initiative. This focuses on mainstream support for breastfeeding and has a rigorous process of assessment where services are inspected against set standards. All staff are involved and have to undergo training and updates to ensure consistency in messaging – and support. Achieving esteemed BFI accreditation was Pauline’s vision and we worked hard to make it happen – success in 1995. It was a huge undertaking that required a shift in culture. This is significant because today ELHT holds the Gold Award, the first in the country.

On a personal level, Pauline was known for her kindness and compassion – her down-to earth and sometimes humorous personality. Pauline remembered staff names and our children’s too -  she took time to ask us about our families. But she was not a soft-touch. What Pauline wanted she got, and here I must add that this was always for the good of women and families and not her ego, Pauline was a force to be reckoned with, she had a presence, commanding respect wherever she went. When we saw Pauline coming along the corridor we would be excited and a little nervous (in a good way) – Pauline was like the Queen…..

I have to mention Pauline’s integrity and sense of justice. We are hearing a lot in the media about NHS whistle-blowers and how often they are vilified in organisations.  There were several occasions when I had to inform Pauline of mal-practice, which I sadly did, she acted immediately – even though it was difficult. Pauline always mentioned the incredible support she had from the CEO John Thomas and Ian Woolly RIP. The executive team obviously valued Pauline’s leadership as much as we did. Another source of support Pauline had was the maternity services liaison committee – made up the local GP’s, the NCT and hospital staff. Pauline would want me to mention them.

I always think it’s a pity that we say wonderful things about people when they have passed away. Like me speaking about Pauline, today. But please be assured most of what I’ve told you today I shared with Pauline herself on several occasions. Pauline always brushed off my accounts of her positive impact on maternity services, telling me I was being dramatic and over the top – she was very humble. But as we spent hours together when she grew frail during the past few months, I reminded her again about the massive difference she had made as we reminisced about various times in her career. Pauline didn’t resist this time, but nodded acceptingly.  

Rest in Peace Mrs Quinn, your work made a difference to the world and as much as I am able, I will make sure you are remembered.  

30th June 2024

I am missing the presence of my friend in my life. I mentioned this on social media and someone suggested I write a letter to Pauline, so I am doing just that. I know she won’t see it of course, but I’m hoping it will help me.

My dear friend,

 You’ve been gone too long already and I’m just missing you so so much. It’s strange but I’m missing those close, deep conversations we had in your final weeks most of all. I saw and felt some of your vulnerability Pauline, and it made me love you more. I told you over and over again how I felt hugely privileged to be one of your chosen ones, to be in your company during your last days. Yet even when you talked about ‘going’ I didn’t want to believe it. Do you know I savoured every moment, although distressing at times, we shared something unique and special. Anyway, I want to tell you about your funeral. It was perfect Po, you would've loved it, I think. Just right for you, small and dignified but tender and meaningful. Your beautiful family spoke lovingly, so lovingly about you in their Eulogies. Brian, Jen, Roy, Anna and Captain.

Normal Physiological Childbirth - the debate goes on...

I am continually dismayed with polarised debates on social media about this topic - going round in circles leaving a degree of frustration and potential fear.

Recently I was alerted to a thread on Twitter where individuals are condemning organisations, particularly universities, where learning modules are on offer supporting or promoting normal physiological childbirth. Rather than try to respond to tweets with insufficient space and ability to expand, I am writing this blog post. I will draw on evidence already published on the topic and the words of experts in an attempt to clarify why such programmes are not only necessary but crucial - if we are to improve safety within maternity services and increase the potential for enhanced maternal and child health outcomes both in the short and long term.

Let’s consider the facts about normal, physiological birth:

1. According to the evidence most women want a physiological labour and birth.

2. For midwives:

   - necessary as part of midwifery degree regulation and UK’s Nursing and Midwifery standards

   - to meet international standards of midwifery education

   - that ongoing postgraduate education in this field is a legitimate and necessary part of ensuring that women and birthing people and their babies have safe and positive maternity care that is appropriate for them if they choose physiological labour and birth.

   - Not only is physiological birth the mode of birth most women want, but it is also the mode of birth most women in the world have – and care for these women must be safe. Therefore midwives and students must learn how to keep it safe. If midwives do not learn about physiological processes, it will make women LESS safe – introducing increased risk for the majority of women who have physiological births, and making it harder for midwives to identify deviations from normality (and therefore making it less safe for women and babies with complications).

In correspondence relating to NMC standards (2021), Professor Mary Renfrew stated:

..’the NMC standards of proficiency for midwives set mandatory standards for all UK midwives as well as for the education of students. They were set through an extensive process of evidence review and consultation and engagement with more than a thousand individuals and organisations, and they align with international standards. These standards make it clear that a) promoting/supporting normality is a core part of midwifery requiring knowledge and an essential set of skills, and b) that women’s decisions are fundamental, and c) that midwives are key to interdisciplinary collaboration and partnership working when complications arise. For women and babies to be truly safe, they need midwives with the knowledge, understanding, and skills to practice in this way, and who are supported and enabled to do so.

Normality is clear throughout these standards – in the role and scope of practice of the midwife, in the key themes, and in specific Domains and individual standards - as examples see the Introduction, Domain 3b (eg 3.12), 3c (eg 3.24, 3.25) and Domain 6 (eg 6.21, 6.65), but there are relevant standards throughout - recognising that normality matters not only for birth but throughout pregnancy, labour and birth, postpartum, and the early weeks of life - as well as more descriptive/specific standards such as ‘promote the woman’s confidence in her own body, health and well-being, and in her own ability to be pregnant, give birth, build a relationship, and nurture, feed, love, and respond to her newborn infant’ (6.14). In addition to midwives’ key role in supporting and enabling physiological processes, there are of course detailed sections on the midwife’s role in recognition and deviation from normal processes and effective actions when needed in the context of interdisciplinary working (Domains 4 and 5a) – the standards make it clear that collaboration with medical colleagues and others, and rapid effective action when needed, are essential for women and babies to be safe at all times.

The broader context of the standards matter – no individual standard can be seen out of context – importantly, they have a strong focus throughout on safety (which includes physical, social, psychological, cultural, spiritual aspects for both woman and baby), on building relationships with women, partners, and families and sharing complex information (including sensitive, individualised conversations, listening and responding to women’s concerns and decisions), as well as professional accountability and the use of evidence. The standards are all based on a human rights perspective (1.3), and set within the context of ‘always working in partnership with women, basing care on individual women’s needs, views, preferences, and decisions, and working to strengthen women’s own capabilities to care for themselves and their newborn infant’ (1.13).

In addition, on the 17th September 2021, the International Federation of Gynaecology and Obstetrics (FIGO) published an ethical framework for respectful maternity care during pregnancy and childbirth which states:

• Maternity care must be supportive, individualised and value-based – it is best served as a partnership model between health care practitioners and the 'MotherBaby–Family'.

• Health care practitioners are expected to routinely provide maternity care for mother, baby and family – they must ensure that their practices are driven by health needs and expectations, as well as by health outcomes and cost-effectiveness based on optimising the normal processes of childbirth.

• Health care practitioners are expected to follow evidence-based practice – they will promote practices proven to be beneficial in supporting the normal physiology of labour, birth and the postpartum and neonatal periods.

Professor Soo Downe added:

‘It is understandable that individuals who feel they have not been supported in their decision making (either around spontaneous labour and birth or around wanting to have a specific intervention) may feel that education and training should be focused on the kind of care they wanted or needed, and not on any other alternative. But maternity care is about both-and: both understanding pathology and treatment, and about understanding physiology and how to preserve it. To deny professional staff the education they need in physiology and in safely preserving the physiological processes that are the norm for the majority of human beings (normal pregnancy, normal blood pressure, normal fetal development as well as normal labour and birth) is as dangerous as to deny professionals the education they need in pathology and treatment, so they can effectively support those who need or want safe and personalised interventions.

For the sake of all women, birthing people, babies, families and partners, It really is long past time for all of us to stop sniping across lines of division, and to truly, authentically, have a dialogue between us that properly listens to, values, and educates for the whole range of maternity care that service users need and want. This includes education, training and updating in the knowledge and skills needed to support normal physiological processes, as well as in recognising and responding to the need or desire for intervention’.

We wait in anticipation for the results of the Re:birth project being led by the RCM and RCOG. If the issue is in the wording used and not the content of university programmes, then maybe it’s a compromise we have to make. If the conclusion is that ‘optimising normal physiological processes’ is the preferred term, then we can get on with supporting midwives and obstetricians to do just that, and to enable them to provide safe, evidence-based maternity care.

A glimpse of injustice - when caring is a 'crime'.

It’s been quite a while since I posted here. I’ve been working hard on creating and developing resources for midwives and student midwives with my eldest daughter, Anna - who is also a midwife. More about that later!

So I’m writing a book - a sequel to Catching Babies. Really, I’m writing about my life since leaving the NHS for anyone interested and as a keepsake for my children and their children’s children. I’ve been keeping notes for a couple of years - and with the onslaught of the COVID-19 Pandemic and Lockdown I’ve had the time to really get down to it.

There’s been plenty of opportunity for me to reflect on some of the happy and exciting times and some of the difficulties we’ve faced over the past 9 years, and as I go for walks most days Paul and I try and recall events (for the book). Based on what I had to do for my last book - we categorise them:

1. Heartwarming occasions

2. Funny moments

3. Exciting times

4. Shared grief - always important

5. Things that bothered us (though PB doesn’t worry)

6. Interesting situations we found ourselves in

7. Travel and incidences

8. Challenges I’ve or we’ve faced

Oh that last one! Well, I’m still learning how to deal with ‘thinking’ about some of the challenges. When I came to the events I’m telling you about below (which I feel should be included) - I shuddered. Because I’d put them to the back of my mind. That’s how it is sometimes, isn’t it? I’m not a big believer in dwelling on the past and certainly consider myself to be a cup-half-full person, but writing a memoir or biography means you just have to do it. I had a ghost writer for Catching Babies and she absolutely made me go back to the times I thought had gone from my memory forever!

I actually wrote some of this a couple of years ago after speaking at an Association of Radical Midwives (ARM) conference on this traumatic event. It was published in the ARM journal shorty afterwards. So here goes…

---

‘It’s in the paper, Sheena. Don’t read it.’

