DON'T JUDGE ME: I was a victim.

Image: www.slate.com

Anon.

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

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

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

I am not stupid

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

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

Photo: Pinterest

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

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

You have not walked a mile in my shoes

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

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

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

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

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

It's not over...

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

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

I need to thank the women who picked me up

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

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

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

A glimpse of childbirth in Bulgaria: time to ROAR

Dr. Tracey Cooper is a consultant midwife, who works in Lancashire, England. Tracey is probably the most courageous midwife I have ever met, her strength and courage fuelled by compassion.  

Tracey won a COST research grant from the European Union with Bulgarian midwife Yoanna Stancheva, at the Zebra Midwifery Practice (ZMP) in Bulgaria. The project involved Tracey's travel to Bulgaria to work with the practice for 10 days, to help improve the midwives' decision-making and confidence in providing quality antenatal care within the current legal framework. This research project represents a first attempt to describe and optimise midwifery competencies, as well as to define a strategy for moving towards midwifery-led care in the future. It is a component of a long-term commitment, which members of international midwifery alliances have made in order to improve the organisation of care in the country.

Tracey said: 'My observations are that Bulgarian midwives have very restricted competencies in comparison to other midwives in the EU, and that maternal and neonatal outcomes ranked Bulgaria low compared to the rest of the EU.  By observing the prenatal consultations taking place at the Zebra Midwives practice, I could assess their level of comfort when using essential midwifery skills, such as abdominal palpation, fetal auscultation with a Pinnard and a Doppler, blood and urine test reading, diet recommendations, etc. The midwives at the Zebra Midwifery practice had difficulties recognising these skills as solid clinical evidence for the woman and baby’s wellbeing. These results were congruent with the restrictive legislation and medicalised culture of birth prevalent in the country'.

Photo: Midwife Iona Nashkova learning new skills, with Tracey 

The Zebra Midwifery Practice is the only registered midwifery practice in the country. It is a surprising fact that although midwives have been legally allowed to open midwifery practices since 2011, it took five years before the newly graduated midwives from Zebra were able to take advantage of this opportunity.

Midwives are not interested in opening their own practices because they are not allowed legally to provide the full spectrum of midwifery services required for basic antenatal care, such as prescribing tests and making clinical decisions. These elements of antenatal care are only within the obstetricians’ capacities even in physiological pregnancy and birth.

The ZMP provides severely restricted midwifery care by UK standards. Moreover, midwives cannot get contracts with the national insurance company, and women have to pay for this restricted version of midwifery care.

The number of registered midwives in Bulgaria is 5897. The majority of midwives are at a retirement age, average age of midwives is 52 years. A  large number leave the country for other places where they can practise autonomously and have opportunities for professional growth. The vast majority work in 2 places, having at least 2 jobs.

This is midwifery crisis as midwives are leaving, and many will come to a retirement age within the next 10 years. Because of this, action needs to be taken to make the profession attractive for midwives, so they want to stay and work in Bulgaria, and for midwives from other countries to want to work in Bulgaria, too. 

In the photograph below, Tracey attempts to influence decision making about the issues surrounding maternity care in Bulgaria, with the WHO, the British Embassy, the union and midwifery leaders, birth activists, women and their families at a Round Table meeting. The obstetricians union and the Department of Health were also invited, but did not attend. 

Tracey found during her short visit the following issues:

• Pregnancy and birth viewed by current care providers as risky and a medical event for all women and not a normal life event.
   
• Reliance on technology and not on midwifery care and relationship based skills - many interventions performed unnecessarily for no clinical reason:

 - during pregnancy - medication, scanning
 - during birth - enema, shave, fundal pressure, routine use of oxytocin and episiotomy.

Babies are separated from their mothers, and kept in a nursery. The mother only has access to her baby twice a day, for two 30 minute periods.  There are no guidelines for rooming in, and a three day stay following a normal birth is compulsory.

Photo: Nadezhda Chipeva

Tracey told me: 'Many women only have one child, and some I spoke to said this was because they felt they could not go through the childbirth experience again. Others were considering freebirthing at home alone, as they were too scared to go back to the hospital for birth.  Care is not based on evidence but routine, outdated practices'.

In Bulgaria, there are no unified, nationally applicable guidelines for quality midwifery care.

