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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A Passion for Birth: passing on the baton

                    My family - 5 girls

I recently read Sheila Kitzinger’s biography – A Passion for Birth. The first thing that struck me was the synergy between Sheila’s life and mine. It was quite a revelation.  Poles apart in terms of heritage and social standing, Sheila and I not only have similar names, but Sheila was born to a strong rebellious mother as I was, she was mother to five girls, and I am the youngest of five girls.  Like Sheila, there is no division in my life between work and home – it all blends into one, and childbirth and women’s human rights thread through the core.

Until I read her biography, I wasn’t aware of these aspects of Sheila’s life. The book reveals facts about this legendary woman, who set the scene for radical change in childbirth practice in the UK and around the world, and challenged us to think about the experience of childbirth as a potentially exciting, exhilarating, and fundamentally important event.  Sheila's work and passion epitomizes the ROAR of childbirth activism.

During the first part of my career, in the early 1980s, birth activists were mystical beings that I never saw – and inspirational texts were far less accessible.  Individuals like Ina May Gaskin and Sheila Kitzinger influenced my thinking, my practice, but their physical presence was far from my life.  These inspirational women provided me with ideas for ‘another way’, when I was immersed in a culture where ‘doing to’ women was the norm, and permission was not sought for routine unnecessary medical intervention.

Having been brought up in a family of only girls, gender inequality hadn’t occurred to me, even though my wonderful mother, like most women, did the ‘double shift’ of paid work and unpaid housework and motherhood.  Until I read Sheila’s work I didn’t understand the enormity of women’s rights, and how childbirth was fundamental to the struggle.  During my early career childbearing women were compliant, and any woman revealing that she’d attended NCT classes was labeled ‘difficult’ even before the next sentence. Midwives conformed to hierarchies too, and bullying was accepted. I remember a time when I was reprimanded by my colleagues for ‘allowing’ a woman to have a bath shortly after giving birth. The midwives were horrified, as it was the usual routine for a woman to have a bed bath shortly before being transferred to the postnatal area. I couldn’t believe it. I’d worked in the GP maternity unit (that was part of the same organisation) for years prior to this, and there it was normal practice for women to soak in a bath immediately after birth. My superiors told me I was practising dangerously. I challenged the directive, and there began my first move to try to influence maternity care, and I contacted other units in search for evidence. I was never confident even though my belief was strong.  I was considered rebellious (for such a simple thing) and ‘alternative’.  It was around this time that I read Sheila’s book, Pregnancy and Childbirth (1980) – it was a revelation.  My instinct to question unnecessary rituals was founded, and looking back, it was then I began to ROAR.  With a few like-minded midwives, mostly fellow members of the Association of Radical Midwives we searched for evidence to support change. I was fortunate to work with an enlightened head of midwifery, Pauline Quinn, who listened to feedback about our maternity service from women who had their babies with us, via a local NCT tutor. Clare Harding was a highly educated individual, and a member of the Maternity Services Liaison Committee.  Slowly, things began to change. The separation of mothers and babies, binding engorged breasts, giving milk supplements to breast-fed babies, and enemas, pubic shaving, routine episiotomy gradually became activities of the past. But it wasn’t easy, and if it wasn’t for the injection of information and assurance via articles and books from people such as Sheila, I would have been more reticent.  The compassion within me that lead me to choose midwifery as a profession, that helped me to try to be courageous, was often tested. Like others, I was often fearful….

Today we have evidence, and greater access to midwifery and obstetric leaders who continue to push boundaries to promote and support women centred care. We can even chat to them via social media channels. Social media also enables us to learn about innovative practice, and can link us with like-minded individuals then we can join together to enable a greater, unified message.  However, we also have the increasing fear of recrimination, of litigation and doing the ‘wrong thing’, that is leading to defensive practice and vicious circles of despair and distress. This isn’t resulting in a safer service, quite the opposite.  Because of this, and due to our extensive networks, Soo Downe and I decided to bring together a global voice to speak out and identify the need for another way, and to highlight practice where positive change has been made.  We wanted to convey the notion of a link between compassion and love as a antidote to fear, and to try to encourage practitioners to acknowledge the difference between real fear that protects us, and manufactured fear that potentially leads us to practice defensively, and adds to an already stressful situation (Dahlen 2010),.   

And through the years leading up to the birth of The ROAR Behind the Silence, Sheila’s philosophy has underpinned my actions, my search for courage, and my attempt to spread compassion.