My husband Paul came into the bedroom and made this announcement. 

I woke up with a jump, and an immediate adrenaline surge of anxiety hit me. Two days previously, I’d received this email:

 Dear Sheena,

I am a journalist at the Daily Mail. I am writing a story for tomorrow's newspaper about training at NHS trusts - please could you provide a comment.

The article will say that you gave a lecture at the progressive births conference teaching, amongst others, Derby Teaching Hospitals Trust midwives. In that talk you said: 'We need a solution to increasing intervention. We can't continue as we are.’ You also said: ‘Do we really believe that women's bodies are so faulty that less than 40 per cent will give birth without intervention?'

Later you said: 'Women across the world want straightforward birth.’

You have also given a number of study days at xxxxx Trust with similar pro-natural birth messages. The handout material for those study days say that ‘for most mothers’ natural birth 'is the safest way to give birth' and that NHS staff should ensure ‘normal birth’ should be 'facilitated for all women’. The overall tone is that women should be encouraged to give birth normally.

Parents who have lost babies after, they say, being pushed into a natural birth against their wishes, say the material is 'terrifying' and 'dangerous'.

They say you are a normal birth campaigner, citing your comment: 'protecting normal birth is a midwife’s core function'.

Could you please respond to their comments?

 I provided a detailed response (see below), but it was ignored. The journalist chose to ignore my response and publish the allegations anyway.

Paul was awake early and had the read the article on his tablet. When he told me what he was reading, I instantly felt vulnerable, and physically sick. 

‘Mum, are you OK?’ The message pinged in on my phone. It was Anna, my eldest daughter who is also a midwife, jumping to my side in support. ‘I’ve seen it. Don’t read it, Mum.’ 

Months before, I’d been invited to the maternity service in England mentioned above, to help them to reduce their Caesarean section rate; one of the actions they had been charged with, following the mandatory CQC inspection. It was a big decision to accept, as I would need to stay away from home – and my life already full. The maternity service had employed a consultant obstetrician too, to support the team making necessary improvements highlighted in the same review. I was commissioned to work with multidisciplinary teams, and I began by spending time observing the service and speaking to staff. Like the obstetrician, I was paid for the work I did. As I usually provide my services pro-bono and with a background of working in public services, I find it hard to charge a fee for what I do. ‘Hmm, I’m not sure what is reasonable’ I said to the manager wishing to secure my help. ‘I maybe could ask for same amount that I was paid in the last service I worked for?’  So that amount, which I was assured was minimal compared to the visiting obstetrician, was agreed. I thought nothing more of it and worked hard in return. It’s always daunting going into an organisation as an outsider, as a critical but supportive friend. Yet the staff were accepting and kind to me, keen to learn and to explore different ways of working. 

 So I began my task of attempting to influence the culture of the maternity service by facilitating workshops and meetings with ALL members of staff. These sessions were enlightening to me – staff revealed organisational and personal barriers to practice and came up with their own suggestions for improvement. We revisited the basic physiology of labouring women and considered the influences of the environment, rituals and guidelines – and staff attitude. We explored the importance of respecting physiology for ALL births, and paid attention to babies born by Caesarean section or with the help of instruments.  After several weeks, the organisation employed a midwife permanently to deliver the strategy, and my task was complete.  The output from the events was used to formulate a normal birth strategy - to be considered by the management team.

Several months after I left, to my alarm, I received an email from the Chief Executive Officer of this same organisation advising me that someone had served a Freedom of Information request for the amount of salary I was paid to work with the maternity service. Why?The person making the request was someone who has publicly criticised me on social media for many years. I was shocked. Why would they do this? What was the purpose of knowing this information? I had nothing to hide, but the intimidation, the harassment, made me feel vulnerable. The CEO was responsive and kind, and together we looked at the legal implications surrounding the release of this information. The day after I was informed that the detail of my fee had been revealed and that was when I was contacted by the press as mentioned above. This is the article and you will see that it also includes the fact that I had delivered a talk at a conference on the subject of ‘normal birth’ - my area of interest. The article states:

‘At least two Trusts have allowed Sheena Byrom to give talks to midwives that include pro-natural birth messages, enraging parents who have lost babies after being encouraged towards normal birth’.

Maureen Treadwell, of the Birth Trauma Association, said: ‘There’s this powerful lobby that want to keep the normal birth agenda going. They have to remember it has been responsible for babies dying.’

The outcry, supportive emails, tweets, direct messages and cards received after the publication of the news article, was absolutely overwhelming. Complaints to the Press Commission were made by others, that I couldn’t follow through because of my state of mind. My reaction was dramatic, mainly because I was frustrated with the injustice of it all – once more attacked for supporting maternity services, midwives and mothers in their quest for better birthing practices. 

I feel it’s important to share my responses to the young male journalist who contacted me - I presented him with the evidence behind each point (which were, by the way, taken from the tweets of one of the delegates):

'We need a solution to increasing intervention. We can't continue as we are’ 

This is a global goal, identified by several international organisations– including The Lancet Maternal Health Series  and the series on Optimising Caesarean section use.

'Women across the world want straightforward birth.’ 

A systematic qualitative review of 35 studies in 19 countries by Soo Downe et al in 2018 highlighted this point. 

‘Do we really believe that women's bodies are so faulty that less than 40 per cent will give birth without intervention?' 

A study in 2016 revealed that less than 40% of babies are born without any medical intervention and NHS Data demonstrates the increasing induction rate.  A report in 2019 revealed shocking variations in the induction rates between maternity services (even when controlled for casemix).

Slide by Alison McFarlane, City University London

It is important to note that the International Confederation of Midwives’ scope of midwifery practice is clear – ‘The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures’ – yet the media and normal birth opponents feel it what I do is a crime, and newsworthy? It is harassment. 

We increasingly hear accounts of bullying in midwifery, of intimidation and distress. Midwives are being marginalised in many countries, and unable to make their voice heard.  Whilst I am free to practise, to be an activist to influence change, there is an online and very public resistance by some to anything related to normal birth.  Whilst I have felt traumatised and unable to provide accuracy, I have learned to cope by continuing to engage positively. My position is clear – I continue to write and speak about the importance of humanised maternity care, of the fundamental importance compassion and respect – and positive birth outcomes for all women. In addition I will continue to raise awareness of the need to respect the physiology of childbirth as part of this agenda, against a backdrop of rising unnecessary medical intervention. 

My talk at the ARM conference 2018 gave me the space for my voice to be heard, yet many aren’t afforded that opportunity. I hope that by sharing my story I will encourage others to find the courage to continue despite oppression and conflict. In the end, we can only do the best we can.

A message for graduate midwives - from my heart

In the space of two years I been overwhelmed and flabbergasted simultaneously, to receive two honorary doctorates. OK, I've not written this post to brag about that fact, but to share some of my thoughts with you. Whilst I was absolutely thrilled when I received the letter for the first doctorate, from Bournemouth University, I actually had to research what the award was. My second doctorate was from the University of Central Lancashire, which is my local university, and the place where studied and gained a Master's Degree, and worked as a consultant midwife. The celebrations for the latter where particularly poignant, as exactly a year before I was targeted in the media, wrongfully. I will be writing about the trauma surrounding this at some stage, to set things straight and to get it off my chest.

During both events I was invited to give a short address to the graduands - who were waiting patiently to receive their hard earned degree certificates. I was instructed to be brief - and so I tried. Here is the ceremony at UCLan - my award and speech is around 21.27 mins in

This was my short address to delegates...

First of all, I would like to express my thanks to the University of Central Lancashire; thank you for such a humbling citation, and for bestowing this prestigious award on me. This is my local university, and one which I have a deep connection as you have just heard. I am forever grateful.

Eternal gratitude to those who are close to me, my husband Paul, children Anna James Tom and Olivia, my sisters and brother in laws, Anne & Peter, Susan and John, Eileen and Denis, Gill and Mark and my dear friends Lynne and Frank. For each of you have influenced by life, encouraged, supported and been there for me. And to our parents, who aren’t with us any more. James, our Irish dad, who passed on a love for fun and friendship. And our beautiful and courageous mother Kathleen, who gave us the example and the capacity to be kind – a quality that is irreplaceable, and holds the potential to change the world. There are others too, who have mentored and guided me, and modelled behaviours that I’ve tried to emulate. There are two special midwives who have majorly influenced my life and my career, I owe so much to Pauline Quinn, my role model and mentor, and to Soo Downe, who is always be my side inspiring, coaching, encouraging, and loving. 

My attention now must go to those in the room who are graduating on this very special day.  Your journey so far will have been both joyous and challenging – I remember it well.  During my work I visit universities and talk to students and also connect regularly with many on social media. You give me so much hope – many of you are already leaders, they are our future, and I feel it is safe in their hands, minds and hearts. Recently a student midwife, unhappy with some of her mentors, told me that she would be happier once qualified. I gently reminded her that there will always be challenges and walls to climb, some you will conquer, and others it will be better to walk around. 

As you celebrate today, I’d like to respectfully offer you some of my thoughts for you to consider as you follow your dream

·      Remember Love and Science are the two most important things. The skills you have and build on are fundamentally important, but the kindness and compassion you show will make the difference. Your eyes tell a story to the people you care for. 

·      Keep those you serve at the centre of all your actions. Speak up for your rights to have enough time and resources to provide the care you are qualified to give. 

·      Don’t fit in with negative culture. Remember the passion and desire you talked about at your interview to become a student here – the words that got you chosen. Keep them close to your heart.

·      Remember the importance of authentic, positive feedback. It creates virtuous cycles, take care of yourself, and nurture those you work with. 

·      You are going to be professional servants to the public. More often than not you will be an uninvited guest into a sacred space where people are vulnerable. What you do & how you do it, what you say & how you say it may be remembered for the rest of their lives.  

·      One thing for sure, your work will take you to the core of life itself. Birth and death are most important times for humanity. Everyone is born, and we all die. For the future midwives in the room, birth is a right of passage that makes a difference to women, her infant and her family - socially, physically, psychologically and spiritually. For all the other future health and social care workers here today, you may be dealing with the consequences of how a baby was born.