During antenatal care, midwives are not allowed to:
- prescribe routine urine and blood tests. This is basic care for pregnant women and midwives cannot prescribe the tests even though they are trained to do so and it is part of their competencies.
- perform vaginal examinations or recognise onset and progress of labour using behavioural cues. By national law, midwives are not trained and allowed to perform vaginal examinations, which is a breach of the EU directives on midwives’ competencies;
- assess CTG monitoring;
- work outside hospitals and without supervision of obstetricians;
- make contracts with the Bulgarian national healthcare service which puts them at a disadvantaged position.

During birth, midwives are not allowed to:
- Make clinical decisions for physiological birth;
- Make vaginal exams to assess dilation in labour;
- Repair vaginal tears and episiotomy.
Although directive 1 of the national law describing the midwifery scope of practice allows midwives to assist birth with a cephalic presentation, the midwives’ role during birth is limited to supporting the perineum which is a completely technical detail at the end of birth and does not reflect the meaning of the phrase “assisting birth”.
 

Midwifery care during the postpartum period was practised until 20 years ago. Nowadays, postnatal care is not part of state sponsored maternity services. Even in Bulgaria, postpartum care has always been an essential element of midwifery work, but at the moment there is a troubling gap in the care for mothers and newborns. Midwives need to be able to offer breastfeeding support, to assess the mother’s physical and emotional recovery, as well as the newborn’s health. The national insurance company does not consider it an element of basic maternity care.

Women have to attend the hospital on their own when they are in labour, with no support persons. Babies are taken away from them following birth. The baby is kept in the nursery, the woman only has access twice a day for two 30 minute periods. This increases the potential for mental health issues, problems with breastfeeding and emotional attachment issues for woman and baby.

Tracey found the situation very disturbing. 'Women were extremely anxious, as told everything that can go wrong, with no reassurance during consultations with obstetricians. The intervention and the obstetrician being the lead care provider has not reduced intervention or helped mortality rates. The caesarean section rate is 42%, Perinatal mortality11/1000, compared to EU mean average 7.14/1000, Stillbirth 8%, compared to EU mean average 5.27%, Neonatal mortality 4.5%, compared to EU mean average 2.74%'.

A delivery in Bulgaria. Photo: Nadezhda Chipeva 

Tracey asked you to think about this: 

'Can you imagine being in labour, with no birth partner,  in a room full of people? You are in lithotomy and a midwife is lying across you, pushing on your fundus (abdomen) with all her weight, while a routine episiotomy is performed. Then, when your baby's head is born, an obstetrician pulls out the baby without a contraction. Your baby is taken away, and you can’t see him or her for at least two hours? This goes on all day every day! It has to stop!

We have to find some way of supporting our midwifery colleagues in Bulgaria to end this inhumane practice'.

I asked Tracey what we could do to help: 

'Be aware of the suffering both women and midwives endure in Bulgaria, and keep this highlighted on social media. We must try to persuade the government in Bulgaria to remove their law that birth is a medical emergency, and to recognise the value of midwifery led care to improve quality and therefore the future wellbeing of Bulgarian women and their families, and also reduce unnecessary costs'.

---

Yoana Stancheva and colleague IIona Neshkova are dynamic midwifery leaders, who are working hard to influence maternity care in their country.

Here is Yoana, speaking up at the Young Midwife Symposium at Women Deliver Global Conference, Copenhagen 2016

Yoana feels Tracey's visit to Bulgaria has been invaluable: 

'Tracey's visit provided the most comprehensive review of the state of midwifery in Bulgaria that an independent observer has ever done. What's more, Tracey was immensely involved in understanding the motives behind the system of maternity care that we have deemed "working" for us. These motives are difficult to comprehend for people who don't belong to the general culture of institutional responsibilities and personal involvement of caregivers with the concept of care. Tracey was committed to grasp it all, with patience and compassion which the system of abuse does not deserve. Her observations were like a large, inspiring breath of fresh air that promised hope for a hopeless situation.'

You can find Tracey Cooper on Twitter , IIona Neshkova on Twitter  and Yoana Stancheva on Facebook

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

Photo: Midwiferyaction.org

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

Tracey (pictured above):

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

The framework for quality maternal and newborn care

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

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

Key messages

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

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

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

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

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

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

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

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

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

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

For more information see the Executive Summary

Reference:

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

Dr Tracey Cooper can be found on Twitter

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

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

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

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

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

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

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

 The panel:

Professor Soo Downe OBE (Midwife)

Elizabeth Prochaska (Lawyer-Public Law and Human Rights)

Milli Hill (Journalist-Mother-Doula)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

If you have anything else to add….

