England needs more midwives: but legal services are fine

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

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

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

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

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

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

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

Lively interview with student midwife Liz!

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

So, here's Liz Blamire!

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

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

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

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

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

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

And what things would you change, if you could?

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

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

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

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

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

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

What are your long term plans?

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

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

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

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

Liz can be contacted via Twitter :  @Li33ieBee

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

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

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

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

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

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

 The panel:

Professor Soo Downe OBE (Midwife)

Elizabeth Prochaska (Lawyer-Public Law and Human Rights)

Milli Hill (Journalist-Mother-Doula)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

If you have anything else to add….

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

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

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

More about the contributors

Milli Hill:

Founder Positive Birth Movement Twitter: ‪@birthpositive

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

Birth Columnist for Best Mag Daily ‪@BestMagDaily

Blog: the-mule.com Twitter @Millihill

Elizabeth Prochaska:   

Lawyer, Matrix Chambers 

Founder: Birthrights Twitter @birthrightsorg

Professor Soo Downe OBE

Professor of Midwifery University of Central Lancashire 

Previous post interviewing Soo Downe

Dear Mum and Dad

Dear Mum and Dad,

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

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

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

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

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

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

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

Loving you always, Sheena xx

Guest post: an interview with Professor Soo Downe OBE

Added comment - March 2019

Professor Soo downe obe

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

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

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

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

When did you first become interested in becoming a midwife?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Photo: sarah brown

What are your plans for the future Soo?

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

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

All the factors above, I think! 

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

You can contact Soo at:

SDowne@uclan.ac.uk

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

My thoughts:

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

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

For childbearing women and partners

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

For midwives/doctors:

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

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

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

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

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

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

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

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

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

In response to Kirstie's radio programme:

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

And finally, a note for our Governmental Ministers

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

Photo credit 

Three babies and a party!

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

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

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

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

My reflections of the three births in a nutshell:

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

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

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

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

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

PRECIOUS CARGO-the birth of an important project

Just recently I was contacted by Ron Common, asking me to help with an exciting fundraising project, bringing student midwives and midwives from around the world together. Ron told me:

'Midwives around the world shape the beginnings of a person's life and it's a sad fact that a great many people globally still do not have easy access to a trained health professional at crucial times in life, such as during pregnancy, birth and the early years of childhood.

This collaborative project aims to send a beautifully decorated scroll around the world to collect as many signatures as possible. The scroll is one of the oldest forms of written communication in history, having played a major role in shaping our world today, so there is no better way to celebrate one of the oldest professions in the world - midwifery!  The Precious Cargo project and scroll's aim is to raise awareness of access to healthcare for all in promotion of maternal and child health, alongside raising funds to help Motorcycle Outreach expand its mission to improve health care delivery to remote areas of developing countries.'Motorcycle Outreach's current project and its wonderful outcomes can be seen on their WEBSITE

In order for our project to be a huge success, we are looking for as many members/student midwives/midwives to get involved and support us on this project.

HOW TO GET INVOLVED

There are 3 main ways to get involved:

 

-Raising awareness of the project within your local hospitals, clinical centres and universities and organise to get as many signatures on the scroll as possible within your local area/maternity unit

- Organising fundraising events and/or sponsorship (to raise funds and awareness of the project)

- Signing the scroll when it travels to your area and make a donation

We are also looking for a number of volunteers to act as regional coordinators to help us manage the project. We feel that this is a valuable opportunity to help improve maternity services worldwide, alongside undertaking a unique opportunity which may, in turn, be used within supporting statements and PREP requirements in the future!

LOGISTICS OF THE PROJECT – UK

The UK section of the scroll will be 20 meters long - enough for 10,000 signatures.

Its borders will be decorated with colourful drawings by patients of the Children's Hospital and interspersed with messages from midwives about “what being a midwife means to them. The scroll's journey will commence in the UK with a tour of approximately  55 hospitals around England, Scotland & Wales.  (Students attend 196 centres but time doesn’t allow us to visit them all).Selection of the hospitals to be visited will be based on the location of the volunteers engaged in the project. (A schedule of each hospital visit will be published in advance).The start point will be Hampton Court Palace, London on 7th September 2013 and last for up to 55 days (allowing 1 day for each hospital being visited).In the weeks leading up to each hospital visit, students/midwives are encouraged to raise awareness of the project at their hospital and, if possible, undertake local fund-raising events.

A team of motorcyclists will courier the scroll from hospital to hospital on a daily basis.

Drop off and collection times will be published in advance.

