Midwife Diaries and more - an interview with Ellie!

        Midwifery support giver - Ellie Durant 

I was absolutely thrilled when Ellie Durant said YES to writing a guest post for my blog. Read on...and you'll see why! 

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Sheena, it’s a huge honour to be asked to write for your blog. You’ve asked me some things about myself and my midwifery support business, and I’ve also included a little something extra for your readers that I hope they’ll enjoy and find useful…

This is what Midwife Diaries is all about!

Hi Ellie, I’ve heard you speak at a conference, and seen your positive presence on social media, but I would love to know more about you…

To cut a long and meandering journey short, I started my website Midwife Diaries when I moved to New Zealand to practise as a midwife. It was a way of recording that journey, fulfilling my passion for writing and keeping friends and family in the loop about what I was up to 12,000 miles from home.

Midwife Diaries is now my full-time business that works to support aspiring, student and newly qualified midwives in particular, though we have many experienced midwives who are part of the community too.

On a personal note I love cycling and running – these are what have kept me passionate (and sane!) both as a midwife and in my own business.

I think many midwives are devoted to their one true calling and I have huge respect for this. I also know my own nature is to ‘cross-pollinate’ and entrepreneurial drive for helping midwives and my passion for writing are the things that fuel me.

 What made you want to become a midwife, Ellie?

My story is that I got obsessed with midwifery when I was a teenager, trained in Leicester, worked in Peterborough for 18 months and then went to New Zealand.

I wanted to become a midwife for the reasons most aspiring midwives have: women and their lives fascinate me.

I also wanted to do something useful and meaningful. Now that energy goes into Midwife Diaries.

I’ve seen that you’ve published a book, and that your focus is on supporting student midwives and newly qualified midwives - tell us more!

My book Becoming a Student Midwife: The Survival Guide For Passionate Applicants is about the process of getting into midwifery.

It’s a bit of a ‘Trojan horse’ - most people expect Becoming a Student Midwife to simply help them into the profession by the way of personal statement advice and interview technique. But, though that is a large part of it, the reality is that admissions tutors are rather astute and perceptive individuals, and to truly have the best chance of winning a place an aspiring student midwife has to become the best candidate. So, Becoming a Student Midwife actually teaches aspiring students the fundamental ideas, philosophy and research behind modern midwifery. Important things like why we use words such as 'women' and 'client' rather than 'patient', and the fundamental differences between holistic midwifery care for healthy 'normal' women and other medical professions that are geared towards treating the unwell.

My intent was that Becoming a Student Midwife would be enlightening and thought-provoking for people new to the ideas within midwifery and its unique style of care, whilst also giving them the practical tools and techniques to demonstrate their knowledge and qualities at the application level.

I believe the strengths needed for a good application are the same strengths needed throughout your midwifery career.

These are high-level communication skills, self-belief and huge amounts of compassion both for yourself and everyone around you.

There’s a new version of Becoming a Student Midwife in the works which covers recent politics and everything I’ve learnt from successful student midwives.

There’s even a chapter by Virginia Howes, independent midwife, which suggests career pathways into independent practice, something that sits in line with the continuity models suggested by The National Maternity Review.

Ellie, I love your website - and just wish I had had this kind of resource when I was a midwife wannabe, or student. What kind of feedback do you receive?

That means the world to me, Sheena. The best feedback is always along the lines of ‘your blog posts make me feel normal’.

Feeling you are in the company of others who know and respect what you’re going through is a much more significant thing than it first appears. Especially when you hit the dark patches.

I also get some great feedback from student and newly qualified midwives who like the summary pieces, for instance on The National Maternity Review, or MBRRACE.

Midwife Diaries content is supposed to be inspirational and very easy to read, particularly where the subject matter is complex.

This is because midwives are so busy and often just need the facts presented in a way that’s going to stick.

 Do you find social media helps your goals?

Very much so, I run ‘The Secret Community For Midwives In The Making’ which is a Facebook group. We’re now 2 years old and have nearly 12,000 members. Movers and shakers in the birth world do Q&As (thanks Sheena!).

We also have various members of the multidisciplinary team come and chat to us – last night an expert Family Worker who specialises in supporting women experiencing domestic violence was a guest: see the bottom of this post for the ten most significant things we learnt from her!

Members can contact myself and the other moderators and we can post anonymised questions for them so they can have the benefit of the Community without risking confidentiality.

The level of support is brilliant and we have a phenomenal volunteer moderator team.

Can you tell us what your plans are for the future?

Just to confuse everyone further, I’m writing a novel about a student midwife called Chloe. It covers controversial subjects, like abortion and drug abuse, but it’s actually quite upbeat!

A major dream of mine is to one day start a 24 hour, free support line for midwives to be able to debrief, completely confidentially. I have plenty more ideas for Midwife Diaries, perhaps more than I can actually pull off, but I'll keep them under my hat for now.

Right, enough about me!

The Ten Most Crucial Things We Learnt About Domestic Violence and Midwifery from Our Family Worker Q&A:

1.    A major problem with a professional’s role in domestic abuse intervention is that the perpetrators tend to be convincing, manipulative and charming. It’s a very hard job!

2.    Follow safeguarding procedures at your Trust – at some point during pregnancy all women are supposed to be asked about domestic violence, while they are alone. Studies show that women not experiencing domestic violence don’t mind being asked and, those that are, need to be asked.

3. Perpetrators of domestic violence target women when they are at their most vulnerable, so well-known signs/situations include women who:

Have experienced domestic abuse in a previous relationship

Have learning difficulties

Have grown up in care

A surprising number have lost their mother or ex-partner within the last 6 months

A significant age gap between partners, 9 years, or less if the woman is younger

4.    Words to avoid when talking to sufferers include ‘victim’ because it suggests someone who is powerless and women will already be feeling that way because of the perpetrator. Don’t shy away from the correct terms ‘rape’ and 'abuse’ though, if this is what’s happening. This gets easier with practice.