Sheila Kitzinger certainly handed me the baton, and I am always willing to pass it on.

Reference:

Dahlen H (2010) Undone by fear? Deluded by trust?  Midwifery 26, 156-162

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

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

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

Women want to be treated as individuals.

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

Women want to be listened to.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

You can follow Michelle on Twitter @QuashieMichelle 

Neighbourhood Midwives' Mothers Fund: guest post by Annie Francis

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

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

Annie Francis CEO Neihbourhood midwives

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Website: neighbourhoodmidwives.org.uk

Twitter:  @neighbourhoodmw

Facebook: www.facebook.com/nbrhoodmidwives

Part of the tipping point: a time to ROAR

Reflecting on the roar....Torquay, Australia

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

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

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

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

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

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

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

Screen Shot 2015-01-23 at 15.58.27

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

Claire with baby, and Lynda her midwife and friend

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

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

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

Claire Riding

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

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

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

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

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

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

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

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

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

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

What was the extent of your involvement?

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

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

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

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

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

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

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

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

And now we must speak out.

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

Find Petra on Twitter at: @Ptenh

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

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

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

When did you realise you wanted to be a midwife? 

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

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

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

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

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

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

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

What other areas of maternity care are you interested in?

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

What are your plans for the future Hannah?

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

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

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

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

You can follow Hannah on Twitter:  @hannahdahlen

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

Photograph by Holly Priddis

Obstetric violence and humanized birth in Brazil

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

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

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

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

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

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

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

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

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

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

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

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

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

Oli Armshaw @olvinda, April 2014 #NOobstetricviolence

Oli Armshaw @olvinda, April 2014

C/S Photo source

England needs more midwives: but legal services are fine

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

My thoughts:

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

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

For childbearing women and partners

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

For midwives/doctors:

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

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

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

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

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

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

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

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

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

In response to Kirstie's radio programme:

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

And finally, a note for our Governmental Ministers

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

Photo credit 

Hypnotherapy research-SHIP Trial Update

The SHIP Trial (Self-Hypnosis for Intrapartum Pain management) lead by the University of Central Lancashire and involving East Lancashire Hospitals Maternity Services, involved offering a group of pregnant women the opportunity to attend a short course explaining how to use self-hypnosis to control the pain associated with childbirth. The course involved two one hour training sessions with an experienced midwife as well as a self-hypnosis CD to take home and practice with. This group of women will be compared with another (similar) group of pregnant women who will not receive any self-hypnosis training. By comparing the childbirth experiences of the two groups, and paying particular attention to the type of pain relief they receive, the study should be able to tell whether self-hypnosis is a useful way of reducing and controlling the pain associated with giving birth.

The steering group for the study recently reported:

Our youngest SHIP baby is 6 weeks old this week, so the last of the 6 week postnatal questionnaires for study participants has gone out.

We’re hoping that any participants who haven’t yet filled in or sent back their questionnaires etc. will do so now, before it’s too late.  The information they contain is really important to us.

The last prize draws for participants who return all study questionnaires will take place in 2 weeks.

More news to follow!

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Midwifery in the NHS: my opinion

Those who know me well will confirm that I have spent most of my 35 years as a midwife, pushing for change to improve care. Just last week I was asked for my opinion of current NHS midwifery services, for a TV programme claiming to be supporting the cause for more midwives. Whilst I haven't worked in the NHS for more than two years, I am in constant contact with midwives and student midwives throughout the UK.

So these are some of the questions I was asked, and my brief responses. I would love to know your thoughts too, via the comments box at the end of the post.

How do you feel the role of a midwife has changed from when you first went into the profession? (Staff numbers, continuity of care etc)

The work of a midwife is significantly different now, in terms of workload pressures as a result of inadequate staffing levels, medical and social complexities of women's pregnancies, increased UNNECESSARY intervention rates, service models and bureaucracy. So much has impacted on maternity services, and midwives are increasingly under pressure due to the afore mentioned, and also due to fear of recrimination. Lack of understanding of the purpose and use of clinical guidelines, and activities related to Clinical Negligence Scheme for Trusts (CNST) has added to midwifery workloads, and the fear factor.