For each delivery, a "lead" rider will hand the scroll to a student midwife on arrival at the hospital for safe-keeping and to facilitate the signing of the scroll during its 24 hour visit.

We are in the process of creating a dedicated website for the project that will included a "scroll tracker", blog pages, space for photos etc.

The UK leg of the tour is being used as a "pilot" for the Rest of the World tour.

If the UK leg is successful then it is anticipated that the process will be replicated in at least 40 other countries around the world - so we REALLY want to give it our best shot. The UK will be the "standard-bearer" for other countries to follow.To add a bit of extra spice , an application has been made to the Guinness World Records for a world record attempt at "the most signatures on an item" .We're very passionate about this project and we hope to get as many people involved who care about midwifery as possible.

For more information either visit the SMNET website or contact one of the project managers:

Ron Common email: ron@motorcycleoutreach.org

Kelly Silk email: kelly@studentmidwife.net

Ron said: I hope that student midwives and midwives in the UK see that this is a great opportunity for them to make a direct and personal contribution to improve the delivery of mother and child health care around the world, and inspire an international initiative that will eventually impact hundreds of thousands of people.  The scroll is the thread that links us all together and will become the symbol of our united mission.

Hope you can get involved, I certainly will!

'The facts behind the print' Sudden Infant Death Syndrome: Professor Helen Ball

                      Professor helen ball 

This post has been updated in November 2016

As usual, the media recently  succeeded in increasing the fear of new parents, in relation to infant sleeping and bed sharing with baby. Oh my word. Those of us working or who have worked in field sigh with frustration, but the flurry of panic amongst those with babes in arms is almost palpable. In addition, the Department of Health has instructed the National Institute for Clinical Excellence (NICE) to undertake an extraordinary review of the section of the postnatal care guideline (CG 37) on reducing the risk of sudden infant death syndrome (SIDS). As I was on the original postnatal care guideline development group, my opinion is being sought.

Thank goodness we have sensible experts in the field, who are able to shed light on the real facts behind the print. You are about to meet one!

I have been fortunate enough to hear Professor Helen Ball speak about the topic of safe bed sharing and SIDS on a few occasions at conferences, and I am delighted that she agreed to be interviewed for my blog.

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

Hi Sheena, I am Professor of Anthropology at Durham University and Director of the Parent-Infant Sleep Lab. This is my 24th year at Durham!

When did you first become interested in infant sleep patterns? 

I started reading academic research about infant sleep in 1992 while I was pregnant with my first child. I didn't start thinking about researching infant sleep myself then, however. At the time I had recently finished my PhD in primatology and was living in the US and lecturing part-time. A few years later, after I had been appointed as a lecturer at Durham, and I was pregnant with my 2nd child, I decided I wanted to switch to a research field that didn't require overseas fieldwork, and could be done closer to home — and the idea to study infant sleep was born!

What does your average working day consist of?

This year I have ‘Research Leave’ to catch up on all of the research I didn’t have time to do over the past 3 years while I was Head of the Anthropology Dept in Durham. So, this at the moment my work day consists of writing academic papers and grant applications, meeting with my lab manager Charlotte about PhD student projects, updates to the ISIS (Infant Sleep Info Source) website, or training sessions we might be running. I also have time to speak at conferences and travel, so in September I went to Uruguay to the SIDS International Conference, in October I was invited to speak at a national conference in Lisbon, and I have just come back from the UNICEF UK Baby Friendly Conference. 

Has much changed regarding cosleeping and SIDS since we last spoke?

Yes, there have been some quite significant changes – principally around the ways in which health professionals engage with parents on this issue. For the past decade or more there has been a tendency to avoid conversations about cosleeping/bed-sharing with parents, and to issue ‘one size fits all’ advice to avoid bed-sharing under any circumstances. However in 2014 NICE reviewed all the evidence pertaining to SIDS and cosleeping and came to the conclusion that the research data was not strong enough to say cosleeping causes SIDS, but that there were some circumstances in which there is (or may be) an association between co-sleeping (bed and sofa-sharing) and SIDS. The NICE guidance recommends that health professionals discuss with parents the fact that cosleeping happens, both deliberately and unintentionally, and inform them of the associations between smoking, drug and alcohol use, prematurity and low birth weight infants with cosleeping and SIDS. The key message was to empower parents with information so they can make their own informed choices about cosleeping.

One issue that NICE did not draw out in their evidence review, was the difference between sofa and bed-sharing (hence their use of the catch-all term ‘co-sleeping’). A SIDS case-control study conducted in the South-West of England clarified the dangers of sofa-sharing and other hazardous forms of bed-sharing (with tobacco, alcohol or drug consumption) and found that in the absence of these hazards, there was no association between bed-sharing and SIDS. To clarify these factors UNICEF UK have now produced an infographic and guide for health professionals.