4. If you have a woman who doesn’t speak English it’s best not to get a relative, male or female, to translate, as they could be a perpetrator of abuse too.

5. Discussing domestic violence with men on a global scale is important. It’s not a ‘women’s issue’, it’s an ‘everybody's issue’.

6. The best way to protect a woman is a safety plan. Women’s Aid trained domestic violence and abuse professionals will make these mainly. Safety plans include knowing which areas of the house to avoid arguments in (bathroom and kitchen as there are sharp objects) and what to do if he comes home in a bad mood. Also having someone to contact for help, and advising to call the police early.

7.    It may be that women will not disclose abuse or ask for help. However, offering the National Domestic Violence Helpline and talking about the issue could help ‘loosen the jar’ for the next professional who comes along, who can then ‘pop the lid’.

8.    Don’t ever give out leaflets about domestic violence as it’s not safe. Numbers should be written on a plain piece of paper or women can save the numbers on their phone under a different name.

9.    These women often have isolated lives. Calling just to see how they are will demonstrate you are there to help. That small act of kindness can make all the difference. Calling when you say you’re going to call definitely helps.

Huge thanks to the lovely and accomplished Rosa Sampson Geroski, a Family Worker from Cambridge, with an experienced background in intervention for domestic abuse.

I hope you found this helpful. I’d love to see you over on Midwife Diaries, or in The Secret Community!

You can find me:

MidwifeDiaries.com (subscribe for free to weekly blog posts)

In The Secret Community For Midwives In The Making

Ellie x

A Passion for Birth: passing on the baton

                    My family - 5 girls

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

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

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

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

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

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

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

Reference:

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

A glimpse of childbirth in Bulgaria: time to ROAR

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

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

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

Photo: Midwife Iona Nashkova learning new skills, with Tracey 

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

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

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

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

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

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

Tracey found during her short visit the following issues:

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

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

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

Photo: Nadezhda Chipeva

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

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

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

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

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

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

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

A delivery in Bulgaria. Photo: Nadezhda Chipeva 

Tracey asked you to think about this: 

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

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

I asked Tracey what we could do to help: 

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

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

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

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

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

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

CALL TO ACTION: FUTURE OF UK MIDWIVES

Midwives! Your future is being consulted on – please read and respond before 17th June

Last week the NMC sent an email to registered midwives informing us that the UK Department of Health has launched a consultation seeking views on the proposed changes for midwifery legislation. 

You can respond online here

 Please also read the Draft Statutory Instruments

The Royal College of Midwives are encouraging midwives to comment. We are seriously concerned, and urge you and your colleagues to respond

Here is a summary - for your attention and action: 

The Midwives Rules are being completely deleted.

 - There will be no more statutory supervision, which means that there will be no independent professional support for midwives who are working outside of Trust guidelines (but within professional midwifery competencies and obligations, for example, in supporting a woman who is making a good and safe choice for her and her baby, but which the Trust does not support for cost or standardisation reasons).

 - While the employer may choose to provide and pay for supervision, it is very unlikely that this will be set up as anything other than an extra means of discipline, rather than as an independent professional support system.

 - The loss of the supervisory function, that usually results in supervised or supportive practice if a midwife is not practising at an adequate level, will mean that ALL such cases will need to be refereed to either employer disciplinary procedures, or directly to the NMC fitness to practice system (apparently these cases are already mounting up).

 - The NMC Midwifery Committee is being disbanded. This will mean, as we understand it, that there will only be one midwife representing the whole midwifery profession at the national NMC level.

These are very serious changes. They are being introduced with no evidence that they will increase the safety of women and babies, or the professional capacity, status, and credibility of midwives, and, based on logical deduction, a very strong likelihood that they will do the opposite.

Please all consider these issues, and, if you feel strongly enough about them, spread the word among your networks, and let the RCM/your MP  know!

Professor Soo Downe OBE, Sheena Byrom OBE, Neesha Ridley

Click here for how to contact your MP, and here to contact the Royal College of Midwives

When midwives are broken - what can we do?

It’s always a great pleasure to visit universities and meet enthusiastic student midwives. I also have the priviledge of speaking to scores of midwives at conferences and events. Social media is another way I connect with maternity workers, and I read blogs written by midwives about their work both in and out of the NHS. There are many heart soaring moments when I read about innovation, kindness, compassion and women centredness. But I am always alert to messages of distress, and when I hear accounts such as the one below, my heart well and truly sinks. I have written about the overwhelming and increasing pressures of being an NHS midwife, and midwifery manager, before.

I have chosen to share this midwife’s plight for many reasons. Firstly because she asked me to, and because her words represent the feelings of all the others who write to me almost on a weekly basis. And of course I want to add to the lobbying for much needed change in maternity services; how can midwives care and nurture others when they feel stressed, burnt out, and unable to do their work?  The situation is intolerable, and needs action. By using a pseudonym below, I am protecting a midwife’s identity. But many midwives speak out reveal their names, when they don’t feel able to continue. Others reach out to tabloids annonymously to highlight their distress, and recently the mother of a midwife contacted the press. In 2015, the RCM revealed that 50% of midwives in England were stressed. 

Julie is a newly qualified midwife, and like so many others, the NHS is in danger of loosing her.

It's with much sadness and desperation, that at only four months into my midwifery career, I am going off sick for the first time with stress/burnout. Working conditions, despite generally very good support from colleagues and amazing support from my SOM, are untenable. I am completely heartbroken at my inability to give the kind of quality care women deserve due to staffing issues and chronic overworking. And this is despite my unit having some of the highest levels of positive feedback in the country. The price to be paid for this appears to be the health and wellbeing of all staff (particularly midwives and registrars). I'm sharing this with you as you have all been so supportive of my transition to life as a newly qualified midwife. And I believe it is an outrage that four months of work as a midwife is enough to break me, someone who has sought every strategy possible to engage in maintaining resilience (yoga, meditation, peer support, Twitter, reflecting, conferences, self-care, etc), whose passion and love for midwifery is so strong and who has made it their life's work to reach the point of qualification. I have thought about leaving midwifery. In fact, I have thought it almost daily for the past three months. I had no idea working clinically as a midwife would be so distressing. The most profound problem is that there is no time. No time to create meaningful relationships, to properly support people in their journeys, to hold space, to be tender. I have done my very best every shift and believe I have given everything I could have to the families I have been with but that is not the same as it being as good as they deserve.