·      For those of you going to be midwives, you are hugely privileged being part of an English maternity service. I’ve been to, and studied, childbearing practices around the globe, where women and their human rights are violated. There is no such thing as choice, and obstetric violence is accepted. Please learn more about this, and join in the political quest to influence change. Your voice is needed.

As they say, there are two things that define you, your determination when you have nothing, and your attitude when you have everything. So embrace your calling and your work with a smile from your eyes, and courage from your heart. You can and will make a difference, and your work will enrich your life too. 

It’s now time to take flight, where will you soar?

Thank you to the two very special individuals who nominated me. You know who you are.

The contours of childbirth in India - my ROAR

The man with the stick

I followed consultant obstetrician Dr Evita Fernandez through the throngs gathered outside a government hospital in Hyderabad, India.  Despite it being winter, the blinding sun was positioned high in the sky and I hadn’t yet acclimatised to the intense heat.  The people seemed desperate to get inside, but weren’t being successful as a man on the door was yielding a stick to anyone who pushed forward. Frowned faces continued to surge onwards despite the obvious barriers. I looked towards Evita, her calm persistence to gain access gave me some reassurance as we moved closer to the door; this was my first time in India, my eyes were darting around. The man looked up suddenly and caught sight of us at the back of the crowd. He shouted, and the people instantly parted, making a human corridor for Evita and I to walk through. I felt confused. ‘Follow me’ Evita instructed, just before she bowed her head towards the guard who ushered us through the hospital door. We were inside. ‘Why did he do that?’ I asked Evita. ‘Unfortunately, Evita said, there is a hierarchy of class and colour’. I sensed this was as uncomfortable for her, as it was for me. 

I knew the visit to this hospital was going to be difficult. One of my dear friends, Lesley Page, had given me some insights. But really, nothing could have prepared me. I anticipated the dank and prison like environment of the maternity hospital, and was aware that there is little understanding of the value and importance of maternal and neonatal health in India. Resources are limited, mis-aligned, and a multitude of factors influence maternal and child health. I felt a sense of dread as we approached the labour ward. I asked why there were so many barriers – crash gate constructions between each corridor and stairwell, ‘to keep people out’ Evita revealed.

We approached the double doors leading to a vast clinical area, the labour room,  which consisted of partitioned areas each containing one or two steel trollies. I saw glimpses of women through the glass walls of the cubicles, and then Evita drew my attention to something.  ‘Why do they not protect the dignity of women?’ I looked to where she was inferring and saw the flesh of a woman, her bare buttocks, then her genitals as a health worker manoeuvred her to change position.  I felt immediate nausea and alarm, disbelief. A consultant obstetrician approached us, as she recognised Evita. Evita spoke to her and she welcomed us – a conversation ensued, and Evita turned me ‘they are busy, as usual’.

An invitation to ROAR

I spent more than three weeks in India, with Evita and Indie Kaur. Evita is a phenomenal obstetrician, committed to developing professional midwifery in her country. Evita is also influencing at a global level – she is part of several organisations and groups committed to improving maternity services around the world. Indie is a senior and inspirational midwifery leader from the UK. A consultant midwife previously working in London, and now developing midwifery capacity with Evita. Prof Soo Downe and I were invited to deliver workshops to obstetricians, nurses, midwives, doulas and all maternity workers, on the importance of compassionate and respectful maternity care. The invitation came to us after Evita became aware of our book, The Roar Behind the Silence: why kindness, compassion and respect matters in maternity care, and she had bought 50 copies when it was published to use with the nurses, midwives and obstetricians working in Fernandez Hospitals. 

The day I arrived Indie and Evita explained to me that the Indian government had introduced a policy whereby women are given money to go to hospital to give birth. This had been implemented without consideration of resources or capacity, which has left public maternity hospitals unable to cope – overburdened with women and families seeking attention during childbirth – and then not receiving appropriate ‘care’. So I was seeing the consequences of this compulsory measure. 

We were ushered into the centre of the room, and there I saw the horror, women led flat on the steel trolleys, naked from waist down, alone, in labour. I saw their naked genitalia as they splayed their legs, some in obvious active labour – others quiet and subdued. And all the time, attendants, some of them young nurses, chatted with each other, and carried on working oblivious to the fact that women on their watch were being abused, their human rights violated. The young obstetrician was still with us and unconscious to our horror when Dr Evita gently asked her why the women weren’t being covered, or the screens drawn, to protect their basic dignity.   ‘We need to keep an eye on them’ she answered ‘just in case the baby comes out’.  The women all had IVs in situ, and I was informed it was pitocin (oxytocin), though there was no titration, the drug was running freely, unmonitored. A single woman lay quiet, on her side, in the last room. She told Evita she was being observed, awaiting induction. Her face was full of fear, her body listless, and the coverless metal frame she lay on was dirty – smeared with the blood from previous women.

When we left, we were quiet. I was trying to rationalise what I’d just witnessed. Was this a cultural norm, or was it the result of loss of hope and desperation, and becoming desensitised from reality   a coping mechanism for the staff? What I found alarming was the fact the workers we saw and met in this room were women. Women treating other women disrespectfully. Would these women want the same treatment for themselves of their families? It was hard for me to digest what I had witnessed, and I didn't sleep that night. And it seems this violation of childbearing women is widespread throughout India. 

Horror

Image: Indie Kaur, permission given

This shocking image was taken by Indie whilst visiting a maternity hospital last year, and represents the horror for most childbearing women in India. There are so many violations apparent in this one moment. Imagine the fear of the women, the degradation and humiliation they must be feeling. Look at the degrading scene. One of the women is covering her face. The other woman, who actually has a companion is compliant - her supporter looks afraid too. Where is the advocacy from these health care workers, for each woman? In his outdoor clothes, the doctor takes a phone call between a woman's legs, her vulva and vagina exposed. She hears what he is saying. They all do. One worker looks bored, and disrespectfully and disgracefully leans her gloved hand on the woman's leg. There is NO confidentiality, no kindness, no respect. Appalling. Do you think the two women health workers would want to be treated this way, if they had children? Why is this acceptable to them?

'When you were having sex, did you know know it would lead to this?'

In the end Soo couldn’t come to India, due to an accident, so Indie, Evita and I facilitated the workshops. The sessions were planned to include aspects of human rights in childbirth and bodily autonomy – ranging from childbearing woman’s inability to make decisions about her care, to lack of basic privacy and dignity, and outright disrespect and abuse.  We used drama to demonstrate the issues, tailored according to specific needs of the each service we worked with. We travelled to and delivered sessions in 5 regions: Hyderabad, Telangana, Maharashtra, Tamilnadu, and Keralaand and approximately 600 delegates attended including nurses, midwives, obstetricians, doulas, support workers and childbirth activists. At each workshop - delegates got involved. Women and health care workers had informed us in advance of the practices in maternity services, how women were treated in general and what the specific issues for them were.

One common theme that emerged from accounts of maternity expereince was how women were birthing alone, 'not allowed' to have a birth partner of any sort. They were left alone, treated disrespectfully as described above, and beaten or humiliated routinely by doctors and nurses.  This was one of the stories we worked with the develop a scene, which we enacted. 

“I have to examine you. It will not hurt if you can relax.”  The woman replies “how can I relax when I am in so much of pain.” The doctor answers “I am afraid I can’t help you there. Now draw up your legs I need to examine you.  I have other patients waiting.”

The woman is afraid and says “please don’t these examinations hurt”. Nurse retorts “when you were having sex, did you not know it would lead to this?” Woman is holding her thighs together to protect herself against a vaginal examination.  Nurse slaps woman on her thighs and screams at the woman “if you don’t allow me to examine you, I can’t help you, I will leave you and attend to other women.  I need to know if you are progressing or if you need a caesarean”.  The woman begs the nurse to let her mother in as she is afraid. Nurse refuses. 

The photograph above is the scene recreated by 'actors' - I was the nurse,  Dr Rajitha, who is one of the obstetricians from Fernandez Hopspitals played the part of the doctor, and Indie the labouring woman.  We facilitated this particular workshop with nurses who are training to be midwives - exploring and internalising typical scenarios. After watching this short snapshot of disrespectful, abusive care, we invited participants to comment, with some prompt questions:

'Does this happen where you work?' At every workshop there was a resounding YES. 

'Why do you think this happens?' Suggestions overwhelmingly alluded to lack of time, pressure of work. And of course, the notion that doctor knows best, and the belief that women should do as they are told. Learnt behaviours - delegates told us this is how it's always done. 

'What do you think the obstetrician/nurse/midwife was feeling during this time?' We explored the potential back stories of each person involved, which opened up debates relating to fear, power structures and hierarchies. We all got to look through different lenses, and walk in the shoes of others. This was important. 

'How do you think the woman feels?'  This gave delagates the opportunity to really think about the woman's emotional wellbeing, and how isolating and fear inducing some of the actions are. 

Would you like this to happen to you, or your sister?' Many of the nurses told us it already had. Some cried.

From cruelty to compassion - modelling behaviour

Following the discussions we revised the scenario, acting it again using kindness and compassion - here the images are demonstrating loving care - with one of the participants stepping in as the the labouring woman to experience how it felt. Evita is the woman's mother - as in the 'good' scene a birth partner was allowed to be present. Of course we were able to dispel the 'time constraints' myth; the replay took no longer than the disrespectful scene. It doesn't take more time to be kind.

This was a scene in a workshop in a different hospital, facilitated for obstetricians. Here you can see a male obstetrician who volunteered to play the part of the labouring woman, being looked after with kindness and compassion.

Unnecessary medical intervention

In many of the hospitals both private and public, the Caesarean section rate is unacceptably high. India is a country that has both sides of the 'Too Little Too Late, Too Much Too Soon' dilemma that has become a global concern.  15% of the world’s maternal deaths occur in India (WRA 2018). Annually, over 44,000 women die in India of maternal causes, despite over 80% delivering in health facilities. India also has the highest number of stillbirths in the world (de Bernis et al 2016).  And there are hospitals where medical intervention is performed routinely. We visited a maternity service and looked in the birth register - 151 Caesarians had been performed over a period of 10 days. Women aren't generally informed or aware of the risks associated with the procedure, nor is there any notion of choice.  