Click on image for access to more information 

 As a midwife, I find some of the information for parents on infant sleep and SIDS confusing, and frequently scary. What are your thoughts?

It is very difficult to understand how you might keep babies safe from something that appears to cause them to die with no apparent explanation. The prospect of your baby dying unexpectedly in their sleep is very scary — but there is a lot of research evidence now to help us pinpoint what might increase the risk of this happening, and how it might be avoided. The biggest success has been with sleep position — when parents were advised to sleep their babies on their back, the SIDS rates plummeted. People are now hoping for another simple piece of advice to be equally effective, but it doesn't seem as though there are any other 'magic bullets'. The remaining risks are far more complex and difficult to change (such as smoking). Some fears around the risks associated with bedsharing have caused authorities in different locations to promote scary campaigns aimed at frightening parents away from bed-sharing. These have been heavily criticised for being insensitive to bereaved parents, for fear-mongering, and for creating a climate in which parents lie to their health care providers about bedsharing, and health care staff avoid discussing bedsharing safety and contraindications with parents. These campaigns have also proved ineffective in reducing SIDS. I am pleased to see that (at least in the UK) we are now moving towards more tailored education for parents that can allow them to consider the risks that may affect their baby and make relevant care decisions.

The media obviously has great influence on behaviours. How best do you think we can steer the information to support parents?

One of the reasons we created the ISIS  website was to ensure there was a reliable source of research info on infant sleep that parents and health professionals could refer to, and where they could find information explaining the controversies and things they should consider in weighing up the evidence. It would be much less confusing for parents if the media hype around parenting stories did not try to polarise issues around infant care such as infant feeding and sleep behaviour. There is far more agreement among the 'experts' in this field than disagreement, but one wouldn't know this from reading some of the media stories! 

Another thing parents find confusing is when media illustrate stories about infant sleep with images of babies sleeping prone or in other situations that to not reflect SIDS-reduction guidance. For this reason we recently created a professional quality image-bank to illustrate what the safest bed-sharing arrangements look like. This can be found at HERE. 

 a screen shot of the images 

What are your plans for the future Helen?

I have just been appointed as (Honorary) Chair of the Scientific Committee for the Lullaby Trust. We are currently writing the Trust’s 10-year research strategy, which will be implemented in January 2017. Our goal is to foster research that will discover ways to lower the SIDS rate in the UK down to 150 per year.

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

I believe strongly that parents should be provided with information they can use to make their own decisions about infant care. So many parents and health professionals contact me to ask questions and seek clarification that I am very aware there is an unmet need for information and education on infant sleep. Many of their questions address issues we don't presently have research to base answers on. I have always felt that as an academic it was important to conduct research that was useful to others, addressed questions that were relevant to non-academics, and would be used by the real world. With our infant sleep research we are achieving this, which makes it worthwhile!

Thank you so much Helen for taking time out of your busy and important schedule to feature here. AND CONGRATULATIONS ON YOUR NEW POST and massive achievement! Wonderful and much deserved success. I wish you lots of luck and send best wishes for the future, and enormous gratitude for the advice and support you give to us all, as health professionals and parents. 

Respect

You can find Helen on Twitter @IsisOnline1

UPDATED NOVEMBER 2016

A Normal Birth week! With Mary Ross-Davie

3rd-7th June 2013

Well, what a week! It was busy, busy, but it was like being in midwives’ heaven. It's one thing being able to listen to inspirational individuals talking about a topic you are passionate about, and quite another being surrounded by like minded ‘maternity’ people for a whole week! Wow.

And Mary Ross-Davie and I were together for that week, at three different Normal Birth events!  So, whilst now missing each other’s company, we decided to write a joint post on our reflections of each event, and to share the pleasure with you all. Hope you find it useful…

The first event was the Royal Society of Medicine, Maternal and Infant Health Normal birth Symposium, in London on the 3rd June 2013.

Congratulations must to go to RCM President Prof Lesley Page, on the organisation of such a stimulating and successful study day!

With more than 300 delegates, the whole day felt alive with passion, inspiration and hope for the future…and it was wonderful to see vibrant, enthusiastic student midwives such as Oli Armshaw, Hana Ruth Abel and Natalie Buschman mingling with midwifery greats such as Caroline Flint and Nicky Leap. These students are our future (and we have so much faith in them!!), and they are hungrily receiving the baton.

The programme was a great mix of speakers sharing research findings, experience from clinical practice and exploring and celebrating normal birth. 