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

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

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

More about the contributors

Milli Hill:

Founder Positive Birth Movement Twitter: ‪@birthpositive

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

Birth Columnist for Best Mag Daily ‪@BestMagDaily

Blog: the-mule.com Twitter @Millihill

Elizabeth Prochaska:   

Lawyer, Matrix Chambers 

Founder: Birthrights Twitter @birthrightsorg

Professor Soo Downe OBE

Professor of Midwifery University of Central Lancashire 

Previous post interviewing Soo Downe

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)

What Twitter did, and what student midwives say!

twitter1

It's been a while since I started using Twitter. It was my daughter, @acbmidwife who first stirred my interest. I don't know how it all happened, but now most of my days involve 'tweeting' or 'chirping', and the result is I am increasingly connected with like minded folks across the globe.  Not only am I in touch with inspirational leaders from nursing and midwifery,  but NHS CEO's such as Lisa Rodrigues @LisaSaysThis  and Mark Newbold @drmarknewbold always have great information to share. I communicate with local GPs, and Stuart Berry @StuartBerry1 is one of them. Stuart and I have never met, but we have some similar interest and can promote each others' work through Twitter channels. Amazing. Interestingly, Stuart posted this  about the use of Twitter this morning. Great stuff!

There isn't a week goes by when I'm not contacted by individuals asking me for help and support, or inviting me to speak at study days an other events. I am particularly happy with this, as it helps me to share expertise gained by working in the NHS for 35 years.

Last week was a particularly busy week, and almost everything that I did was either initiated or organised via Twitter! I happened to be in London, for some 'away time' with the Trustees of the Iolanthe Midwifery Trust on Saturday...and then the fun started.

photo

On Monday  morning I met with the wonderful Alison Baum from Best Beginnings, to see how I could help her with the amazing new smartphone app for new parents. This all came about when I retweeted a short film about the app, and Alison asked to see me. I visited Alison's office and we didn't pause for breath for two hours. Lots of ideas and plans...including a small package to be sent to the Duchess of Cambridge! Take a look at this film to learn more about the Bump Buddy app....

https://vimeo.com/65375471

I then scurried to St Pancras to meet Murray Chick (yes that's his real name). Murray is the owner and brainchild of Britain's Nurses, and I LOVE the site. Again, this opportunity was made via Twitter, I found the site there, and made some enquiries. Incredibly easy, and so effective! Previous to this meeting, and through Twitter, @Britainsnurses picked up two of my blogs to share with nurses for International Nurses Day! Sorry about that @gbutcher17!

The day after I went to Kings College London again to meet a group of wonderfully enthusiastic and very smily  positive student midwives, organised via Twitter following a lovely invite by student midwife Natalie Buschman @Birthsandmore. It wasn't the first time Natalie and I connected and made a plan via Twitter; she also took up the challenge to do the Prudential Ride London, in aid of the  Iolanthe Midwifery Trust, after seeing me advertise the opportunity on Twitter! Great work Natalie! If you want to sponsor Natalie, and thereby support the Iolanthe Midwifery Trust, you can do so here!

After being with the students I ran round the corner to enjoy lunch with three formidably inspirational women: Maggie Howell @MaggieHowell from Natal Hypnotherapy , Independent Midwife extraordinaire Pam Wild @Pamoneuk  and journalist Beverley Turner @BeverleyTurner . What a treat. Again...lot's to chat about and plan in limited time...and it all started with Twitter!

photo

And then a couple of weeks ago Dean Beaumont @DaddyNatal from Daddy Natal, invited me to review his book...'The Expectant Dad's Handbook' on Twitter. We exchanged contact details through the direct message function, and voila! The book plopped through my letterbox and was avidly devoured within a few days. The book, by the way, is spot on. Sensible and sensitive...with great advice for all Dads-to be. I will be writing a review Dean!

I have the feeling that my Twitter support of StudentMidwife.Net went some way to their decision to invite me to be their Patron. Whoop! What a privilege and an opportunity. Also, through Twitter I saw an chance to be involved with @WeNurses, by running regular @WeMidwives chats...which has been a steep learning curve! This has really given a new voice to Midwifery.

And then there's the fabulous Doulas. I 'met' many of them through Twitter, and we connect so regularly I feel like I know some of them well, even though I have never seen them in person.  There are too many Doula friends to mention here, but you know who you are! (I'll probably cause offence if I miss anyone out!). Through Twitter, I have come to know and appreciate your valuable contribution to childbirth.