Because of excessive workload issues, midwives have less time to spend with women, and this in itself is stressful, and demoralising. Midwives (and obstetricians) increasingly practice defensively, over treating those in their care because of fear of reprimand or litigation. It's the 'just in case' scenario.  Maternity services seem to be entirely focused on the reduction of  'risk', which has the potential to cause more harm. Over medicalisation of childbirth can lead to iatrogenic damage, and it feels as though the more maternity services focus on safety and risk, the more worried and frightened women become. Pressure to save money in the NHS is taking it's toll on maternity services, and because there are few Trust targets for maternity, the service is more likely to be bypassed. Maternity services' position within an NHS organisation's budget or profile isn't a priority, and therefore departments such as medicine and surgery frequently take precedence (in terms of resources). Women didn't seem to be as fearful of childbirth during my early years as a midwife, and whilst services weren't ideal,  in the main women believed in themselves, and their ability to birth their baby. As we have unwittingly 'done to' women, increased screening, focused on reducing risk, we have disempowered women.

What are the main concerns for midwives today?

Lack of time to do their work well, fear of recrimination (getting into trouble).

Do you think midwives today are over stretched and unable to perform their role sufficiently? Or does this depend on the hospital in which you work? 

This is addressed above. I think in the main midwives are overstretched. There are some services with exemplary models of care for women, where midwives, obstetricians and mothers feel respected, valued and able to do their work even if it is busy. We must highlight those services, learn from them, and channel energies into getting it right for all families.

Francesca and Flo 

And do you feel there is sufficient postnatal care in place for women? 

Postnatal care is suffering due to lack of human resources, and because of the focus on risk, areas of the service where 'risk' is deemed to be greatest (delivery suite/labour ward) takes priority. Because of increased unnecessary intervention in the antenatal and intrapartum period, postnatal wards are busier too. Bed reduction programmes in NHS organisations significantly reduced ability for women to stay until feeding is established, so women get little support to breast feed. Postnatal care in the community is reducing due to pressure on resources. This is a great pity as the lack of support potentially leads to morbidities that cost more for the NHS.

There is no resemblance to the postnatal care I delivered on postnatal wards during the first half of my career, to latterly. This is because there are more:

-Operative births

-Babies who need extra monitoring due to an issue that was potentially caused by mode of birth, or choices made.

- Excessive use of antibiotics on neonates ('just in case'), and the extra input needed from staff.

- Excessive record keeping activity and paper work, which is duplicated unnecessarily. 

Did you ever experience or see women's lives being put in danger because of a lack of resources? 

This is hard to determine. Midwives and doctors always try to do their best, and usually go way beyond the call of duty. Sometimes, however, the pressure on staffing is so great that women receive substandard support and care, usually by way of time spent with them. The potential for harm is always greater when there aren't enough midwives to care for women, at any given moment.

Could I also gain a bit more information about your career as a Midwife - how many years you were in the profession? What you liked / disliked about the role?

I worked as a midwife for more than 35 years in the NHS, and continue to work freelance, mostly on a voluntary basis. I feel immensely privileged and honoured to have been part of each woman's journey into motherhood, and to have worked with the most inspirational teams. Women, both those I cared for and worked with, never fail to amaze me with their courage, strength and determination. Whilst working in the NHS I loved most of my work as a midwife, and grossly disliked the pressure and desperation when unable to help women, and midwives.

There is so much to do. The Royal College of Midwives continue to lobby for more midwives, and a group of well respected activists are pushing for better continuity of care, amongst other things related to Maternity Services. We mustn't give up.

What do you think?

Related articles

• A Normal Birth week! With Mary Ross-Davie (sheenabyrom.com)
• Meet Geraldine Butcher: a wee wonder! (sheenabyrom.com)
• What Twitter did, and what student midwives say! (sheenabyrom.com)

Childbirth and the language we use: does it really matter?

PHOTOGRAPH TAKEN OF WHITE BOARD IN A MATERNITY BIRTH SUITE - AFTER SHIFT IN LANGUAGE FROM 'DELIVERED' TO 'BORN' 

Yesterday several student midwives tweeted about their dislike of some of the language used in maternity services.

‘I hate the phrase “failure to progress” it's so disempowering’ was one comment. And "trial of scar”’ was another phrase tweeters disapproved of. Indeed.

It’s an old issue. I remember in the early 1990’s the Head of Midwifery (Pauline Quinn) where I worked saying how she didn’t like the use of the word ‘patient’ as she felt it disempowered women. She also disliked women who used maternity services being called ‘ladies’, as she thought it patronising and it reminded her of ‘ladies’ at the golf club! And in addition to that, could saying  ‘she’s one of my ladies’ be an even bigger crime, even though unintentional? The woman doesn’t really belong to anyone, does she?