Mary Ross-Davie presented her ground breaking PhD research findings. Now I believe Mary’s work has the potential to change midwifery services, and if used, can add strength to influencing staffing levels. Mary's study, SMILI (Supportive Midwifery in Labour Instrument) looked into the nature of midwifery support in labour. The results are powerful yet not surprising, and include evidence that having enough midwives makes a difference to normal birth rates and satisfaction of childbearing women.  Mary's thesis can be found here.

Mary said:

When I started my PhD studentship in 2009 I hadn’t imagined that at the end of it the President of the RCM would be inviting me to speak about my study at a Normal Birth symposium alongside Professor Nicky Leap, Professor Cecily Begley and Professor Lisa Kane Low.

Nicky Leap has written widely about the power of midwives’ approaches to pain in shaping women’s experiences: where we talk about ‘pain relief’ rather than talking positively about the pain of labour we can undermine women’s confidence in their own abilities. Nicky encourages midwives to use the phrase ‘Working with Pain’, and pointed delegates to an NCT resource http://www.nct.org.uk/birth/working-pain-labour) . Nicky’s most recent research has reaffirmed the power of listening to women’s words and stories to learn how to provide better care. It also reminded me of the great impact that film can have in getting women’s voices heard. Nicky and the team of researchers from Kings College London, used videos of women talking about their experiences of care in a learning package for staff.  Nicky showed a short extract of one of the films and the message from the women was clear: what midwives say and do and how we do it has a huge impact.   You can see what Nicky has to say about workshops for maternity workers when working with women who request epidural anaesthesia in labour.

Consultant Obstetrician Amali Lokugamage never fails to silence an audience. Her articulate, sure, yet gentle style is immediately capturing. And Amali is a unique speaker in that she provides delegates with a detailed and understandable insight into the world of medical practitioners. Maternity services frequently fail women and families when collaboration between health professionals is absent, and so often we hear of tensions between midwives and obstetricians. If health professionals understand each other's back stories and perspectives, and the underlying reasoning behind those perspectives, then there is potential for positive relationships to develop and flourish. After having a home birth, Amali is able to draw on both that experience, and her medical training, to help us to consider the best way forward. Amali's book, The Heart in the Womb, is a must read. Really.

To be honest, the third stage of labour has never really captured my imagination as much as other parts of the childbirth journey, but Cecily Begley’s talk, along with seeing Dr David Hutchon at the Mama Conference  earlier this year, has changed that.  Her research into Third Stage Management has included a Cochrane systematic review and the ‘MEET’ study which explored Irish and New Zealand midwives’ expertise in expectant management of third stage.  There is a growing body of work about the impact of early cord clamping and the importance of taking time to get that first hour after the baby is born right. Cecily powerfully argued that physiological management of third stage should be a basic midwifery competency.

 Kenny Finlayson from UCLan reported on the feasibility issues of The SHIP Trial (Self Hypnosis for Intrapartum Pain)  which is due to be reported on at the end of 2013. We look forward to that.

Kathryn Gutteridge shared some of her philosophy of birth and how she has worked to make this a reality at the new birth centre where she is consultant midwife in Birmingham.  She spoke about getting the physical and emotional environment right for women, for them to have the most positive birth experience possible: she and staff at the unit approach the labour and birth as a unique day in a woman’s life much like a wedding day.  Imagine if we treated all the families we look after as if we were their wedding planners for the day…

Mary said:

I loved presenting my research alongside these and other great speakers on the day.  As a new researcher presenting my findings I have found it so helpful and encouraging to get instant feedback from people after my presentations through Twitter.  Research can be quite an arduous and lonely process, peoples’ responses raise my spirits and encourage me to keep going. What people pick out to tweet shows me what messages really come across strongly.  You can find comments (Tweets) about Mary’s talk, amongst the others, here! 

The next event was UCLan's Normal Birth conference, Grange over Sands 5th-7th June, 2013

        ‘Getting it right first time: normal birth and the individual, family, and society’

This famous international conference, organised by Professor Soo Downe and her team from UCLan, always attracts researchers, obstetricians, doulas and midwives from all over the world. This year delegates travelled from many countries including New York,  Netherlands, Germany, Brazil, Australia and Italy. The conference has a unique atmosphere – a beautiful location where the sun always seems to shine, with a relaxed feel that belies the serious research that is presented.