And of course this isn't just all about me. I couldn't ask many, but these two student midwives have had opportunities too, through using Twitter:

Student Midwife @Li33ieBee said -'Via Twitter I have had articles proofread by experts and been sent hard to find research papers'.

Sarah Tuke @sazzletastic told me- I have become a more compassionate 'put hands on' midwife after reading quotes from Sheila Kitzinger at a conference to put hands on to reassure to increase oxytocin. It works! Wouldn't have known about what she said without tweeting from that conference as I couldn't make it :)

HOW GOOD IS THAT?

But there aren't many midwives using Twitter, and there are still a considerable number of individuals and organisations that are fearful of using social media.  I know that several health professionals have lost their jobs or places at University, due to inappropriate postings. But this is a pity. There's lots of guidance out there, and with common sense you really can avoid the pitfalls.

SoMe

Need help?

Check out the Nursing and Midwifery Council guidance on the use of social media 

The NHS Social Media site has lots of useful tips

Guidance for NHS Caremakers is useful for all health care professionals

Here are some great folks to follow or connect with:

Sarah Stewart- Midwife Educator and Professional Development Officer with Australian College of Midwives @SarahStewart (and quite a whizz with social media matters)

Jacque Gerrard -Director for England Royal College of Midwives @jacquegerrard

Mark Newbold -Chief Executive of Heart of Birmingham FT @drmarknewbold

Anne Cooper -Nurse working in informatics interested in leadership @anniecoops

Teresa Chinn-Nurse and social media specialist @AgencyNurse

And if you are unsure about what Twitter is, and why or how it would be useful to you, @pam007nelmes is a social media expert, AND she believes kindness is magic which for me, is the best. Pam is worth following as she has lots of tips! Here is one of Pam's presentations-Social Media for Nurses Oct 2012

For me, Twitter brings fabulous worthwhile interactions with others, the sharing of current and interesting news or information, and unique and exciting opportunities. And every now and then, there'll be a gem that pops up, such as Molly Case's inspirational poem, read by her at the RCN Congress 2013.

http://www.youtube.com/watch?v=XOCda6OiYpg

So, last night I asked several student midwives who are already engaged with Twitter, what benefits they felt it brought them...and here are a few of their 'tweet responses' back to me!

@dawn_t12 -'Twitter for me is invaluable as a student. It keeps me updated on news/new research/study days, but more than that it's another form of support. I love that through twitter I've made friends with people at different unis in different towns and we help each other through the bad days and celebrate the good. It's just sad some students & midwives are missing out on this world!'

@Beetrooter- 'Twitter brings fellowship with ppl passionate about midwifery from across the world & across spectrum of professional roles. Its my inspiration for learning, gives evidence to inform my practice, rolemodels for me to aspire. Instant access to womens' experience jubilant/ anguish. Twitter is conversations. It's life squished beautifully into 140 characters'.

@Birthsandmore -'great way to broaden mind, horizon and tweet with like minded people you otherwise would not have met. t lifts my spirit to read and hear from so many passionate people, especially after a tough day 'at the office'!

@Josie_jo_F-'from a v.small Uni, twitter gives me a chance to find out what happens in other trusts, have contact with other SMs, learn from MWs, lecturers&other inspirational ppl I'd never meet in my isolated neck o'the woods.glad to have found this community'

@sazzletastic-People on twitter have been an amazing support to me throughout my 3rd yr studying giving me encouragement and reassurance to keep going and have confidence in my knowledge and abilities. Having access to organisations and big names in the field that actually reply to you is brilliant! I've learnt so much via twitter, I only wish I'd had it for the first 2yrs of study too!

So, come on midwives and student midwives....Twitter has so much to offer. Facebook keeps you in touch with friends, but Twitter helps you find those you would never have met, who hold the potential to open up a new world for you! As student midwife Hana Ruth Abel  

@Hana_Studentmid

so eloquently puts it:

'

Twitter is the thread that binds me across the globe, weaving me into the fabric of international midwifery & making me a piece of the puzzle that builds up a global voice, I am an equal part of that voice. Ever changing and pushing myself to grow with a community of individuals who share my philosophy and question practice. Twitter shines a light on every end of the spectrum. United we stand on our virtual platform- Speaking up and stepping forward, one tweet at a time'. 

Wow Hana!