On the advice of my supervisor of midwives I'm going to my GP tomorrow to get signed off for two weeks. In this time I will be reviewing my finances to see how I can reduce my clinical hours as a midwife. As someone with a disability who already works 34.5 hours I don't know how I will survive financially. I may look for another part time job to make up the shortfall. My (retired) mother has spoken of giving me a monthly allowance. All this to enable me to practice midwifery. I am angry. I am angry for myself but I am angrier for the people we serve, that working conditions for midwives are so far from adequate and sustainable that they are unable to provide the care they deserve.

If you have any ideas as to how to come back to the vocation I truly love and an identity that shapes who I am, in a way that is healthy and productive then I would be so grateful. And if you can, in any way, publicly share what I have told you (anonymously, as I fear being open may negatively impact me) then I beg of you to please do so. Tell everybody what is happening. That conditions are now so bad they are beyond normal newly qualified midwife transition. That we are experiencing burnout in months. My unit is struggling to retain even the most committed staff. We are demoralised. Not by the wonderful women and families, not by our colleagues, but by the inability to provide truly compassionate, individualised, safe, holistic care and support. The 'workload' is relentless and the only thing left to give is ourselves. And I am broken.

Please share my story if you can.

In response to my supportive email to her, Julie later wrote:

It's reassuring to know I'm not the only one struggling! I really feel that the public deserve to know the real state of affairs. There seems to be an expectation for midwives to be virtuous and perfect (a mother-type complex?), able to carry all burdens without complaint, ever grateful for the 'privilege' and 'joy' of the job. That is not to say midwifery work is without these elements but I do not feel 'privileged' on most shifts! The stress is too great to even appreciate the beauty and wonder that exist. I live with a fellow (non-disabled) NQM, who is on the verge of breakdown too and she has had two two-week long absences from work from physical illnesses she attributes to internalised stress. Again, this is within a four month period of working clinically. I just wanted to let you know as it does affect my ability to earn extra income by managing the potential work-load of another part-time job in order to facilitate reduced clinical hours as a midwife and thus it makes me intensely financially vulnerable (I am 30, live independently with a housemate and all the associated costs). This on top of the stress of working in a busy, high risk obstetric unit with chronic understaffing, demoralised midwives and unmanageable workloads is just horrible. However, to temper this I would like to add that the labour ward co-ordinators, my incredible SOM and colleagues are doing their very best on a daily basis to support me and everyone else, however there is nothing they can do about the staffing and workload issues which underpin everything.

Thank you for taking time out to listen to me. I feel heard and understood which is so lovely in these trying times.

‘...if I'd known the realities I think I would have pursued doula-ing. It's a shame as midwifery is such a beautiful paradigm in its own right but enacting it authentically in the UK, particularly in a hospital setting, seems almost impossible’

If you have any ideas as to how to come back to the vocation I truly love and an identity that shapes who I am, in a way that is healthy and productive then I would be so grateful. And if you can, in any way, publicly share what I have told you (anonymously, as I fear being open may negatively impact me) then I beg of you to please do so. Tell everybody what is happening. That conditions are now so bad they are beyond normal NQM transition. That we are experiencing burnout in months. My unit is struggling to retain even the most committed staff. We are demoralised. Not by the wonderful women and families, not by our colleagues, but by the inability to provide truly compassionate, individualised, safe, holistic care and support. The 'workload' is relentless and the only thing left to give is ourselves. And I am broken. Please share my story if you can.

So what’s the solution? I offer some suggestions. Please comment below and add yours

Strategic

• WE ARE SHORT OF MIDWIVES, especially in England. The RCM’s calculation is that England needs 2,600 more midwives.
• The proposed NHS savings of £22bn by 2020 isn’t going to happen unless we work in different ways, and become more innovative and dexterous.
• The Better Births report tells us this too, and provides some solutions to improving the working lives of maternity care workers, by supporting the development of new models of care, increasing choice of place of birth, and proposing the exploration of no fault compensation.

Organisational

Heads of midwifery, consultant midwives and leaders do you:

• Meet regularly with your staff, seek opinion on pressures within your services, then lobby for change using quantitative and qualitative data, and benchmarking tools such as BirthRate Plus?
• Establish schedule of meeting with student midwives and newly qualified midwives? Their views will reflect the culture of your services.
• Know if your service offers women the full choice offer of place of birth, which gives midwives the opportunity to experience and use their full range of midwifery skills?
• Monitor your services’ continuity of midwifery care (r) levels, which evidence tells us improves outcomes and experience for mothers, and increases midwives job satisfaction? 
• Carry in-depth analysis of sickness episodes/levels?
• Obtain regular feedback from service users via MSLCs or other forums, and frequent audit of views?
• Work closely with RCM and other union reps to seek opinion on working conditions and job satisfaction, and to share knowledge of your service?

Rewarding staff and showing appreciation, such as organising a celebration event where staff nominate peers is a great way of lifting morale, and increasing motivation.

Individual

• Look after yourself. You are your greatest asset, and listening to your body and mind then acting on signs of stress are crucial.
• Talk to someone you admire and trust, and ask for their guidance. This may be your supervisor of midwives, or a member of your team.
• Stay close to your positive role models.  
• Exercise regularly, and eat well. Use relaxation aid such as Elly Copp’s The Relaxed Midwife - A meditation aid to pause, rest and recharge and Maggie Howell's Midwives Companion
• Join the Royal College of Midwives, and meet with your local representative
• Network with wider groups, such as closed Facebook groups, and seek positive support from others via social media sites such as Twitter. 
• Read this Hannah Dahlen paper which highlights the importance of identifying real and manufactured fear.
• Read Chapter 17 in The Roar Behind the Silence – entitled Caring for Ourselves: the key to resilience by Hunter and Warren.