Jenni Cole gave a keynote address on day one, which focused on Anti-microbial resistance (AMR) and the overuse of antibiotics in neonatal care. It is estimated that between 90 and 99% of antibiotics administered to newborns are unnecessary, costing the NHS as much as £150 million per annum. In August 2012, NICE published Clinical Guideline 149: setting out clear guidance on when antibiotics should be administered and when they can be withheld. Whilst in theory compliance with the guideline should have reduced antibiotic use, there is evidence that doctors and other health care workers are reluctant to change embedded behaviour patterns. Jenni is looking for English Trusts to participate in research into the issue, and wants to be contacted by email here: JenniferC@rusi.org

This year some of the keynote speakers highlighted initiatives aimed at improving normal birth rates in the USA, Brazil and the Sudan.  One of the key shared threads between these talks was the need for strong collaboration between midwives and obstetricians, to strengthen normal birth.  Dr Nasr Adalla from Sudan, where less than 50% of women give birth with a skilled attendant, spoke about his belief in the right of women to choose a  home birth with skilled support. Keynote speaker Maria do Carmo Leal spoke about the challenges faced in Brazil, with only 15% of births assisted by a nurse or midwife and a very high caesarean section rate (overall 45%, though in Rio the rate is 80-90%). A new programme of work there led by obstetricians, midwives and politicians, called ‘Rede Cocogna’ is working to change this and has led to the opening of 42 new birth centres.

So many fascinating insights have come out of the NPEU Birthplace study. Professor Christine McCourt shared some of the qualitative results in her talk. The study confirmed how far we have come from the simplistic midwife v doctor dichotomy in relation to normal birth, highlighting more tensions between midwives working in alongside midwife led units and their midwifery colleagues in consultant led units than between midwives and obstetricians.  It made me wonder what we can do to try to lessen these damaging divisions within our profession (answers on a Tweet to me please! ‘@maryrossdavie’).

Miranda Dodwell from Birthchoice UK has been working with Prof Jane Sandall’s team at Kings College London. This work has highlighted the huge variations in normal birth rates between NHS trusts in England:  ranging from 30-50%.  A number of factors appear to make a normal birth less likely for women including being over 30 years old and from the least deprived quintiles. Miranda undertook some really interesting subgroup analysis of the data and found that ‘low risk’ multips had a 75% normal birth rate compared to 15% in ‘high risk’ primiparous women.

Another fascinating source of comparative data is the Europeristat programme of work, presented by Alison MacFarlane, this compares key information about birth processes and outcomes between European countries.  Again this raises so many questions for me: why are our stillbirth and neonatal death rates in the UK so much higher than Scandanavian countries?  Why did the caesarean section rate in Scotland rise by 3% from 2004-2010, compared to a rise of 1.6% in England? Why are normal birth rates so variable: 42% in Scotland in 2010 compared to 47.2% in England and 50.2% in Finland?

The great thing about this conference (apart from the brilliant people to talk to over the wonderful food) is the sense that you get of a very lively questioning research community that is searching for the answers to how we can make positive normal birth a reality for more women.  We didn’t get to see other top speakers: Professor Billie Hunter talking about her work investigating resilience in midwifery and Mary Sheridan on her work exploring vaginal breech.

The next Normal Birth conference is being planned to be in Rio, Brazil in 2014. Now THAT should be one not to miss!

To read more about the conference, see the Twitter feed here, and Consultant Midwife Dr Tracey Cooper has written extensive notes and made them available here Normal Labour and Birth Conf 2013

Believe in Birth Study Day, Montrose, 7th June 2013

Last but not least, Mary and I (and Kathryn Gutteridge too!) were honoured to be invited to the famous Montrose Birth Centre, in Scotland, to speak at their study day ‘Believe in Birth’. When we arrived the sun was still shinning outside and in, that is there was an abundance of smiles and warm welcomes from ALL the staff who work there. Delegates were offered a visit to the Birth Centre in the morning before inspirational leader Phyllis Winters opened the day with enthusiasm and positivity.

There wasn’t a murmur in the room when consultant midwife Kathryn Gutteridge sensitively talked of the effects of child abuse on childbearing women. Kathryn’s words shook us all, and it was clear from the faces of delegates that there was recognition of suffering.

One of the wonderful Birth Centre midwives, Iona Duckett, spoke passionately about her work, building on Mary Ross Davy’s SMILI study, using the ‘TEA’ tool, for emotional assessment in labour. Another special midwife, Jane Wanless, told the story of her midwifery journey. She made us laugh and cry.

Read more about this not to be missed study day here on Twitter!

At the end of the week we felt totally invigorated and enthused to continue with drive to support and protect midwifery and obstetric practice that respects and upholds physiological childbirth. The practitioners who were fortunate to be part of these three amazing events will hopefully be uplifted too, and feel energised to take messages back to their areas of work.