Social Media Posting Guide

'Who's got the pan?' A precious piece of midwifery history.

Joan Fenton with prince charles, at the opeing of the edith watson maternity unit in 1968

'So, did you ride a bicycle when you worked in the community as a midwife?' asked Prince Charles. 'No! Not in Manchester. We couldn't as our wheels would go in the tram lines!' That was Miss Joan Fenton's answer when the Prince came to open the Edith Watson Maternity Unit in Burnley, in 1968.

Miss Fenton as she was fondly known when I worked at this same maternity unit in the 1970's, was the lovely 'Nursing Officer' described in my book, Catching Babies. She had (and still has!) the most compelling twinkling eyes, was strict but jolly, and she always called us by our surnames. I loved working under her leadership as a pupil midwife, and when newly qualified.

Joan Fenton is now 93. We haven't seen each other for more than 30 years, and became connected again when she read my book, by chance. I went to see her this week in her home;  the same house I once collected her from when giving her a lift to work, in 1978. I had the most amazing two hours. We chatted about times gone by, and I asked her a few questions. Here's a small glimpse of  what she told me.

'I began working as a nurse's help in 1936, when I was 16 years old. I had to leave my home, and live in the accommodation provided at the hospital.  The hospital was at Lostock Hall in Preston and was a 'continuation hospital' where patients, mainly children, went to convalesce.  I loved it. I remember my work involved cleaning only, there was no contact at all with patients! The Matron was strict, but we all respected her. When I was 18 I went to Wigan to do State Registered Nurse training. It was a four year programme in those days, and the first year was spent mainly in the sluice cleaning bed pans! ! It was never questioned, and felt like a real privilege. I also polished all the sliver and brass accessories in the sluice, bathrooms and kitchens. Student nurses didn't have contact with patients until the second year of training, and we looked forward to that moment with great excitement'.

'We worked 72 hours per week, starting at 6.30 until 8pm, and although we had two hours off in the afternoon one was spent having a lecture, and the other writing it up! We got a half day off only each week, but we had to be back at the nurses home by 9pm. We had to get special permission to go to the pictures to the 1st house, which was at 6pm. My salary was 5 shillings per week, £12 per year.'

'Once a month, on our half day, we were allowed to go home. My Mum used to wait at the train station for me, and we would be so excited to see each other. I had to be back by 9pm, so time was precious. She used to say "Let's go and get some Clifton's Chocolates!"  They were expensive, and I knew my family couldn't afford them really, but it was our treat'.

'Once qualified, I went straight to St Mary's in Manchester to do my midwifery training. It was done in two parts; Part 1 was in the hospital (which was then actually opposite the Palace Theatre in Oxford Rd) and Part 2  was on the district. The areas I worked in was Ancoats and Beswick.

Joan saw it all. Extreme poverty, the blackouts of the Second World War, forceps being used at home, and a Caesarian Section being performed on the kitchen table. She told me of the lifesaving exchange transfusions that were carried out on Rhesus negative babies (before Anti D). 'Most women had their babies at home', she said, 'and there was no fear of birth. Women just got on with it, and birth was viewed as an every day event. There had to be a real necessity to do Caesarean Section, and women weren't rushed! I don't know what's happening these days, everyone's rushed!'

'Everyone helped each other, and there was no money. It was before the NHS of course and women had to pay for the delivery. Women having their first baby paid two pounds (because it took longer) and subsequent babies cost £1.10 shillings'. 'Did you get the money'? I asked. 'NO! Did I fiddle' Joan proclaimed 'it went to the authorities! I had a book, and collected the money every Monday morning. Some women couldn't afford to pay me, and I felt bad when I had to keep asking them for it. The poverty was bad. Families shared a pan (to boil the hot water for the birth) between three families. The first thing we said when we got to a house with a labouring woman was "Where's the pan?" We had to call the police to get it if it was in the night, we weren't allowed to disturb others without that authority.'

Image - Daily Mail

'I was so happy. I loved my job even though I was tired and hardly had any recreational time. We didn't get married because our job was everything to us. I lived and breathed it.'

When it was time to leave Joan, I asked her if she thought the 'Call the Midwife' programme was a good representative of those years. 'Oh yes!' she said. 'Although my time began much before that!' And it did. There won't be many more opportunities to capture these memories, and record the history of our midwifery profession.

I am delighted I had some time with you Joan. You are here forever now.

Joan fenton with sheena byrom

Ancoats Photo

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