Mrs Quinn interestingly also changed our midwifery titles, and dropped the use of ‘sister’ and ‘staff midwife’, as she believed it potentially influenced the midwife-mother relationship by establishing a defined hierarchy.

These ideas really made me think. I was always careful from then on to consider the words I used. I listened to others, and read interesting articles on the topic. I became more and more aware, and talked to others about it.

The words ‘Not allowed’ became intolerable. Hearing women saying ‘Theywouldn’t let me go over my dates’ started to sadden me.

Other examples:

‘She told me I was only 3cms’ instead of ‘Wow! You are 3cms! Your body is working brilliantly!’

Using the name Labour Ward, or Central Delivery Suite instead of Birth Suite.

The list goes on.

Research carried out into the power of language in relation to infant feeding suggested that midwives used language that influenced decision making to what the midwife wanted rather than words that enabled the woman to make her own choices. Interestingly, the study’s (Furber and Thompson 2000) implications for practice confirmed my managers beliefs from all those years ago:

‘It is important that the language used when interacting with women is considered carefully in order to facilitate an unbiased perspective and to promote partnership. The word ‘women’, rather than ‘girls’ or ‘ladies’, should be used when referring to users of the maternity services.

Working in the same organisation, decades later, things were different. From time to time my colleagues would ask me, ‘does using different words really matter Sheena? We don’t mean harm and what we do is more important than what we say. We have enough to worry about!’ But my answer was (and is) it does matter. Because what we say and how we say it, influences what we do. If we are mindful of the language we use ( i.e. facilitate not teach, share instead of educate) we are thinking about the relationship we have with women and families and our actions will reflect that. Being with, not doing to. It doesn't take much effort, and needs no extra resources.

See the photograph at the beginning of this post? The use of the word ‘BORN’ instead of ‘DELIVERED’ on the Birth Suite board to let staff know the woman has given birth? This is the result of a couple of committed and courageous midwives and a supportive obstetrician thinking about the language they used and the consequential impact on care. They started the ball rolling and although there was much opposition, years later it’s regular practice. It makes my heart sing.

So maternity care workers. Words do matter. To you and to all in earshot of you.

Lead the shift in your workplace even though it may take years for others to follow. Remember Pauline Quinn OBE, and golf. Make a difference, and

‘Be the change you want to see!’ (Ghandi)

Reference

Furber CM, Thomson AM (2010) The power of language: a secondary analysis of a qualitative study exploring English midwives’ support of mother's baby-feeding practice MidwiferyVolume 26, Issue 2, April 2010, Pages 232–240

Photograph

Childbirth and infant feeding: why the war?

The polarisation of opinion with regard to these topics is growing by the minute…and there is much to debate. For this post my thoughts are focused on childbirth, although both subjects are absolutely interlinked.

My initial response when I read condemnations for those who promote and support normal physiological childbirth or breastfeeding is of sadness and shame. Sadness that there has potentially been some degree of personal distress for the one proclaiming their opinion. Shame that my profession is often part of the ‘problem.’

I see and hear opposing yet valid viewpoints about childbirth on almost a daily basis, mainly via blogs, Facebook and Twitter. We are all entitled to our opinion, and it’s good that there can now be a degree of open debate via social media channels. The problem arises when journalists and high profile individuals sensationalise a particular topic through mass media, basing their opinion on their personal experience. This can be inadvertently damaging, especially when related to childbirth.

Kirstie Allsopp’s response to the recent ‘too posh to push’ coverage in the Telegraph is an example of this. I can fully understand Kirstie’s retaliation to the implications that the Caesarean Section (CS) rate is higher in middle class areas, there may be something personal in that. The fact may have an element of truth, but the reasons for the increasing unnecessary intervention and related CS rates aren’t as simple as this. There are other suggestions for the relentless shift.

As stated in the Telegraph article, and in opposition to what the article headline actually suggests, women choosing to have major surgery instead of giving birth naturally are in the minority, and if there is a request is it usually for a very valid reason, usually associated with unprecedented fear.