The Roar Behind the Silence: why kindness, compassion and respect matter in maternity care – has many examples and ideas for change in maternity care, for all levels.

It doesn’t have to be like this. Carmel McCalmont is an Associate Director of Nursing and Midwifery, and co-wrote a chapter for ROAR, about supporting student midwives in practice. She said:

We try to carry on the work we do with our student midwives into the NQM phase. I personally visit each clinical area every morning and talk to all staff. It is important to learn the names of new  before they start working, to say ‘Hello’ and call them by name from day one. I speak to them during preceptorship at their formal programme, and advise them that I have an open door as do the matrons. It is vital to check their well being to empower and support them.

If we have an incident involving a NQM we try to wrap our arms around them to support, reassure and guide because we really can't afford to loose these amazing midwives who are the future of midwifery.

Carmel's contact details:

carmel.mccalmont@uhcw.nhs.uk

Twitter: @UHCW_Midwife

'There is nothing higher value to society than improving the way we are born'

An interview with Dr Neel Shah MD, MPP, Assistant Professor, Harvard Medical School 

Hello Dr Shah, what an absolute pleasure it is for me to have the opportunity to interview you for my blog. Thank you so much for your time!   I first became aware of your work via social media, and I was instantly intrigued by your interests, and approach to maternity care. The article below drew my attention (click on image).

For those who don’t know you, could you tell me a little more about yourself, your background, and your current position?

Sure! I wear a few professional hats, but first I am an Obstetrician/Gynaecologist, which means I get to care for patients at critical life moments that range from surgery to primary care to childbirth. I’m also a scientist that focuses on designing, testing, and spreading health systems innovations that can measurably improve patient care.

 What made you choose the field of obstetrics and gynaecology? 

The clinical breadth was compelling—because we provide primary care we need to consider how patients are accessing the healthcare system; because we perform surgery, we need to consider how we deploy expensive technologies equitably. But most of all, I just loved delivering babies. Even when you are exhausted and it’s the middle of the night, there is no existential crisis when you are assisting a birth. It’s awesome every time. Never gets old.

 What do you think are the main barriers to improving maternity care and outcomes in the USA?

It is not knowledge. There is a tremendous gap between what we know and what we actually do. Closing this gap feels imminently possible to me. Improving care requires science and measurement and value propositions. But it also requires effective advocacy—building coalitions with aligned interests and establishing consensus.

I understand as well as working was a clinical doctor, you are the founder and executive director of www.CostsOfCare.org.  Can you tell us a little bit about this organisation, and why you set it up? 

My profession provides the most expensive services that any patient (or society) will spend money on in their lifetimes, but at the point of service we rarely know what anything costs. In medical school this drove me crazy. It also occurred to me that although nobody goes to medical school to treat the GGP (Gross Domestic Product - healthcare in the U.S. is nearly 18%GDP which means about 1 in 5 dollars is spent of healthcare), my colleagues often had important insights into the opportunities to make care more affordable. I formed Costs of Care six years ago to ensure that these insights percolate into the public discourse.

It is obvious you are passionate about making childbirth safer, and less expensive, and you are undertaking research in this area. What does the research entail, and why do you think this is important?

Most of health services research is about diagnosing problems – we detect variation in the quality of care but fall short of doing anything about it. Instead, intervention is left to administrators, policymakers, and other “implementers.” By contrast, my research (based at a place called Ariadne Labs in Boston) is predicated on the idea that we have a role to play in intervention too – in designing solutions that have potential for scale, and then fielding, monitoring, evaluating, and many cases spreading these solutions far and wide.

We are becoming increasingly aware of the iatrogenic damage caused by unnecessary interventions in childbirth, and the potential consequences. You have been recognised for your work New York Times, in this area, can you elaborate?

Media attention is helpful because ultimately, women have to be the driving force behind changes and improvements to our system. There are two ways that we inadvertently harm patients. The first is by doing too little – there is a broad and intuitive understanding of this. The second way is by doing too much – this has been much more challenging to explain. I agree with you that there is increasing awareness and awareness is a necessary first step. The next step, the hard work in front of all of us, is to then do something about it.

I was thrilled to see that you are listed amongst the 40 smartest people in health care - WOW! What an accolade! How did you feel about that?

Superlatives are always great! You have to be suspicious of any list that aims to plausibly put me next to Barack Obama, but flattering nonetheless. Hopefully this type of attention will help elevate the visibility of the issues we are aiming to fix in maternal health.

If you had 3 wishes granted which you feel would improve outcomes for childbearing women and their babies, what would they be?

There is nothing higher value to society than improving the way we are born. And there is a lot to improve. In the United States right now, 80% of government spending on healthcare goes to the last month of life. With a fraction of that investment, we could do a lot to ensure women and babies are getting better care.

 Lastly….who are your inspirations, and why?

I’m so fortunate to be surrounded by people who inspire me. My dad taught me to be curious. My mom taught me to be resilient. My brother taught me to take the road less traveled.

Professionally, I work with one of the people I admire most - Atul Gawande. He’s inspiring because he is a tremendously gifted writer, researcher, and surgeon, but there is more to it than that. He is also one of the most generous mentors and leaders I have worked with, and has this unflappable sense of purpose and focus on doing work that will have impact.

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Dr Shah, I am forever grateful to you for highlighting and taking action on matters that affect us all, wherever we live, or are born. And also, for connecting with me when I invited you to, and for responding to me so generously. I hope to meet you one day!

Dr Neel Shah can be found on Twitter @Neel_Shah

Voicing the silence: Elizabeth's story

Dr Elsa Montgomery is the Head of the Department of Midwifery at King’s College, London. I met her recently and she told me about her research into the experience of childbirth for women who had been sexually abused in childhood.