We now need to follow up the suggestion from the RCM's Campaign for Normal Birth steering group (of which we are both members) for a Normal Birth week every year, and also to make events more accessible for maternity workers at all levels.

What are your thoughts on this? Please leave your comments below!

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!

Photo source

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)

The Expectant Dad's Handbook: a book review

I don’t usually like parenting advice books. I had a bad experience of reading one when I was pregnant with my first child, and I believe some directives within many parenting books are potentially harmful, whilst exploiting the vulnerability of parents to be or new parents.  But I’ve now had two heartwarming surprises! The first was Sarah Ockwell-Smith’s book Baby Calm, and I have just finished the Expectant Dad's Handbook, by Dean Beaumont

I loved Dean’s book. In my opinion it is absolutely perfect, and a must read for all expectant Dads. Really. It is easy to read, engaging, and is packed with common sense. I can almost hear Dean's voice, as though he's just chatting to another man, whose partner is pregnant.  I found the case study format of the information in the book  so useful, and can imagine that this too will appeal to Dads-to-be, excited or apprehensive, as it seems to bring each topic to life.

In fact, here are so many positives about the book, I can't mention them all. The greatest has got to be that it’s non-prescriptive. Dean gives inside information about certain situations, and then offers suggestions, which are absolutely spot on. He uses humour too, and diagrams wherever possible. I particularly like the drawing that demonstrates the effect of stress on labour progress! Brilliant, and perfectly true!

Rather than advice, Dean offers tips. He encourages Dads to stay positive, and that even if they are worried at any stage, to try not to display anxiety to their partner. ‘She will SMELL your fear’ Dean warns, and that can disturb labour.  Another recommendation for expectant Dads is for them not to think they can ‘fix it’. Meaning, men instinctively try to solve every problem by 'fixing it', but when they are with their partner in labour it isn't going to be possible. Dean encourages Dads not to 'take over' during the birth, but to try to focus on supporting his partner. But Dean does encourage Dad to be an advocate, if necessary. If Dad feels concerned about a procedure about to be performed, and feels his partner isn't ready, he suggests  ‘gently ask the person to wait a moment’… so therefore speaking on behalf his partner, being her voice.  Dean explains to readers that sometimes (and this is so true) women in labour say the opposite to what they've decided on pre-labour. For example, they may ask for an epidural, when they were adamant beforehand that they didn't want one. This is confusing for Dads to be, as he is torn between knowing what his partner was sure about, and what she is now pleading for! Dean suggests an agreed  ‘code word’ in advance, that if his partner says, it means I HAVE CHANGED MY MIND!'

One very important aspect of the book is about the 'cascade of intervention', choice, and decision making. Dean, this is brilliant. I can't begin to tell parents how important it is for parents to really understand the evidence behind, and implications of, some of the procedures offered to them, or choices they make. Perfect Dean.

The only suggestion I would offer for any reprint of the book in the future, would be to mention research physiology and purpose of labour pain, and support couples to work with labour pain, rather than trying to getting rid of it. The language we use is important here, too.

But I am totally impressed with this book, so much so that we have added it to the resources for Dads on the new, parent-led Birth in East Lancs website, and I will recommend it to all expectant Dads, whenever I can.

Congratulations Dean, and thank you for making a positive step towards supporting women and families to have a positive birth experience, which holds the potential to influence the world.

Readers can find Dean's website here, and on Twitter via @daddynatal

The book can be purchased from Amazon.

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

Meet Geraldine Butcher: a wee wonder!

In the theme of 'Nursing and Midwifery History', and after the great response to my last post about Miss Fenton, I thought it would be great to interview a couple of 'midwifery greats' and to publish their stories right here, on Five Girls.  Here is the first midwife, the wonderful Geraldine Butcher! 

I first met Geraldine at the MAMA Conference last year in Troon, Scotland, and immediately felt a connection with her. Her smiling face beamed across the dinning table, and she made me feel welcome in her country. 

Geraldine began nurse training in 1978 and  thought she wanted to work in surgery or in coronary care…until she went to the maternity unit during the second year of her training. At that time they were chronically short of midwives and she was often caring for women until the second stage of labour (fills her with horror now but in her naivety she felt trusted, and loved it). Due to this experience, Geraldine decided to become a midwife. However…..that same year she had become instantly broody, which resulted in her sitting her nursing finals 36 weeks pregnant!

When Geraldine's baby son was 7 months old she worked as a staff nurse mainly doing postnatal care of women and babies (that was quite common in those days). When her second child was 3 yrs old she began her midwifery training in the same hospital; completing in November 1987.