Because of this, our workshops also included the concept of choice, and we used an example of induction of labour for post-maturity. The issues facing both the mother and her family as well as those providing maternity care are similar to those in other countries including the UK - though the 'doctor knows best' is firmly embedded in Indian culture, and this was clearly apparent during our sessions. Fear is palpable at all levels, and complexities overwhelming at times. I was particularly horrified to hear of increasing violence in some areas, where obstetricians were physically attacked by families if outcomes didn't match expectations. 

But India is waking up...

Amidst it all, change is coming, with an increasing number of women and policy makers starting to pay attention to the disrespect agenda, and the exploitation of unnecessary surgery.  Some government maternity hospitals are notably making changes  and Evita and her team are part of the revolution. In fact Evita Fernandez is developing a professional midwifery programme - based on International Confederation of Midwives global midwifery education standards . Dr Fernandez and her team have a well established charity PROMISE which supports the developments, and recently the Indian government has invited Evita to lead more programmes of midwifery. 

Evita Fernandez, with the help of Indie and others are really moving mountains in this amazing country, in challenging times. I am proud to know them both, and to have had the opportunity to ROAR with them, in India. 

Just enjoying being together at lunch time - left to right - Indie Kaur, Dr Rajitha, midwives Manjula, Siji, me, midwife Prasanna and Dr Evita Fernandez 

References

De Bernis et al (2016) Stillbirths: ending preventable deaths by 2016 Lancet. Volume 387, No. 10019, p703–716, 13

WRA White Ribbon Alliance India (2018) Accessed at http://www.whiteribbonalliance.org/india/

Increasing concern about the possible dangers of frequent ultrasound

I have added several abstracts of papers here on this topic - descriptive blog post to follow 

J Obstet Gynaecol Can. 2005 Jun;27(6):572-80.

Obstetric ultrasound biological effects and safety.

[Article in English, French]

Bly S, Van den Hof MC; Diagnostic Imaging Committee, Society of Obstetricians and Gynaecologists of Canada.

Abstract

OBJECTIVE:

To review the biological effects and safety of obstetric ultrasound.

OUTCOME:

Outline the circumstances in which safety may be a concern with obstetric ultrasound.

EVIDENCE:

Medline was searched, and a review of a document on this subject published by Health Canada and of bibliographies from identified articles was conducted.

VALUES:

Review by principal authors and the Diagnostic Imaging Committee of the SOGC. The level of evidence was judged as outlined by the Canadian Task Force on the Periodic Health Examination.

BENEFITS, HARMS, AND COSTS:

Obstetric ultrasound should only be done for medical reasons, and exposure should be kept as low as reasonably achievable (ALARA) because of the potential for tissue heating. Higher energy is of particular concern for pulsed Doppler, colour flow, first trimester ultrasound with a long transvesical path (> 5 cm), second or third trimester exams when bone is in the focal zone, as well as when scanning tissue with minimal perfusion (embryonic) or in patients who are febrile. Operators can minimize risk by limiting dwell time, limiting exposure to critical structures, and following equipment generated exposure information. Recommendations 1. Obstetric ultrasound should only be used when the potential medical benefit outweighs any theoretical or potential risk (II-2A). 2. Obstetric ultrasound should not be used for nonmedical reasons, such as sex determination, producing nonmedical photos or videos, or for commercial purposes ( III-B). 3. Ultrasound exposure should be as low as reasonably achievable (ALARA) because of the potential for tissue heating when the thermal index exceeds 1. Exposure can be reduced through the use of output control and (or) by reducing the amount of time the beam is focused on one place (dwell time) (II-1A). 4. All diagnostic ultrasound devices should comply with the output display standards (MI and TI) (III-B). 5. When ultrasound is done for research or teaching purposes, exposed individuals should be informed if either the MI or TI are greater than 1 and how this exposure compares to that found in normal diagnostic practice (III-B). 6. While imaging the fetus in the first trimester, Doppler and colour Doppler should be avoided (III-B).

Med Hypotheses. 2012 Apr;78(4):539-41. doi: 10.1016/j.mehy.2012.01.030. Epub 2012 Feb 10.

Long-term effects of in utero Doppler ultrasound scanning--a developmental programming perspective.

Aiken CE1, Lees CC.

Abstract

Ultrasound scanning has been used as a diagnostic and screening tool in obstetric practice for over 50 years. There is no evidence of immediate or long-term harm to the developing fetus from exposure to B mode ultrasound. However, exposure to high levels of Doppler ultrasound during early development is increasingly common, and the full safety implications of this exposure are not clear. Doppler ultrasound exposure in utero gives rise to increased apoptosis in animal models, and there is evidence of the effects of exposure to Doppler ultrasound persisting throughout life, with increased non-right-handedness observed in human epidemiological studies. We consider the idea that there may be long-term developmental implications for fetuses exposed to Doppler ultrasound early in gestation. These effects may be mediated via thermal or mechanical disruption to the developing conceptus, giving rise to free radical damage. Excess free radical exposure early in gestation is a strong candidate for the final common pathway underlying developmental programming effects, and gives rise to concern that fetuses exposed to high levels of ultrasound are at risk of a developmental programming effect. It is suggested that there is a need for animal studies of developmental programming using exposure to Doppler ultrasound scanning as the exposure of interest, and for more observational data to be collected in the clinical setting. While these data are collected, it seems prudent to continue to adhere to the principle of 'as low as reasonably achievable' (ALARA) when exposing first-trimester fetuses to Doppler ultrasound.

Clin Obstet Gynecol. 2012 Mar;55(1):188-98. doi: 10.1097/GRF.0b013e3182488386.

A symposium on obstetrical ultrasound: is all this safe for the fetus?

Sheiner E1, Abramowicz JS.

Abstract

Diagnostic ultrasound is a form of energy that has the potential for effects in tissues (bioeffects). The 2 most likely mechanisms are heating and cavitation. The thermal index (TI) expresses the potential for rise in temperature. The MI indicates the potential for the ultrasound to induce inertial cavitation. Scarce data exist regarding instrument's acoustic output for routine ultrasound examinations. Data collected during routine ultrasound examinations (first trimester for viability, nuchal translucency, anatomy surveys including 3-dimensional/4-dimensional studies and growth studies) show that "gray-scale" B-mode ultrasound is associated with a negligible rise in TI. However, Doppler studies show significantly higher levels of TI, which can reach 1.5 and above.

Ann Afr Med. 2012 Jan-Mar;11(1):1-4. doi: 10.4103/1596-3519.91006.

On the safety of diagnostic ultrasound in pregnancy: have we handled the available data correctly?

Bello SO1, Ekele BA.

Abstract

Robust evidence of the bioeffects of ultrasound is available from animal studies but human studies are less convincing. Nevertheless, it is disturbing that the only response to safety issues is a twenty-year old principle known as ALARA (As Low As Reasonably Applicable). Using experience from obstetrics and toxicology, and drawing information mainly from two recent systematic reviews and meta-analysis that extensively covered the subject of ultrasound safety, this review captures the current knowledge of ultrasound bioeffects and suggests that it may be time for an international, multidisciplinary meeting on ultrasound safety to decide how to provide the evidence (available data) to patients and sonographers in a succinct manner.

Birth (and midwives) in the media

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

Twitter: @godfrey_isaacs

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

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

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

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

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

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

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

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

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

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

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

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

NORMAL BIRTH - evidence and facts

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

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

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

Shame on you all.

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

EVIDENCE AND FACTS

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

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

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

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

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

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

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

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

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

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

Seek truth and report it

Minimise harm

Act independently

Be accountable and transparent

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

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

Professor Soo Downe OBE

DON'T JUDGE ME: I was a victim.

Image: www.slate.com

Anon.

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

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

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

I am not stupid

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

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

Photo: Pinterest

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

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

You have not walked a mile in my shoes

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

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

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

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

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

It's not over...

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

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

I need to thank the women who picked me up

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

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

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

We need a rethink - maternity services in England

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

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

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

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

so much desire to improve maternity services…

Brighton student midwife conference - july 21st 

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

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

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

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

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

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

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

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

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

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

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

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

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

Photo: Sorry, a midwife speaks.

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

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

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

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

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

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

Why is this happening?

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

We need a rethink and your suggestions are welcome. 

Reference

Downe, S (2017) Personal communication 

The Land of the Respirators - #ENOUGH

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

Hannah Dahlen making us think…. #ENOUGH

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

We are now in a modern world..

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

Submissions in the basement

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

The End...

Can you help?

HISTORY OF INTERNATIONAL CONFEDERATION OF MIDWIVES

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

CAN YOU HELP?

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

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

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

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

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

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

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

Ann M Thomson

Professor (Emerita) of Midwifery

University of Manchester

Ann.thomson@manchester.ac.uk

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

This is a post about the term Obstetric Violence.

It isn’t about doctors.

It isn’t about midwives.

It’s about both.

BUT, it’s really about childbearing women.

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

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

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

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

What is Obstetric Violence?

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

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

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

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

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

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

Obstetric Violence.

So I asked an open question on Twitter:

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

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

Why do I care?

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

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

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

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

---

4th April 2017, posted on Twitter.

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

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

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

Please leave your comments...

Normal birth - a moral and ethical imperative

Updated on the 14th August, 2017 

It has been a very troublesome weekend. 

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

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

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

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

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

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

May 2017

Sheena Byrom OBE with Professor Soo Downe OBE

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

Why does 'normal birth' matter?

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

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

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

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

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

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

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

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

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

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

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

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

A moral and ethical imperitive 

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

It is very far past time to turn the tide. 

References:

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

Lancet Midwifery Series (2014) 

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

All this push for 'normal birth' - why I keep pushing.

Photo credit and copyright: Claire Riding. Midwife Lynda Drummond 

Guest blog post by Australian student midwife @MegHitchick

“All this push for ‘normal birth’ – what’s the point? Women and babies used to die all the time in childbirth, so who cares if we have high rates of intervention? What does it matter which way we give birth, as long as the baby is healthy?”

As a consumer of the media, I see this - or some variation on this theme - so often. In a somewhat sinister twist, I occasionally see this one:

“Midwives endanger lives with their stubborn insistence on pushing for normal birth.”