I was impressed by the way Elsa has used her findings to create an accessible and innovative way to enable silent voices to be heard, and shared widely.  When I saw the animation - Elizabeth's story (see below), I felt uncomfortable, just as I had done in the 1970s, when I was first exposed to a scene like this in real time. I remember the horror that I felt as a young woman, seeing another so vulnerable and helpless. I also remember looking round the room and seeing no emotion in my colleagues' faces, just composed stares, intent on the job in hand. I had to try hard to get used to it. Conditioning. Becoming de-sensitised. It is, after all, part of our education.

Or is it? 

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Elsa:

On the 1st October 2015 Sheena posted a blog entitled ‘Silenced and shamed – speak and reclaim – the journey of a midwife’. In it the author told of how her journey into midwifery triggered memories of her childhood sexual abuse.

Silence was a key theme in my research into the maternity care experiences of women who were sexually abused in childhood and many of my findings were reflected in the experiences the midwife shared. Since I completed my study I have worked on ‘Voicing the Silence’ in order to raise awareness of this hidden issue through the powerful words of the women who spoke to me and who deserve to be heard. This blog explores the experiences of one of those women.

This week has seen the publication of two important reports: the MBRRACE-UK Maternal Report 2015 and the Annual Report of the Chief Medical Officer, 2014 which focuses on women’s health. Both include case studies of women who experienced abuse in childhood. However, despite the magnitude of the problem – approximately 20% of women have experienced some form of childhood sexual abuse – it remains a hidden issue and those affected are frequently silent due to fear, shame and guilt. These women are encountered in the everyday situations of midwifery practice and many of those situations will be reminiscent of their abuse – even if the care they receive is sensitive (Montgomery et al 2015). Lack of disclosure means that their trauma is likely to go unrecognised.

Like nearly a quarter of the women who died between six weeks and one year after pregnancy, Elizabeth (a pseudonym chosen by the woman) experienced significant mental health problems in pregnancy and even made an attempt on her life:

'I just felt overwhelmed with everything and I just thought I would be better off dead, I’d be – this baby would be better off without a mother like me and I would be better off dead.'

None of those caring for Elizabeth in her first pregnancy knew of her history of childhood sexual abuse. Not even the Perinatal Mental Health team to whom she was referred by her GP after she tried to take her life:

'I suppose then people caught glimpses of how bad things were but - I couldn’t, I still really couldn’t tell anybody.  I couldn’t, I couldn’t tell anybody about the abuse – and that was really where it all stemmed from'.

Before she became pregnant, Elizabeth had believed that she had left her childhood history in the past, yet, like many other survivors, she discovered that childhood sexual abuse casts a long shadow (Children’s Commissioner 2015).

CLICK ON THIS link  to read more about the animation below created by a film production company, JMotion, as a result of a Collaborative Innovation Award from King’s Cultural Institute. It is hard-hitting and portrays Elizabeth’s experience in labour with her first child. She had been so bemused by the number of people in the room that she had asked her husband: ‘Are they selling tickets outside?’

This scene is played out in maternity units across the country every day. The word cloud below was created from the evaluations of the first group of students to see the animation.

They found it disturbing because it is so familiar to those who work in high risk maternity settings and they feared they may have been ‘colluders’ in trauma for women. Elizabeth’s experience is an indictment of what can happen in our maternity care system – especially when control is taken from women and they are not heard. Elizabeth’s story has happy ending even though the journey was a difficult one. Like some of the women mentioned in the midwife’s blog, Elizabeth planned a home birth for her second baby. Although that did not work out, the midwife listened and she had the birth she hoped for. Looking back over her experiences, she was able to say: 

And that made me feel so much better about myself, um – that my body could be actually used for some good and, and could make this beautiful baby ….

Although continuity of care is likely to make disclosure of sensitive issues easier for women, Elizabeth’s experience shows that it isn’t essential. Dignity, respect and compassion can and should be available to all women.

References

Children’s Commissioner (2015) Protecting Children from Harm: a critical assessment of child sexual abuse in the family network in England and priorities for action. London:

Davies SC (2015) Annual Report of the Chief Medical Officer, 2104, The health of the 51%: women. London: Department of Health.

Knight M, Tuffnell D, Kenyon S, Shakespeare J, Gray R, Kurinczuk JJ (Eds.) (2015) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care - Surveillance of maternal deaths in the UK 2011-13 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-13. Oxford: National Perinatal Epidemiology Unit, University of Oxford.

Montgomery, E., Pope, C., Rogers, J. (2015) The re-enactment of childhood sexual abuse in maternity care. BMC Pregnancy and Childbirth 15:194
DOI: 10.1186/s12884-015-0626-9  

Further papers from my study:

Montgomery, E., Pope, C., Rogers, J. (2015) A feminist narrative study of the maternity care experiences of women who were sexually abused in childhood. Midwifery, Vol. 31, No. 1 pp 54-60

http://www.sciencedirect.com/science/article/pii/S0266613814001521

Montgomery, E. (2013) Feeling safe: a metasynthesis of the maternity care needs of women who were sexually abused in childhood.  Birth, Vol. 40, No. 2 pp 88-95

http://onlinelibrary.wiley.com/doi/10.1111/birt.12043/abstract

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Thank you so much Elsa for sharing your important research in such an accessible and innovative way, to maximise the potential for health care workers to understand the importance of dignity, kindness and respect.  

THERE ARE NO EXCUSES

Elsa can be contacted via Email: elsa.montgomery@kcl.ac.uk      Twitter @elsamwm

The pressure must stop - a young midwife's first ROAR

Yesterday a man came to me livid with frustration 'this is not good enough' he told me 'my daughter has been waiting hours to be seen' He went on to tell me 'it isn't you. It isn't the other midwives, the care has been impeccable but the situation just isn't good enough.' 