Instead, the evidence and debate on the declining normal birth rate points to factors such as increasing maternal age, complexities of pregnancy, increased numbers of multiple pregnancies due to assisted conception, lack of senior doctors to make decisions on birth suite, low midwifery numbers, midwifery skill mix, focus on risk factors, women’s uninformed choices, inappropriate use of clinical ‘guidelines’….the list goes on.

For decades, childbearing women have been marginalised. I witnessed this during the thirty plus years I worked as a midwife, as did (and still do) my midwifery colleagues throughout the UK and beyond. Women’s belief in their ability to birth their babies is declining rapidly as a result of unnecessary medicalisation in maternity care. This was recognised as a growing problem more than thirty years ago, and midwifery organisations such as the Association of Radical Midwives and service user organisations such as the National Childbirth Trust thankfully and successfully campaigned for change.

Whilst practices of unnecessary medical intervention in the childbirth process continues globally, there is a continued and renewed uprising; women, midwives and obstetricians are recognising the potential consequential harm to mother and baby. Childbearing women in particular are the catalyst for change. Instead of remaining afraid, women are forming organisations to support parents to be, such as The Birth I Want, The Positive Birth Movement, One World Birth and Birthrights. Doctors and Midwives are active too. I imagine if Kirstie was having her babies twenty years ago she would been amongst those initial radicals campaigning for change. But with the drive and energy for change comes expectations of parents, and when those expectations aren’t reached for whatever reason, disappointment seems to initiate the need to blame instead of pursuing further change.

The topic is a complex one. But take a look at the chart here. The Caesarean section rate is increasing, and the normal birth rate decreasing. This alarming fact isn’t matched with improved health for mother and baby, in fact I would suggest it has had the opposite effect.

So, are we wrong to try to influence the way babies are born? I think not. But instead of arguing and blaming others, women, men and families must try to move together. The evidence is stacked high that where birth is as close to nature as possible, where women are cared for respectfully and her caregivers are respected then maternal and child health is at it’s best. Some women need intervention. Both my daughters did, and it was life saving. But we are now in a danger zone where medical advances are replacing nature, and that causes harm and was never meant to be.

So come on. Women are not ‘too posh to push’. They are strong and powerful, and if they are given respectful and supportive maternity care they will flourish as women and as mothers. But they need to know and understand the evidence behind the implications of some of the choices they make, and that others try to make for them. Those providing that information and encouraging them to achieve their goal does not mean they have a ‘luddite obsession’ and they are not the purporters of guilt. Midwives are feeling more desperate for change by the day, and they need women (and their partners) to help them to reverse the trend.

Let’s get together Kirstie, and see what we can do.

Childbirth chart BirthChoiceUK

Photograph copyrighted to SevernJonesPhotography

The National Childbirth Trust are not to blame....

Kirstie Allsopp’s recent criticism of the National Childbirth Trust (NCT) is very sad indeed, but I am afraid it’s yet another sign of the times. The article in The Telegraph strikes me as another ‘who can I blame?’ dialogue that is usually focused on breastfeeding. But this misguided condemnation of an organisation that has for decades campaigned, championed and worked very hard to support positive childbirth outcomes through supporting information sharing to expectant couples isn't helpful. 

I have been a midwife for 35 years. During that time midwives (including me) and doctors have unwittingly and relentlessly nudged childbirth from a social family centred occasion towards an increasingly perceived 'risky' medical event, and now women are fearful of giving birth and reliant on unnecessary medical intervention. 

The article reminds us that it is absolutely critical that no women should feel that she has 'failed' if she needs a Caesarean section for the safe delivery of her baby. A positive childbirth experience is most important. But women's disappointment needs careful support and attention, and blaming a whole organisation does not contribute to that. 

Charities like the NCT are part of a global surge to reverse the trend of increasing UNNECESSARY intervention, and their work maximizes the opportunity for women to feel empowered, to be less afraid, and to understand and believe in their ability to give birth. So if women attend NCT antenatal ‘classes’ and become strong and inspired as their baby’s due date advances, they are fortunate and in a much better position to negotiate the corridor of countless doors that face them when labour starts. But, if each of those doors sadly close due to rigid hospital guidelines, ill-informed health care professionals, hospital cultures and systems, or as often happens a change of plan from a confused mother to be, then the NCT are not to blame. 

What do you think?

Why is the birth room being used for mass entertainment?

I don't like this photograph. It actually depicts the worst possible scenario. That is, a labouring mother flat on her back, vulnerable with her legs wide open. The midwives hold the power. As a midwife this is certainly not how I want my profession to be represented.