I’m a third year student midwife, and a birth addict. In October last year, I attended the International Normal Labour and Birth Conference in Sydney, Australia. Seeing so many esteemed, brilliant and passionate people assemble to protect and promote normal birth was somewhat overwhelming, and possibly even more so was trying to keep up with it all on social media! Thousands upon thousands of tweets, Facebook posts and #normalbirth16 hashtags flooded the web, drawing many comments from people near and far. During one session, as I scrolled through my Twitter feed, one heartfelt comment stood out to me among the many. I won’t quote it directly, but in essence it said this:

“Great. Way to go making all us mums who had to have Caesarians or other help to give birth feel like crap. All this ‘normal birth’ stuff does is make a competition out of motherhood. I’m healthy, my baby is alive and that’s all that matters. So shut up with the ‘normal birth’ trumpet.”

In that moment, my heart broke. Not just a little bit, either - a big, frustrated ‘snap’.

It broke for this amazing, tough, proud mother who has come out the other side of birth feeling like a fighter, a survivor, and who hears the message of ‘failure’ in the normal birth movement.

It broke for all the women who feel that they are constantly judged for a choice that their bodies made for them.

It broke for mothers who did the best things for themselves and their babies - the best they could in the time and the place where they faced birth, and with the people and facilities that they were surrounded by - and who still feel that they need to justify themselves for it. They’re angry. And I’m angry for them. I’m angry alongside them.

Because the move to protect normal birth is not, and has never been, about trying to conscript women into accepting less intervention, less Caesarian section, less pain relief in birth. The purpose of such advocacy is never about blaming women for their choices and experiences. The point of the exercise is NOT to make mothers feel like failures if their birth did not meet the ‘optimum’ recommendations. Birth is not, and should never be, a competitive sport.

Advocating for normal birth is NOT about holding women accountable.

Advocating for normal birth IS about holding birth workers accountable.

The purpose of the movement towards more normal birth is to hold professionals, doctors, midwives and policy makers responsible for the way in which they provide care for women and their families through pregnancy and birth. It is to challenge systems that create the conditions under which so many women’s bodily processes and births are chosen for them.

And women should never, ever be given the ridiculous idea that in birthing, they were somehow not good enough, not strong enough, not natural enough. Instead, we must take great care to ensure that women hear the message right: it is up to us birth workers to be the best we can be, so that we don’t cause you harm or disrupt birth unnecessarily under the banner of ‘keeping you safe’.

It is entirely on the shoulders of midwives, doctors, policy makers and governments, to use the most recent evidence we have to give the best care: evidence that shows that continuous care by a known midwife improves outcomes (Sandall, et al, 2016) and increases maternal satisfaction (Forster, et al, 2016). Evidence that shows that continuous electronic monitoring in low-risk labour doesn't change how often we lose babies, but it changes how often we perform c-sections (Alfirevic, Devane & Gyte, 2006). Evidence that flies in the face of a whole lot of policy, procedure and propaganda.

So don’t be fooled - advocating normal birth is not some crazy, midwife-led agenda to keep obstetricians out of work and see women suffer through difficult labour without pain relief (although that’s what some outspoken critics might have you believe). It’s true that many of the most articulate advocates for normal birth are midwives, but are midwives really that vicious?

What possible motivation could a midwife have, for wanting to see less unnecessary intervention in birth? It's not like midwives are naive to the things that can go wrong - they see it often. They are trained to recognise impending problems, and to refer as necessary. Chances are, in a low risk pregnancy, it will be a midwife who first detects a possible pregnancy complication - and they DO recognise them. It would be a fair bet to say that a midwife has seen pregnancy, labour and birth unravel into disaster more often than the average person walking down the street. So by seeking to reduce interventions, can we infer that midwives harbour some secret desire to see these adverse events more often?!

Anyone who has stumbled upon a midwife shaking silently in the tea room over a near miss would know otherwise. Anyone who has seen a midwife arrive home from a shift where the unthinkable has happened, would know otherwise. Nobody wishes these things to happen - especially not midwives.

Midwives do not benefit financially from less intervention. Less use of 'technology' during labour creates more work for the midwife, not less. Midwives who provide the gold standard of midwifery care - continuous care with a known midwife throughout pregnancy, labour and birth - experience considerable disruption to their personal and social lives. So why should midwives care? There is nothing in it for them, not personally, anyway. The motivation is purely a deep conviction that pregnancy, birth and mothering are profound life events that can be source of incredible empowerment, when women are upheld in the centre of them. This conviction brings with it the determination to ensure that women do not only 'survive' their experience, they 'thrive' through it. 

That’s why I’m determined to continue to advocate for normal birth. Not because I think birth intervention is the sign of a ‘failed woman’. Not because I want women to feel ‘crap’ about the way in which they have given birth. But because I never want to see our systems of care undervalue and underrate the incredible intuition of a woman birthing in a supported, protected and empowered space. The process and power of normal, uninterrupted birth must be the focus of curiosity and deep respect for all birth workers. Only when this is true, can women be confident that their birth experiences represent the optimum for themselves and their babies. And then my heart won’t be broken anymore.

---

Meg Hitchick is an exceptionally talented student midwife at Western Sydney University. Meg has written a beautiful piece about eye contact and the importance of communication for The Practising Midwife, which is available here for you to read. 

I met Meg last year at the International Normal Labour and Birth Conference in Sydney. Meg wrote and performed an incredibly revealing 'skit' about the choices (or lack of) women have to negotiate during childbirth.  I recorded it LIVE via Facebook, and after making it publicly accessible, the video went viral. The performance has been replicated by others in England (with permission), and midwifery leaders are using it as part of a training tool. You can watch a recording of the skit below...please leave your comments.

References

Forster, D. A., McLachlan, H. L., Davey, M., Biro, M. A., Farrell, T., Gold, L., Flood, M., Shafiei, T. and Waldenstrom, U. (2016). Continuity of care by a primary midwife (caseload midwifery) increases womens satisfaction with antenatal, intrapartum and postpartum care: Results from the COSMOS randomised controlled trial. BMC Pregnancy and Childbirth, 16 doi:http://dx.doi.org.ezproxy.uws.edu.au/10.1186/s12884-016-0798-y

Sandall J., Soltani H., Gates S., Shennan, A. & Devane, D. 2016. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2016, Issue 4. Art. No.: CD004667. DOI: 10.1002/14651858.CD004667.pub5

Alfirevic, Z., Devane, D. & Gyte, G. 2006. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane database of systematic reviews(3): CD006066.

A cultural glimpse into a pregnancy childbirth session in Mumbai

By Lina Duncan

It was a hot and muggy July monsoon day, minus the rain, and I was off to share a "preparation for birth" session with a new gathering of women. These women had never attended a pregnancy 'class' in their life. Some of them may have attended school to some level. The Foundation of Mother and Child Health (FMCH) started this project, had previously surveyed the area, focussing on the needs of the community, with an aim to improve the health and quality of life for children there. They looked at dietary issues and sharing cost effective methods of making food to benefit children that are anaemic and malnourished. Other interventions include child spacing, family planning, pregnancy and preparing the women for birth. A large proportion of the FMCH time is spent focusing on exclusive breastfeeding and healthy weaning. I admire the work of the close-knit team and always accept invitations to share my experiences and tips to any pregnant women who express interest in childbirth education.

So I jumped on the local train (with no doors, like in the film “Slumdog Millionaire) with my baby doll, pelvis, placenta, a knitted boob, all stuffed in my backpack. I also carried an illustrated large display book with diagrams of baby in the womb, baby’s growth through trimesters, and what the body does to prepare for birth. 

It was not easy to reach the little room where session was to be held, and I asked my guide how the women could even get out to the hospital in the middle of night, as the road went far inside to a dead end place and climbed uphill where it ended. Many families live on the hill in a jumbled puzzle of chaotically placed, simple homes. The bus from the station had been overflowing, we could not get on, and the rickshaws (like Thai tuk tuks) did not want to take us "such a short distance" - I was thinking it was about half an hour walk from the station.

Eventually a rikshaw driver agreed to take us to the start of the road and we walked into the slum. My mind was imagining young women in labour in the middle of the night and the hassle it would be to try to get anywhere near a hospital. These women need to travel to a government hospital in labour which would take a minimum of 20-30 minutes.

In recent years the government have been on a major push to lower maternal and neonatal mortality, institutional births are encouraged. You can read more about this here. An alternative would be to go and birth in the village with a traditional "dai", a midwife who has probably learned her trade from generations past, or from an interest in birth, maybe starting with helping goats, and moving on to humans.  

The small room was opened already, and some wide eyed and shy women were eagerly sitting on the floor. As we waited for the late-comers I introduced them to my baby girl doll and took every moment as an opportunity to bring positive truths to them. My doll being the first of these as she is black and unfortunately people prefer fair skin babies, all over Asia. So I affirmed her beauty and her female sex, and spoke to her as if she was my longed for, and loved baby of my own. There is a campaign called "Dark is Beautiful" in India that “seeks to draw attention to the unjust effects of skin colour bias and also celebrates the beauty and diversity of all skin tones”. One very special 7 year old I know washes her face and arms with toothpaste because her classmates tell her she is too dark. Kids pick up all these messages from the TV where skin lighteners are adverstised etc. Even the poorest communities have TVs. It saddens me to see this predjudice and preference for lighter skin colours.

With the last arrivals all squashed in to the small room, I moved on to female anatomy, womb, cord, placenta, amniotic fluid etc and we had fun learning and discussing the words in Hindi. Marathi is the local lingo in the area but I teach in Hindi because I can't speak Marathi and because Hindi is the national language. Women from all places come to settle in urban cities. The woman in charge translated into Marathi. Some mothers brought their daughters and sons, they were refused entry (for lack of space) but I managed to persuade the team that it's healthy and natural for them to be included, especially as they barely get any sex education in school. 

We talked about the signs of labour etc, and I could see these bright shiny eyes smiling back at me as they recognised and understood what had happened in their previous births, as I was putting a language to things they had experienced but no one had shared with them. We covered all the possible signs I could think of and then progressed to what happens on admission to hospital and what to expect. 