I know. I agree. I have shed too many tears over a career I could not love more because there is nothing I can do. What he didn't know was that heartbreakingly this is a daily occurrence in my life as a midwife. What he didn't know was that actually yesterday was a rare Saturday off for me yet I had come into work so that my amazing colleagues could have a break from their 13 hour shift. A break they won't be paid for whether they take it or not, but that they physically need as human beings. I had come into the unit so that women like his daughter could be seen. So that our unit could be open to women who needed our skills as midwives, doctors, health care professionals. Women who were in labour. Women who's babies weren't moving much. Women who were concerned about their own wellbeing. 

5 maternity units in the North West of England have been closed over the weekend. These women need our care. We are literally being worked to the ground. I am watching amazing midwives leave a profession they love because the workload and stress is too high. 

Today is a rare Sunday off for me. But I will be spending it supporting our rights as workers. The NHS is run on good will. But there is only so much we can take. We joke at work that midwives don't need to eat. To rehydrate. To empty our bladders. To sleep. Let us look after ourselves so that we can look after our women. Our future generation of children. 

Earlier this year, our country voted for a government that said no to more midwives. The Conservative party have demonstrated five years of austerity, falling living standards, pay freezes and huge cuts to public services. They have threatened to make cuts to our night shift and weekend enhancements. Over the past 4 years I have missed Christmas days. New Years days. Family's birthdays. Countless nights out. I had a good education and did very well at school. I am 22. I have held the hands of women through the most emotional times of their lives. I have dressed angels we have had to say goodbye too. I have supported women to make decisions that empower them. I have been scared myself. Tired, stressed, emotional every day. Yet I am not and will not be paid well like my friends who have chosen business careers. I am not offered pay rises for my efforts or successes. I don't care because I get something more valuable than that from what I do. I love what I do. I'm passionate about what I do that's why I do it. But I do care that we are the ones who are being threatened with further cuts. Further strain.

So today I stand with doctors, midwives, nurses, teachers, firemen and many other amazing people to spread awareness of a situation that has gone too far. To share information that the general public are oblivious to because as midwives, we will not let these women be failed. I am regularly met by stunned responses from women and their partners to the situation they watch me working under. But today I say no. Enough is enough. 

I have shed too many tears over a career I love. Missed too many meal breaks. Not physically been able to care for too many women the way I wanted to. Spent too many days off in work. Lost too much sleep over the stress I am under. Watched more of my colleagues than I could count (myself included) be signed off work with stress in the early years of their career. Watched too many good midwives leave careers they love. This is not humane. Please let's end this. Protect your NHS. Your children's future. You're education system. The core foundations of Great Britain. 

I have recently learned the world is a selfish place. But I have also learned that there are a lot of very good people in it. The NHS is run on good will and because of this we have been pushed too far. 
 

Let's change this.

This post was written on Facebook, by midwife Hayley Huntoon. We need to make change happen to enable young midwives to ensure mothers and babies are safe #ENOUGH

Have we got lots to learn from the Dutch? Natalie's reflection

Hello!

Sheena asked me to write a little bit about my experience of my midwifery elective placement in The Hague, the Netherlands. This was a very exciting however, I have never written for a blog before and hope it is interesting enough to read! So here we go:

My name is Natalie Buschman, and I have recently finished my midwifery degree at King’s College London.  At the end of our third year we are given the opportunity to work in a different place or country for 2 weeks, and I arranged to go to the Netherlands. I am actually Dutch, but have lived in the UK for the last 17 years, and had my own two children here in the UK. I therefore have never experienced the Dutch maternity system and only know what the majority of birth workers know: the Netherlands is the envy of the world keeping birth physiological without unnecessary medical interventions. The Netherlands is well known for their high home birth rate and while this has steadily declined from 35% in 2000 to 16% in 2013 (Brouwers, Bruinse, Dijs-Elsinga et al., 2014) for a variety of reasons, it is still high in comparison with meagre 2.3% in the UK(Birth Choice UK, 2011), and certainly a desirable statistic to have!  Furthermore a rather unique feature of Dutch maternity care is the “kraamverzorgster” who can be described as a maternity nurse or postnatal doula supporting families after they have a baby. A kraamverzorgster is available to all women and their families, regardless of income. They will assist the midwife during homebirth or in the hospital (midwife-led) during labour and are available for undivided postnatal care for the first week. All in all, my elective was a great opportunity to go home and have a taste of this highly acclaimed maternity care system.

Ellie the kraamverzorgster with traditional ‘beschuit met muisjes’ or crispbake with mice (aniseed with a sugar coating)

The first thing I quickly need to explain is the concept ‘first line’ and ‘second line’ midwifery care. In the Netherlands, like in the UK, you can self-refer to a midwife. Women will contact their midwife/midwifery practise of choice directly for low risk care; this is considered the first line. Only if there are any underlying medical conditions and/or any complications arise during the pregnancy, will the midwife refer the women through to the second line or obstetric care. As such there is a definite divide between first and second line care. As a newly qualified midwife in the Netherlands you are a first line midwife, unless you choose to work in the hospital under obstetric supervision as a second line midwife. Overall, as a second line midwife, you look after women who are already under obstetric care in their pregnancy or who become higher risk for any reason during their labour and birth OR for maternal request for pharmaceutical pain relief such as an epidural. As a first line midwife you look after all women without any specified risks. There is also third line care, which are the big academic specialist hospitals for which women need a referral from the second line or general hospitals.

Midwives Chantal, Anke, Peggy, Carola and Rachelle, their main interim midwife, from midwifery group practice “Anno” in the Hague welcomed me for two weeks this past August and indulged my curiosity.  Anno is an established practice with, on average, between 30 and 35 women on their books each month.