So, Geraldine agreed to answer some of my questions, so you can get to know her a bit better too!

Hi Geraldine, thanks for agreeing to be interviewed! Could you describe briefly what your role is at the moment?

Hi Sheena, I am Consultant Midwife in NHS Ayrshire and Arran with a special interest in Normality

How long have you been working in this position, and what do you like most about it?

I have worked in Practice Development since 1996 (although continuously in clinical practice) and was fortunate to gain my Consultant Midwife post in 2007. At this time posts in all but the smallest health boards were created to implement the Midwife Led aspects of the Framework for Maternity Services. The work was called the Keeping Childbirth Natural and Dynamic Programme and I was proud to be the local champion.

Being a Consultant Midwife allows me to keep in touch with clinical practice, research and audit, professional development and education all within a leadership framework. All of these things are very important to me and I would hate to lose any aspect. I can change local practice (although that brings its own challenges on occasions) and also influence national strategy and developments.

 You have been a midwife for more than 25 years, do you feel maternity services have changed in that time?

I have been a midwife more than 25 years but have worked in maternity services for 30 years. I loved my maternity placement as a student nurse (everyone had to be dual trained then) and got lots of responsibility during my placement. I completed my nurse training sitting my finals at 36 weeks gestation as my maternity secondment had left me so broody. During my second pregnancy I moved back home to Ayrshire. Minutes after giving birth my husband jokingly asked if there were any jobs (I hope he was anyway!) Turned out they were so short of midwives they employed a few staff nurses. When my son was 7 months old I started working in maternity care. Again I did everything but listen to fetal hearts in the ward areas but was not utilized in labour ward, which at least was something. In those days accountability and risking registrations wasn’t really a discussion topic!

In 1985 I started my midwifery training and was extremely proud when I qualified in 1987. There was still a lot of medicalisation of normal birth at that time, and it is hard to change a system that has been in place for nearly 20 yrs. Women declining any antenatal screening was rare, even though the information they got was little or none. Most women had a late antenatal vaginal examination. Induction rates were higher than they are now with most women being induced by 41 weeks gestation. Interestingly though caesarean section rates were much lower…no epidurals, no FBS, VBAC was the norm and I don’t remember anyone expressing a profound fear of birth or requesting caesarean section. Was that because women knew there was little point in not going with what staff recommended, or was it because they were more philosophical about birth? Women getting out of bed during labour never mind birth was virtually unheard of. Episiotomy rates which had been almost 100% in 1980 were now lower…but don’t you dare have a perineal tear!...intact or episiotomy or you are in trouble. Shaves and enemas were on their way out but ARM on admission and IV infusions remained very common place. All women with very few exceptions had continuous monitoring in labour. Postnatal stay for normal birth was 3 days and midwives visited every day until day 10.

 However!....from 1988 we gradually started inching our way back into being lead professional for healthy women having uncomplicated pregnancies…our blue spot ladies didn’t see a consultant at all antenatally and in labour ward our first midwifery cases started…… 

What improvements do you think maternity services need to make, if any?

 We need to listen to women and have stronger focus generally that birth is a psychological emotional and social process, not just a physical one. With limited resources we can't be all things to all people, but care and compassion cost nothing. Women's perspective of risk is not always the same as ours and we need to stop shroud waving.

 In order to give sensitive, individualised care however we really need good continuity of carer (and if that’s not possible good continuity of philosophy). We need the right number of staff to care for them and that is not being achieved in many areas now. Stressed staff caring for too many women will make mistakes and communication will fail.

If we can do the above then everything else should fall into place (rose tinted glasses maybe but need to hope)

As a midwifery leader, how do like to influence future generations of midwives?

 I think I do my wee bit locally by speaking to student midwives but I think social media is a great way to give snippets of good quality information, or provide constructive comment and suggestions with potential to reach many more students or those thinking about midwifery as a career. It is amazing the number of young people on twitter and actively using it and tweetchat. Perceptions of hierarchy disappear when you are behind a computer screen so they can challenge safely..and they do. MAMA conference recently had a large number of student attending and this was very encouraging…they are committed to change and they are the future of maternity care.  

I have also published and presented work, which hopefully helps!

Well, thank you SO much Geraldine, for giving us an insight into your early career, your philosophy of maternity care, and your role as a Consultant Midwife! Keep up the great work you are doing; you are making a difference. 