Now this is like walking a tightrope for me. Is it beneficial to know nothing and just float away into a discounted, “shut down zone” when experiencing pitocin for inducing or augmenting labour with no explanation?  With no pain relief offered, multiple vaginal exams by more than one care provider, with no explanations or consent? Also, with manual dilation of the cervix, fundal pressure, episiotomy and separation from baby? Probably not beneficial as far as the fear factor goes, whilst lying on a table, not allowed to be mobile, not allowed to eat or drink, and with IV fluids running.

 "Masala meds" may be introduced at any time to the iv cannula. "Masalas" in Indian food culture are different, delicious spices mixed together in preparation and whilst cooking, to create amazing food. Masala meds are usually Pitocin, to hurry along the baby, Drocin and Buscopan to relax the cervix and help it to dilate? They are “pushed” / infused in the IV fluids all together, hence the name “Masala Meds”.

I decided that information was better than ignorance, and not wanting to instil fear I passed on to these sweet women some relaxation and comfort tools, something to focus on when things get hard and to look forward to the end result. I also gently explained that they would most probably get an IV, that medicine would inevitably be added to it to speed things up, that they may feel scared and alone but to remember to keep their jaws relaxed and try to relax their bodies and minds inbetween the wave like contractions. I taught them Ina May Gaskin “horse lips”  and how to make low sounds quietly so they are not told to shut up. Women have to be brave to enter a government hospital to give birth, so I tried my best to make them into brave birthing warriors and not to fear the process, and I made them laugh a lot too. Laughter is always good.

It makes me sad that these young girls and women need to know about routine episiotomy and fundal pressure, but these practices are common place (and in the most expensive hospitals in town), and there is no such thing as a birth companion, an explanation or a consenting to a procedure. Tasks are performed and babies are extracted, I cannot really describe what I have seen, during birth. The new baby goes away, upside down for a minute, screaming, and comes back with it's genitals, not its face, to meet it’s mother. I showed them this as an example with my doll, and they all had a good laugh. I had tears in my heart and my throat. What a sad way to meet their special little one that grew inside. I have witnessed young girls eyes either light up or shut off according to what their in-laws are hoping for, mostly male babies, although this is slightly and slowly turning around. This makes my heart sing.

Class ended with my baby doll (with cord still attached) naked and covered with a blanket (and no hat) in skin to skin position. I explained the benefits of exclusive breastfeeding and skin to skin and explained that if they want a healthy and thriving baby, then that's what they can do, as much as possible. I talked about delayed cord clamping and the women who had birthed in the village with dais knew exactly what I was talking about. Dais respect the placenta as a life giving organ and even use it as a tool for resuscitation for “slow to get going babies”. They put the placenta into a bowl of warm water and massage it, and usually the baby soon takes it’s first breath, or breathing and colour imporves with this technique. Of course the babies get their own stem cells too which is most beneficial. I told them I am going to write to the priminister Modi so he may change the protocols, and therefore possibly turn around the huge problems of anemia in India.

A couple of them spoke up about their hospital births and one lady shared about her village homebirth. I smiled knowingly at her and she understood what I was conveying in my smile back to her - well done! 

I lent my doll to a little boy, for a few minutes whilst everyone ate a banana. He had come with his 7 month pregnant mother. She didn't look more than 4-5 months.

As I left and walked down the road to get back to the train station and my home, I day-dreamed of a small community birthing centre there, where women would be shown kindness, dignity and respect, and where babies would be welcomed in a way that honours new life and enhances bonding and nurturing. Maybe.....

One day.

Let's train an army of midwives for a land that has an astronomical amount of births per year. This land where women need an overdose of kindness and compassion whilst giving birth and beginning motherhood. 

Lina Duncan

Lina Duncan lived in Mumbai for 9 years, where she set up a private business providing midwifery services in collaboration with Indian doctors who acknowledged the midwife model of care. In her spare time she volunteered to facilitate local vulnerable women and families to access public health care for all things perinatal and offer support on their journeys. Lina loves to share information and especially enjoyed these classes, run by a local NGO. She is returning briefly to India to speak at the Human Rights in Childbirth conference in Mumbai from 2nd-5th February 2017 (see links below). Follow @HRiCIndia2017 on twitter for pre-conference updates and live tweets from the team.

Human Rights in Childbirth together with Birth India are hosting a conference in Mumbai this 2-5 February. To register click here   or here to find out more!

Speech to Rita: a midwife's experience of birth trauma

The birthday theatre group 

It was 2002. I'd begun my new position as consultant midwife, and part of my role involved listening to women and families in an attempt to influence and improve our maternity service. I did this through various channels, going out to meet parents in local communities, responding to complaints, and involving willing individuals in many aspects of service delivery (peer support) and improvement. This work fed into our MSLC, and I communicated activities via a newsletter. 

I also developed a service where I listened to women who were suffering from fear of childbirth, either as a result of a previous traumatic birth experience, or because of negative stories from others, either friends or family, or in the media. 

‘I was really scared when I was pregnant again, it was awful hanging over you, that this might happen again and it might be worse this time’ [Ann] (Thomson & Downe 2010). 

This fear was like I’d never known before, and I learnt so much about childbirth in the eight years I spent hearing such detailed accounts of consequential self-loathing, anguish, nightmares and horrific flashbacks, relationship breakdown, poor parent-infant attachement and distress. At this stage I had been a midwife for decades, so why had women not talked about these feelings to me before? In my world, birth trauma wasn’t reported in the same way as it is today. I remember speaking to one of my consultant obstetrician colleagues about how birth was affecting some women, and how I felt this was just the tip of the iceberg. He told me he hadn’t come across it, and maybe the women I was seeing were ‘unstable’ already. I was horrified, and saddened by his lack of understanding and compassion, but then I was reminded of the frustration I felt listening first hand in my small office, to personal accounts of horror. Supporting the women referred to me to overcome their fear and distress was my main focus, but it was going to be a challenge sharing the underpinning messages behind the stories of traumatised individuals and their families with those who worked in our maternity unit, and beyond.  There were many reasons why women felt damaged, and my findings reflect those of others. Interestingly, labour ‘pain’ didn’t feature heavily in the overall themes that emerged, as most women who I saw had had epidural anesthesia.  Overwhelmingly, women reported feeling powerless, and totally disconnected from the birth of their baby. Some felt violated. 

'Don't feel I gave birth and had a baby on that day, I just felt I went into a room and was just assaulted'.  [Claire] (Thomson & Downe 2008)

Women frequently described feeling that their baby had been ‘extracted’ not born, and that the process belonged to others, not them.  My increasingly apparent dilemma remained, for a time, unanswered - how could we improve the care we gave, to prevent this from recurring over and over again, when there was just me hearing about these experiences?

I worked closely with Professor Soo Downe at the University of Central Lancashire, and she suggested that we asked the women who had accessed my support, how we could improve services to prevent birth trauma. And so that's what we did. We invited those who had given permission for me to contact them, and invited them for coffee…

Seven women attended that first meeting, and after long chats the women present felt the most important thing was to offer authentic feedback to maternity workers, about their experiences.  One woman suggested using theatre to help them to do this, with themselves as the actresses! Some of the group felt worried about this – not being thespians – but after a couple more meetings they became totally engaged with the idea. So we asked a midwife lecturer who was also an actress, the wonderful Kirsten Baker, if she would help. At the time Kirsten was the owner of the Progress Theatre Group – a team of midwives, parents and maternity workers who use forum theatre to influence change.  Kirsten asked a playwright to transform the mothers' stories into a theatre piece, and 'Speech to Rita' was born.

The women who were keen to be involved needed support and reassurance, to be in a safe place to begin to work through the process of telling their stories. It was a long journey, with many tears shed.  Even though most of the group had had a 'redemptive birth' (Thomson & Downe 2008), reliving their personal experiences in front of others was harder than they had expected. We met in my kitchen, so the environment was non-threatening.  We ate cake, drank lots of tea, and laughed and cried together.  Kirsten did relaxation, breathing and vocal training to help with acting, and I tried to be the nurturer. Once the group felt strong enough, we rehearsed in our local village hall, acting out the 'Speech to Rita' script. The theatre session wasn't about criticising or blaming maternity care workers, but about highlighting the things that potentially cause upset or distress. In the busyness of maternity services, where organisational culture and staff shortages impact on time and emotions, midwives and doctors can become conditioned to just 'getting through' each day. And then there's the fear. Often unaware of the consequences of their actions or words, maternity workers do their best. Listening to feedback can help us to see that simple things like changing the language we use, and connecting compassionately, doesn't take more time but makes a difference. 

Early days in my kitchen

Rehearsals in the village hall

pre-performance rehearsal 

during the first performance normal birth conference, 2004

After years of touring, the group became more pressed for time, due to family and work commitments. Sadly, we needed to disband. But we felt proud that we tried to be the change, to make a difference, and according the this article - we had some impact (Byrom et al 2007).

I made a short film all those years ago, to say thank you to each courageous woman who stood tall, and tried to make a difference. We are still on that journey, trying to maximize potential for ALL women to have a positive birth experience, wherever or however she gives birth. It’s this that keeps me going.

I want to honour the women that taught me so much about childbirth, and my work as a midwife. Kirsten Baker, thank you for believing in and helping me. 

For Helen, Sarah, Maria, Debbie, Sue, Jeanette, Sarika, Nicky and Anna, you gave me, and the world of childbirth, more than you’ll ever know. 

Things you taught me…

• More about the importance of birth experience than I ever learnt in a classroom, or during my years as a clinical midwife
• That listening means more to you than me speaking
• It’s the little things that matter, the language I use, and the compassion I show
• Do ‘with you’, not ‘to you’
• Pain isn’t necessarily an issue, it’s the feeling of powerlessness and lack of dignity that impacts on you the most
• That antenatal education and preparation is important, but where you give birth, and who cares for you has the greatest influence on outcomes
• Our continuity of care model made a positive difference to the birth you had
• Developing respectful, authentic relationships with obstetricians, midwives and neonatologists is crucial when facilitating your choices, and maximising yours and your baby’s safety
• Birth trauma is self diagnosed, and not dependant on mode of birth
• That my actions hold the potential to influence your and your baby's future...
• That I am so fortunate to have met you all, my wisest of teachers.