Light airy clinical room at Anno’s home base in the Tree and Flower quarter

It is usual for a midwifery practice to have a ‘shop front’ in the Netherlands, and Anno’s is warm and inviting with a nice airy waiting area and two welcoming clinical rooms located in the tree and flower quarter of The Hague. They offer preconception, antenatal and six week follow up appointments (if desired as most women do not do this) at Anno’s home base as well as an antenatal clinic at two different GP’s. The midwives will do home births or hospital births, whatever the women desire. Their homebirth rate of approximately 6.5% (about 2 births per month) and is much lower than the latest national average of 16%, which the midwives felt, is due to a ‘city’ thing as well as the population they serve. Additionally, Anno offers dating and growth scans. First line midwives, and hospitals, earn their income from the woman’s health insurance; therefore due to the high percentage of Dutch midwives working independently, competition is fierce.  The idea that you can have your first scan done with your midwife is an appealing one. Perhaps this makes the difference in the amount of women who will go for their nuchal scan and combination test whether there are any chromosomal abnormalities, with the most commonly known being Down’s syndrome, in their pregnancy.  Roughly 50% of the women booked at Anno will go for this test after being counselled by one of the midwives, while in my experience at the Trust where I trained, the vast majority of women will have this test done. It felt like there was a more conscious decision on what they would do with the information rather than going ‘along’: an opt-in instead of an opt-out.

Before I started, the midwives had requested a little ‘bio’ from me and a photograph so the women they cared for could read about me before meeting me. I thought this was a nice touch, and on several occasions the women’s reaction to me was “I was just reading about you - how fun you are from London!” The next comment was mostly how good my Dutch was!  While it is my mother tongue, I have to admit that I mostly eat, sleep and dream English so switching back did cause some initial giggles all round with some literal translations and weird sentence constructions on my part! Luckily, the Dutch side of my brain kicked in fairly quickly and it even managed to get to grips with the Dutch midwifery dialect (i.e. jargon!).  In order to get the most rounded experience in my very short time, I spent time in the antenatal clinic at Anno’s home base as well as at the GP surgery which serves a very large immigrant population, predominately Turkish and Moroccan women, scanning clinic, postnatal visits and being on call for anything and everything. I was also privileged to be at two births and while they were not at home, it was still a great opportunity to see the midwives in action and how it worked being in a hospital without working for that hospital!

So what are my thoughts after this whirlwind of Dutch maternity care? I can only really share my thoughts on the first line midwifery care, as this is what I observed. There were some practical things like how amazing it would be to have kraamverzorgsters, who take care of most of the clinical postnatal issues such as checking stitches, whether the uterus is well contracted, mum’s pulse etc. They also support the family in how to take care of the baby and of course give invaluable breastfeeding support. A midwife visits every other day for at least 8 days, checks with the kraamverzorgster if there are any concerns and there is actually an opportunity to ask the woman how she is! Don’t get me wrong, there was not necessarily time for a cuppa but it definitely felt less rushed then what I have experienced in the UK. Something that did stand out for me was the amount of women that were expressing breast milk. I just did not understand why they expressed rather than put the baby on the breast? What I did forget is that though the Netherlands has an excellent maternity care package, it is very short! Women in the Netherlands are entitled to 16 weeks paid leave (at 100% pay), and are expected to start their maternity leave at minimum 4 weeks before their baby is due. They are then entitled to 10 weeks after the baby is born, even if the baby is born later then the expected date. Maybe this explains the frantic expressing? Funnily enough, midwives recommend you don’t go outside with the baby for at least one week. How old fashioned was my first thought, but upon reflection, how wonderful! There are so many pressures upon new mothers these days: to bounce back into shape, and ideally into those size 8 jeans you never fitted into in the first place, tidy home with of course Mary Berry style cakes for all visitors, and to be out and about with a perfect baby in the perfect pram! Although Dutch mothers are expected to go back to work after only 10 weeks and likely have some of the same pressures, that first week is really protected with being told that the baby should not go outside (which means mothers can stay in too). Furthermore, there is a kraamverzorgster helping several hours each day, and a midwife that comes round at least 4 times! I wonder if the care received in the first week has any impact on issues such as breastfeeding rates, bonding and postnatal depression, it would be interesting to even compare the UK with the Netherlands. PhD anyone?

Furthermore, there were other things that really struck a cord with me like continuity of care and the confidence of the midwives. The midwives are in a position to give great continuity of care, even in a small group practice, from beginning to end and make sure every midwife has seen the women so there is always a familiar face. Even I, in the short amount of time there met the same women and their families on several occasions, which was hugely satisfying all around! And yes we know that true continuity of care has better outcomes for women and their babies (Sandall et al., 2013) and is mentioned as a factor for work satisfaction for the midwives (Warmelink et al, 2015). However, for a lot of midwives in the UK to work this way would be utopia with the ever increasing work load and amount of women to see… it was so satisfying to see continuity of care as normal practise, not some dream… Of course the ability to work this way is also due to the clear separation of first and second line care as outlined by the Dutch Obstetric Indication List (aka the VIL). This list describes what is physiological and what should be considered a pathological pregnancy, labour and birth and decisions on whom to refer to second line and who to keep in first line care should be based on the VIL. Nevertheless, there is change happening in the Netherlands and midwives are fearful what this could mean for their autonomous independent practice serving pregnant women…

What is happening? Surprisingly and also controversially, findings from the Euro-Peristat (2008; 2013) showed the Netherlands to have one of the highest perinatal mortality rates in Europe in 1999 as well as in 2004. Unfortunately, the media seized this opportunity for scaremongering the general public that home births and midwives cause babies to die, and many unwarranted assumptions were made including that the separation of first and second line care is at fault (de Vries et al, 2013). It turned out that preterm births were included in these statistics and a reanalysis showed that the perinatal rate in the Netherlands is lower or not any different to other European countries, where first line care and high rates of homebirths are uncommon (de Jonge et al. 2013). Of course, these corrected findings were never reported in the media and the damage has been done. In view of the Euro-Peristat findings, the Dutch government is trying to ‘improve’ maternity care, depending what way you look at it, by creating more integrated care rather than a more specified divided first and second line care. This is how we work in the UK and there is a lot to be said to be able to provide care as a midwife for all women, no matter the perceived risks their pregnancy potentially carries.