If you want to follow Geraldine (she's a avid 'Tweeter') on Twitter, she can be found at @gbutcher17

'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

Breastfeeding and Baby Friendly Initiative: a success story

I remember it well. Working as a midwife and supporting women to breastfeed wasn't always plain sailing. As I became more confident and skilful, women were becoming more confused due to conflicting advice. I am sure this is still the case in many areas, but in East Lancashire something happened that influenced things for the better. UNICEF's Baby Friendly Initiative was introduced more than 17 years ago at East Lancashire Hospitals NHS Trust in NW England, breast feeding rates have soared from 27% to 70%, and the BFI accreditation has been awarded and maintained for 15 years! This is no mean feat, given the demographics of the local population and the fact that there has been a huge service merger and reconfiguration. The current infant feeding coordinator, Sue Henry (@suziehenry68), has kindly reflected on this success with a guest post. Thanks Sue!

'East Lancashire Hospitals NHS Trust (ELHT) has been accredited with the Baby Friendly Hospital Initiative (BFHI) award for 15 years this year. The maintenance of this award demonstrates the commitment of this hospital Trust to ensure high standards of care in relation to infant feeding. In December 2012 the Baby Friendly Initiative (BFI) team assessed our unit again to ensure these standards have been maintained. The unit demonstrated at this assessment that standards of care remain high and BFI re-accredited us with this prestigious award. Policy and guidelines are evidence based, all staff are trained appropriately, and mums can expect skilled support and sound information. The unit will be re-assessed in four years.

In the beginning, it was the Head of Midwifery (Pauline Quinn) who ensured that ELHT progressed forward with the BFHI standards. Many significant changes were seen including the end of separation of mums and babies, abolition of routine formula supplementation for breastfed babies, the start of skin to skin contact after birth, and closer working with community colleagues to ensure ongoing support in the community. Infant feeding co-ordinators over the years (Catherine Boyle, Cathie Melvin and Sue Henry) supported staff through this change and ensured that they were abreast of the evidence.

As time went by ELHT saw our audit results improve, staff becoming conversant with the standards, a change of hearts and minds was witnessed, and breastfeeding rates rising from then 27% to now 70%, maximising potential for improvement in public health. Two hospitals (Royal Blackburn and Burnley General) merged to become ELHT – and both hospitals gained full BFHI accreditation before the merge.

The BFHI have updated their standards during this time, and more recently launched revised standards (December 2012). ELHT are now working to ensure these revised standards are embedded in practice. These standards now have a focus not just on infant feeding, but also on relationship building between mum and baby. We know the two intertwine and we feel excited about sharing new knowledge with staff and local women and families.

Reflecting on what the BFHI means to us locally in addition to giving us evidence based standards and rising breastfeeding rates, the BFHI team gives support, encouragement, direction, external audit (quality checks), and importantly belief. A belief that it is possible to change lives, not just by increasing breastfeeding rates but also by enhancing the feeding experience and the closeness felt between a mum and baby. These memories for mothers last forever.  We are increasingly aware of the importance of bonding, confidence building, care for preterm babies in the neonatal unit and brain development. We thank UNICEF BFI for taking us forward so that we can do our best for babies and families.

How have we maintained our BFHI standards for so long?  Staying committed with support from all staff levels, constantly re-auditing standards and making improvements, having a project lead to keep driving agenda forward, believing in breast milk / breastfeeding, believing in informed choice for all mums, and believing in equality – every mum being support in her choice. Choice is very important. Every mums feeding experience is important. These are things we at ELHT respect. 

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

Inspirational students and the need for more midwives

I have just finished facilitating the @WeMidwives twitter chat, which runs every two weeks, under the domain of @WeNurses.

Tonight the debate centred around the shortage of midwives in the UK, and the impact this has on mothers and babies. The participants in the chat were raring to go. Interestingly but not surprising the majority of tweeters were student midwives, and they carefully and articulately described the situation in today's NHS maternity services. I believe that the content of the chat found here is a true reflection of things, as I hear from my colleagues around the country on a daily basis.

It is desperately sad. The resources are limited and constrained. It seems ludicrous that the NHS has a financial plan that enforces savings on services that potentially cost the NHS more in the long term.

We must keep raising the issue that radical change is needed to ensure care at the very beginning of life is the best it can be.   Midwifery staffing levels are inadequate, and the workload is increasing for many reasons. I recently wrote a post for the  NHS Confederation's blog for NHS Leaders highlighting the need to take stock of the Francis Report's recommendations and to listen to what service users are telling us, before it's too late.  

The students involved in the chat tonight were insightful, sensible and sensitive. They see and feel the pressure, the tension, the joy and the tiredness. They want to change things, and why shouldn't they get the opportunity? They are the future.

And I think we owe it to them to keep pushing for change. I will try, will you?