I imagine that the photo was taken to attract media attention, to draw potential viewers to the BBC TV programme it is associated with...and there will be those who don't notice the image particularly. But there is a message in the pose that has the potential to negatively influence society, and childbearing women. As the documentary programmes have too....ITV's One Born Every Minute, and BBC's The Midwives.

I have to admit that I always avoid watching TV documentaries about maternity services. My decision stems from the fact that I can’t bear to watch poor midwifery or obstetric practice without the ability to influence, and I think the intimate moment of a baby’s birth should take place in a private ‘space’ where the woman feels safe and protected. It certainly isn’t the place for TV cameras, even those that are hidden.

Childbirth is important for humanity, and the ultimate aim of maternity care workers is to ensure women have a positive childbirth experience. When women are in labour the hormones that aid the birth process are heavily influenced by the environment she is in.  Michel Odent, a highly acclaimed French obstetrician gives his expert opinion; one which I fully support after observing childbirth first hand for 35 years. He said:

The best environment I know for an easy birth is when there is nobody around the woman in labor but an experienced midwife or doula – an experienced mother figure who is there, and who can remain silent. Silence is a basic need for a woman in labor. Privacy is another basic need. Michel Odent

So that's a big enough reason not to have cameras in the birth room that broadcast private and intimate moments to millions, with no control over who watches.

And then there's the issue of editing. The producers want to draw viewers in with drama...and the drama is having the desired effect and the viewing is said to be 'compelling'...but what else is happening?

Globally, we are in a situation where women are becoming increasingly afraid of childbirth and unsure of their ability to give birth without medical assistance. There are lots of factors that influence this position, and the media play a huge part.

As a Facebook and Twitter user I have read so many comments in response to the midwifery documentary programmes, from mothers, women, midwives and student midwives. The comments mostly demonstrate the fact that the content of the programmes have stimulated fear. Some midwives, whilst acknowledging the scary and distressing scenes highlighting their colleagues 'under pressure', believe it to be good as it raises the issue of the shortage of midwives nationally. But should this be at the expense of those potentially and actually using maternity services?

Let's read the comments.

The Telegraph reviewed The Midwives

There is a gruesomeness to childbirth TV that I find partly compelling and mildly horrifying. I understand that births where nothing goes wrong don’t make for exciting enough footage but, as a childless, slightly broody 31 year-old, I found some of the scenes pretty harrowing, and had to watch with my fingers over my eyes. There were complications with almost every birth – is this the BBC’s attempt to keep that soaring birth rate down? If so, it’s certainly worked on me… 

One tweet from a student midwife said that she was scared to go on her next shift following the programme....

Twitter:

'It seems such a shame they always show midwives shouting at women, calling them good girls, or do the 'silent midwives' not want to be on TV…'

Facebook (taken from One Born Every Minute-the truth page)

Susan:

'I watched it last night and couldn't believe the triage midwife with the short blonde hair telling the soon to be mother of 5 that she was definitely not in labour. It was her fifth baby, she knew her own body!! I wanted to shout at the telly. I was so smug when the labouring woman progressed quickly and birthed not long after that. I did not like that midwife's manner at all, and she only seemed to get worse throughout the programme..'

Jane:

'I am 21 weeks pregnant with my third baby, and watched the first programme last night. Honestly, despite having been very lucky both other times, it has left me petrified. Must get a sense of perspective....'

Oh dear. How to demoralise women.

We really need to turn the tide. In addition to #moremidwives we need some positive media....positive stories to raise the bar. What do you think?

P.S. On the contrary, I LOVED Call the Midwife. Quite different.

Photograph 

On the other side of the fence-the relative

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

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

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

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

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

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

Photograph of fence

A Girl for my Girl

Dear Betsy,

The night before last the anticipation of your birth was replaced by sheer joy as you made your grand entrance into the world, and your Mummy and Daddy saw you for the very first time.

As well as shedding plenty of tears, we heaved a sigh of relief; you and your Mummy were safe and happy. And now all we feel is love for you, and we can't wait to share your life with you.

So Betsy, may you give joy to your parents......have fun with your Daddy and be best friends with your Mummy.....

When your Mummy was born, my lovely mother told me:

'A son is a son 'til he takes him a wife

But your daughter's your daughter the rest of her life'

And she should know, she had 5