References:

Byrom S, Baker K, Broome C, Hall J (2007) A Speech to Rita: giving birth to a voice. The Practising Midwife (10) 1 Pp 19-21 (Accessed here)

Thomson G, Downe S (2008) Widening the trauma discourse: the link between childbirth and experiences of abuse.  Journal of Psychosomatic Obstetrics & Gynecology 29(4): 268–273

Thomson G, Downe S (2010) Changing the future to change the past: women's experiences of a positive birth following a traumatic birth experience Journal of Reproductive and Infant Psychology 28 (1): 102 -112

A hero’s tale of childbirth

Birth trauma is a poorly acknowledged phenomena, but one that is gaining momentum within social media channels.  As I reflect on my work from over a decade ago with women who experienced devastating birth trauma, it is important to highlight Gill's work. I was fortunate enough to meet Dr. Gill Thomson in 2005, when she began her PhD studies at the University of Central Lancashire. Gill has written extensively on the topic of women's experience of childbirth, and has kindly provided key insights from her PhD for my blog. I hope this helps to raise more awareness of the effects of childbirth on women and their families, and society as a whole. Thank you Gill.

dr Gill thomson 

My PhD study, completed in 2008 focused on how women who had experienced diverse birth events.  It aimed to explore how women experience and internalise a subjectively determined traumatic birth event, as well as how they were able to develop the strength and resilience to achieve a subsequent positive birth and the impact of this experience on maternal wellbeing.  I used a philosophically informed theoretical and methodological framework, drawing on the work of Martin Heidegger and Hans Georg Gadamer.  Through purposive sampling methods, a total of fourteen women were engaged over two recruitment phases.  In phase one an interview was held with ten women who had already experienced a self-defined traumatic and positive birth.  In phase two, four women were recruited on a longitudinal basis; interviews were held after a traumatic (interview 1) and subsequent birth (interview 2).  In addition, all women (across both phases) were also involved in a final interpretation meeting.  Thirty-two interviews were held in total. 

I present women’s childbearing journey of tragedy and joy through seven interpretive themes and used a theoretical framework to re-conceptualise the women’s birth narratives as a hero’s tale.  A heroic journey of adversity, trials, courage, determination and triumph.  A traumatic birth was a growth-restricting life event; an abusive, deeply distressing experience characterised by a lack of control, isolation, poor care practices and an embodied sense of loss.  The aftermath of trauma held wide scale negative implications for poor maternal health and functioning; women described how it had negatively impacted on their sense of self, they often struggled to form positive relationships with their infants and blamed themselves (and often their partners) for what had occurred.  These women had held what they considered to be realistic expectations of labour and birth, they actively prepared for the birth during pregnancy, and to become a parent was often a long awaited for, and positively anticipated life event. However, the reality left women feeling broken and unable to experience love for their infant.  A trauma birth was imbued with an inherent sense of secrecy as women felt unable or unwilling to discuss their experiences for fear of being perceived as not coping – ‘a bad mother’.  A healthy baby was the only outcome of consideration, and women’s birth experience rendered as a means to an end.  

For a number of the women in my study it took them years before they could consider having another child. They had not originally intended to have large age gaps between their children. However, the impact of a traumatic birth meant this was inevitable, and to a large extent robbed them of their family ideals.  However, becoming pregnant again, and the reality of having a potentially similar birth operated as a catalyst to receive support as women ‘broke down’ during antenatal appointments.  The power and determination to have control and to achieve the birth that they wanted was evident in their narratives.  A number of different strategies and methods were adopted in planning for a subsequent birth.  These included discussing the birth with a midwifery professional, and how this afforded them the opportunity to understand what happened and why it happened.  This was described as highly beneficial in terms of relinquishing self-blame as well as offering reassurance and hope for their forthcoming birth.  Other strategies involved re-visiting the delivery suite, attending further antenatal classes and using homeopathic medicines. A further salutary strategy involved creating multiple birth plans for different birth eventualities – a preparatory approach that helped the women to develop their capacities to respond to the uncertain and erratic nature of childbirth. 

A subsequent positive birth was experienced as a euphoric, joyful, healing life event - an occasion to be celebrated and embraced.  Women experienced person-centred ‘care’ from professionals who they trusted, and who understood what they wanted to achieve. They felt in control over what occurred during the birth and felt they were actively involved in decision-making.  Women felt that they had given birth, irrespective of how the birth had occurred; for example, a woman who had a second caesarean felt that she had given birth due to feeling so involved and connected to the birth process.  In my study, I describe a subsequent positive birth as a ‘redemptive’ experience; a cathartic and self-validating experience that confirmed how bad their former experience had been and enabled women to release and relinquish self-internalisations of blame and guilt.  The transformational nature of redemption was evident through women describing themselves as ‘whole’ and ‘complete’ and able to find ‘the parts of me that were missing’ following a healing, positive birth.  To experience such a different birth on occasion induced anger and discord through women through feeling ‘robbed’ or ‘cheated’ of not achieving this ideal the first time.  However, women spoke of how their subsequent redemptive birth had provided ‘a perfect happy ending’; an occasion that enabled them to hold positive and happy memories of childbirth, rather than ones encroached by trauma and dysphoria.  Similar to insights from wider trauma literature, all of the women referred to how they had, or wanted to engage in altruistic behaviours by sharing their birth experiences to protect, help and inform others. 

A number of practice implications were generated from this study including: proactive opportunities for women to reflect and discuss their birth experience; to encourage the use of expressive writing for women to detail the often ‘unspeakable’ nature of trauma; further research to identify suitable interventions/approaches to help ameliorate the impact of a traumatic birth; for antenatal preparation to be more reflective of the realities of childbirth, and to encourage co-creation of multiple birth plans to prepare women for different birth trajectories; and for appropriate training to be provided to health care providers to enable them to be cognizant of how women experience and internalise trauma, and care practices that promote a positive, fulfilling childbirth event. 

I want to conclude on what I consider to be one of the key revelations from this study.  When I embarked on this project, I had had three experiences of childbirth, one that was highly medicalised (i.e. induction, epidural, episiotomy and forceps) and two that would meet definitions of normality.  I considered, similar to wider literature, that a positive birth was fundamentally related to a ‘normal’ birth that was drug/intervention free, and involved a natural, vaginal delivery.   This is not what was revealed in these women’s accounts.  A number of the negative/traumatic births were straight forward vaginal deliveries, whereas some of the positive births involved a cascade of interventions, operative births and postnatal morbidities (third degree tears, haemorrhages).  These insights highlight that it is not what happens during the birth, but rather how it happens that is crucial.  To a large extent, the current discourses of childbirth serve to dichotomise and polarise women’s experiences; with fulfilment and renewed life meaning achieved through normality - and complexity, complications and interventions associated with adversity.  This study offers a new perspective, of how a birth that is managed with care and sensitivity and for woman’s views and beliefs to be central and considered in all decision-making is one that needs to be strived for.  To provide a model of care based on humanistic values of respect, trust, genuineness, honesty and empathy to enable women, irrespective of how they give birth to achieve an ‘ordinary miracle’ of childbirth.

Please get in touch for further information:  GThomson@uclan.ac.uk

Publications from PhD study:

Thomson, G. & Downe, S. (2013).  A hero’s tale of childbirth.  Midwifery 29(7):765-71.

Thomson, G. and Downe, S.   (2010).  Changing the future to change the past:  Women’s experiences of a positive birth following a traumatic birth experience.  Journal of Reproductive and Infant Psychology, 28(1), 102-112.

Thomson, G. & Downe, S.  (2008) Widening the trauma discourse:  the link between childbirth and experiences of abuse.  Journal of Psychosomatic Obstetrics & Gynaecology, 29(4), 268-273.

Thomson, G.  (2011).  Abandonment of Being in Childbirth.  In:  Thomson, G., Dykes, F.,  Downe, S.  (eds). Qualitative Research in Midwifery and Childbirth:  Phenomenological Approaches.  Routledge:  London.

Thomson , G.  (2009). Birth as a Peak Experience.  In Walsh, D. and Downe, S.  (Eds)  Intrapartum Care (Essential Midwifery Practice), Wiley Blackwell Publishers:  Oxford.

Thomson, G. and Kirk, J.  Tales of Healing.  In Walsh, D. and Byrom, S. (Eds) ‘Birth Stories for the Soul: Tales from Women, Families and Childbirth Professionals’.  Quay Publishers:  London.

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It's Time For Rhyme!

Birth Campaigner, Doula and Spoken Word Artist

Kati Edwards

gives the lowdown on why she gave birth on TV!

Kati with husband Dave and children Matilda and Seraphina 

Having your birth filmed isn’t everyone’s cup of tea.

Airing that birth on mainsteam TV in front of an audience of 1.5 million on BBC1 isn’t either!

So why did I do it?

Well partly it’s because I’m probably a bit bonkers.

But mostly it’s because it’s really important women see undisturbed births.

Most, I think, don’t know it’s possible or what the advantages are.

Seraphina Skye’s birth featured on the BBC1 documentary “Childbirth – All or Nothing”. It aired in February 2015. Here’s a mini clip of it 

I got tremendous feedback after the show aired. To this day people still contact me to say that show inspired them to have a home birth.

Landmark Films who made the show for the BBC did a great job.

My Fear of Childbirth

Pregnant the first time, I thought I had tokophobia, a fear of childbirth but I didn’t.

I had a fear of the medicalisation of childbirth, something there is currently no word for!

My mum told me from a young age birth was the worst thing ever.

She said it was so bad she couldn’t believe women have more than one child!

She hadn’t prepared to feel any pain.

Her very charismatic Gynaecologist told her he would take care of everything.

And when she did feel pain, she was scared.

She had no inner tools to deal with it.

There had been no practice of breathing or visualisations, nothing.

She woke up after the epidural and thought her legs were paralysed.

Then she got an infection and stayed in hospital for two weeks.

Not the best start either for her or me.

But it was catalyst for me to do everything I could not to repeat this experience.

In fact, it was the midwife at my first antenatal appointment in 2011 who suggested I should watch ‘One Born Every Minute’ as it was ‘very realistic’.

And yes, feel free to reel in horror!

I came home and diligently watched the show for the first time. I was petrified!

The women I saw didn’t seem in control. They looked really scared.

Somehow, it just didn’t look right to me. Too much panic and too many distractions.

‘Why can animals birth, almost always, effectively and yet somehow humans are deficient? Surely birth doesn’t need to be like that! What is going on?’ I thought.

 Learning To Relax

And so I started to research. I was working at the time for the NHS in the Psychological Medicines service in Physical Health.

So my interest has always been how the mind affects the body and the body affects the mind.

I wanted to know what I could do to prepare for birth.

I discovered the Association of Radical Midwives, self hypnosis for birth and Ina May Gaskin.

I discovered techniques to calm the mind and affect the body.

I learnt how providing an environment that’s conducive to the birth is so crucial.

And my partner found out how he could be a better birth partner and how his role of keeping me calm was so important.

I feel lucky to have experienced continuity of care from a fabulous midwife and I had a doula too.

The things I learnt were not available in my NHS classes which seemed to be more focused on the various ways of surviving childbirth and how the system worked. There was a great emphasis on the vast array of pain medications available but little about the side effects.

I wanted to know how I could actually support myself to have a better birth experience.

 The Birth You In Love Project

After the show aired, I felt I had more to say. So much was lost in the edit.

I had the idea to create my own series of bitesize films and my friend, Cathy Brewster of Greater Manchester Homebirth Support Group suggested I crowdfund the money to make them.

So I set up the crowdfunding platform and was overwhelmed by the support from friends, family and so many people I didn’t know. Amazing!!!

And so, ‘The Birth You In Love Project’ was born; a series of mini-vids to help empower parents to be.

While they’ve been being being created, I’ve been using spoken word to speak at birth conferences, events, festivals and midwifery study days all over the UK.

Among them, I’ve spoken at the Manchester Home Birth Conference, The MAMA Conference in Scotland, I’ve been on Sprogcast (twice), been on the line up with Ina May Gaskin (twice) and I even got a gig in Norway at a conference called Women’s Right’s In Childbirth: Take Back Control in October 2016

Ina May, Kati and Sara 

After this gig, I changed my twitter profile to Kati Edwards: International Birth Warrior!

No really, I did!

Giving birth in front of 1 ½ million people on mainstream TV gave me a new focus. I left my NHS job and I’m now a doula, a hypnobirthing teacher and I speak and write about the changes I’d like to see in maternity services.

The Birth You In Love Project EMPOWER series will be a FREE video resource to recommend to women wanting to know how they can support themselves through birth.

You can contact me by email, Facebook, Twitter or at www.birthyouinlove.com

The Emperor’s new clothes: the politics of birth research

Professor Hannah Dahlen, University of Western Sydney

Professor Sally Tracy, University of Sydney

In Hans Christian Andersen’s tale of the Emperor’s new clothes no one dares to say they don’t see a suit of clothes on him for fear they will be seen as stupid and incompetent. It takes the cry from a small child, “but he isn’t wearing anything at all”, to identifying the farce being carried out.

Sometimes research papers are put out with misleading media releases and political agendas that go unquestioned by a media hungry for controversy and the next sensational headline. In this blog we will identify the naked Emperor in the form of the recent New Zealand paper (NZ) published by Wernham et al. (2016), titled A Comparison of Midwife-Led and Medical-Led Models of Care and Their Relationship to Adverse Fetal and Neonatal Outcomes: A Retrospective Cohort Study in New Zealand.  The Wernham paper caused consternation around the globe with doctors waving it in triumph pretending the Emperor had a magnificent outfit on while midwives scrambled to understand what was happening, crying amidst the crowd, “but he isn’t wearing anything at all.”  

How did something that was fairly low level scientific evidence get more attention, and lead to such public questioning of the safety of midwifery care, than 15 randomised controlled trials and a Cochrane Systematic Review (CSR) on this issue?

Just a reminder about the Level 1 evidence of continuity of midwifery from over 17,000 women randomised in 15 separate RCTs:

“This review suggests that women who received midwife-led continuity models of care were less likely to experience intervention and more likely to be satisfied with their care with at least comparable adverse outcomes for women or their infants than women who received other models of care. Further research is needed to explore findings of fewer preterm births and fewer fetal deaths less than 24 weeks, and all fetal loss/neonatal death associated with midwife-led continuity models of care.”

 How did we ever think the Emperor had new clothes?

The first alert in this recent saga is the media release that came out from the first author’s university, strictly embargoed beforehand to excite the ‘crowd’ awaiting the emperors arrival. The media release revealed the first bias in the authors’ agenda and was the ultimate hook for the media:

“Mothers using autonomously practising midwives throughout their pregnancy and childbirth are more likely to have adverse outcomes for their newborns than those who use obstetricians, according to a retrospective study of nearly a quarter million babies born in New Zealand published in PLOS Medicine by Ellie Wernham of University of Otago, New Zealand, and colleagues.”

Firstly, this study was never about midwifery care during childbirth, or pregnancy for that matter. Midwives also look after women cared for by private obstetricians so this care is never just about medical care just as it is never just about midwifery care. Secondly, there was no statistical difference in perinatal mortality. You would have hardly known this from the media reports. Thirdly, the authors were clearly data dredging when they combined Intrauterine hypoxia, birth related asphyxia and neonatal encephalopathy in order to get a highly significant outcome. Rare adverse events and small numbers were sensationalised in the media release (“55 percent lower odds of birth related asphyxia, 39 percent lower odds of neonatal encephalopathy, and 48 percent lower odds of a low Apgar score at five minute after delivery”). Neonatal encephalopathy occurs 1-2 in 1000 births and is a rare event. Presented this way makes it sound so dramatic and it takes only one or two cases to change the outcome.

Why the Emperor is actually naked

The authors were unable to look at actual care during childbirth because they don’t appear to have this data, so they took model of care at booking and then misled the media and public that this was an indication of care at birth, when it was not. The problem with this is while all women who book with private obstetricians will remain under the care of private obstetricians from booking to birth, between 30-35% of women under midwifery care will be referred during pregnancy to a doctor. Despite this fact all outcomes (only adverse perinatal ones) in the paper are reported as due to midwifery care, when they are clearly not.

One could argue that the randomised controlled trials (RCTs) of continuity of midwifery care reported in the Cochrane Systematic Review use a similar method - that is model of care on booking and intention to treat analysis. However, the difference is randomisation reduces selection bias and the study groups should be as similar as possible at the outset so the researchers can isolate and quantify the effect of the intervention they are studying (in this case midwife or medical care). In a RCT you can see what care women got and you would also know the mode of birth and maternal outcomes, which are not reported in this study. RCT’s can be used to change practice but lower level evidence should not; yet that has not stopped groups such as the Australian Medical Association calling for this in Australia.

The NZ study had several concerning limitations that were not adequately considered in the unfolding debate:

1.     One of the most significant findings of the CSR of continuity of midwifery care was the 24% reduction in preterm birth under midwifery care. There was also a significant reduction in perinatal mortality. Only women over 37 weeks were included in the recent NZ study, so there was no chance to see whether this important effect was seen in this study.

2.     Not only are Apgar scores a poor clinical predictor of long term outcomes but there were a large number of missing Apgar scores and this was greater for women who booked with obstetricians.

3.     The inclusion of women more than 42 weeks, which were seen in larger numbers in the midwife booked group and are more likely to have stillbirths associated with prolonged pregnancies, is concerning. If the authors took 37 weeks gestation as a cut-off to exclude preterm birth (higher risk), why not take 41+6 to exclude the higher risk post-term pregnancies. It would have been very interesting to know how many adverse events were seen in the post-term group. Women choosing midwifery care are more likely to not want to be induced and to go over 42 weeks, as is seen in this study.

4.     The inability to separate antepartum stillbirth from intrapartum stillbirth is critical in trying to assess the impact of birth provider on outcomes and this could not be done, despite the study protocol suggesting it would be.

5.     In the study protocol published with the paper neonatal nursery admissions were examined but not reported. When we look at the author’s Master’s thesis where this information is available, more neonatal admissions are reported for babies born to women who booked with private obstetricians. This was not reported in this paper. One has to ask, why?

6.     In the first author’s Master’s thesis (where this study originally came from), substantially lower rates of caesarean section (22% vs 32.9%) and instrumental birth rates (9% vs 12.3%) are reported for women who booked with midwives, leading to significantly less maternal morbidity. Again this was not reported, giving a very one-sided view considering the authors are virtually questioning the entire NZ maternity system.

7.     There appears to be quite a bit of missing data in this study and it is unclear how this was dealt with in the analysis.

8.     Many socio demographic variables are not accounted for (e.g. alcohol and drug use), and others such as smoking are notoriously underreported. Midwives tend to look after women with greater socio demographic disadvantage and mental health issues. None of this is adjusted for.

9.     Other medical complications that arise following booking, such as gestational diabetes, pre-eclampsia, etc are not accounted for and may be increased in women who book with midwives due to ethnicity factors, life style etc.

10.  Rurality and birth place were not taken into consideration, limiting the usefulness of this study to help make targeted changes rather than slamming the entire N Z maternity system.

11.  There is no difference in PMR between Australia and NZ despite the fact that 30% of care in Australia is by private obstetricians whilst in NZ around 90% of women have a midwife as a lead care provider.

12.  A previous NZ paper that also hit the media headlines in recent times, purporting to show the risk of perinatal death was higher when midwives were in their first year following graduation, has recently been questioned by the NZ Ministry of Health who have been unable to replicate the study. This is worrying.

13.  When we carefully matched the population of low risk women in NSW who had a birth in a private hospital under private obstetric care with low risk women who had a birth in a public hospital with midwife/medical care we found greater morbidity for women giving birth in a private obstetric model of care.

The one highlight in this whole saga has been the united support of the midwives in NZ by the NZ Ministry of Health, The NZ committee of RANZCOG, senior obstetric academics, consumers and midwifery professional bodies around the world.

The political fallout from this paper has been extraordinary, for it actually tells us very little. No practice changes could ever be made based on this study. The Emperor may have no clothes, but the delusion has been maintained by a misleading media release, politically motivated reporting of findings by the authors, a hungry unquestioning media sensing blood in the water and wanting sensational headlines, and obstetricians determined to drag the advances made by the profession of midwifery back to the ‘good old days’ when they were compliant handmaidens. 

#ENOUGH