In my short time spent with Chantal, Anke, Peggy, Carola and Rachelle I felt they were very certain of their care and decision-making. Listening to phone conversations with clients made me realise that they truly believed in the normality of pregnancy, labour and birth. Perhaps this sound funny but having spent the vast majority of my intrapartum training on an obstetric labour ward, I can vouch for how hard it is to keep hold of that belief and trust in a woman’s body! Regrettably with the current system in the UK, I think there are a lot of midwives have lost this belief and trust…. Notwithstanding the various years of experience of the Anno midwives, in my chats with them there was a positive self-assurance, even in the brand new midwife (she qualified only that week) whom I met when she came to help out one day, something I have not always felt chatting with (NHS) midwives in the UK. Absolutely, UK midwives also have self-confidence but it felt different … It could just be a cultural difference, with the Dutch being more extrovert by nature, or maybe it is because in the in the NHS, doctors are always in the background to keep a watchful eye out just in case resulting in midwives feeling and acting more cautious?

While a large proportion of midwives think integrated care can be a positive thing, there are many others who fear this change. Professor Raymond de Vries and his colleagues describe this glass half full or half empty standpoint poignantly in his article in Midwifery (2013). It gives the reader not only some ideas as to why the Dutch maternity care is changing but it also highlights the scary truth that scientific evidence is not enough to convince the greater public of the benefits of midwifery care, people also need to be convinced also on social and cultural levels (de Vries et al., 2013).  I feel this is true not only for the Netherlands but also the UK and any other Western country where midwifery offers a safe and viable alternate option to obstetric care. Whatever direction integrated care will go in the Netherlands, I hope the Dutch people will keep their faith in their midwives and wish that the midwives I met and all their colleagues will keep believing in women, their bodies and stay positively self assured and confident in the care they provide! The Hague and the rest of the Netherlands are lucky to have them!

The Hague coastline

References:

Brouwers HA, Bruinse W, Dijs-Elsinga J, et al. (2014) Netherlands Perinatal Registry. Perinatal Care in the Netherlands 2013. Utrecht: Netherlands Perinatal Registry, 2014.

Birth Choice UK (2011). National Statistics. Available at http://www.birthchoiceuk.com/Professionals/BirthChoiceUKFrame.htm?http://www.birthchoiceuk.com/Professionals/statistics.htm. 

De Vries, R., Nieuwenhuijze, M., Buitendijk,  S., E. (2013). What does it take to have a strong and independent profession of midwifery? Lessons from the Netherlands. Midwifery, 29 (10),  1122-1128.

De Jonge, A,. Baron R., Westerneng, M., Twist, J,. Horton EK (2013) Perinatal mortality rate in the Netherlands compared to other European countries: a secondary analysis of Euro-PERISTAT data. Midwifery, 29 (8), 1011-1018.

Europeristat (2008,2013). Available at http://europeristat.com/. Last accessed 23 September 2015. 

Sandall J., Soltani H., Gates S., Shennan A., Devane D. (2013) Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, Issue 8. Art. No.: CD004667. DOI: 10.1002/14651858.CD004667.pub3.

Warmelink, C.,J., Hoijtink, K., Noppers, M., Wiegers, T., A., de Cock, P., Klomp, T., Hutton, E.,K. (2015). An explorative study of factors contributing to the job statisfaction of primary care midwives. Midwifery, 31 (4), 482-488. 

Silenced and shamed - speak and reclaim - the journey of a midwife

This midwife contacted me and offered this post for my blog. She wishes to remain anonymous. Her message is hard-hitting, emotive, and real. Please take time to read, reflect and act. 

Image: http://www.freedigitalphotos.net

The book The Roar Behind the Silence: why kindness, compassion and respect in maternity care matters has highlighted issues, and given many practical tools that are so important in the on-going training and care that midwives and other maternity care workers provide. Reading about others’ experiences and gleaning from their wisdom has added jewels to my midwife treasure trove.

I would like to take this opportunity to talk about the “unspoken” and the not so pleasant things, the secrets that many women hold in their bodies, hearts, and minds. It’s my hope that in speaking out about these subjects, that it will give you courage on your road as a care provider, widen your perspective of the women in you are serving, and encourage you to be someone who creates safe spaces for pregnant women to share their situations. Don't be afraid to reach out for help when you need to.  One small opportunity or intervention, on your part may save a life, or two.

We midwives are humans too. 

The Royal College of Midwives chosen charity of the year has recently been announced as Women’s Aid. Women's Aid is a charitable organisation concerned with supporting women who are suffering from domestic abuse.  “Domestic abuse is a significant factor in the ill health and mortality of mothers and pregnant women (1). It can have significant physical and emotional impact on the woman and can lead to miscarriage, low birth weight, ruptured uterus and pre-term labour.” (2) 

Violence and abuse are usually secret and hidden. Victims are shamed into silence by fear and control. 

Women's Aid uses the Home Office definition of domestic violence which is: 
Any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members regardless of gender or sexuality. This can encompass but is not limited to the following types of abuse:

• Psychological
• Physical
• Sexual
• Emotional 

As a midwife in training I thoroughly enjoyed studying and learning skills, but when it came to hands on experience it was as if the connection between my acquired knowledge and my physical intuition to connect, was blocked. I knew the kind of midwife I wanted to be, I was surrounded by great role models. I felt disappointed with my apparent dysfunction to give what I had never experienced, human connection,  deficient in oxytocin and the container of it.  I grew up in a violent environment with touch and comfort withheld. I was punished and suffered violence daily, and observed other forms of violence and dysfunction in family life. As a student midwife, I felt extremely uncomfortable to offer any kind of physical reassurance to a woman in labour. Even rubbing her back was a huge obstacle for me. Witnessing someone, struggling to cope alone, and lost in her own fearful space, I was able to overcome my own lack of confidence, to reach out to show her kindness and compassionate care.

Being a midwife is one of the most rewarding life responsibilities in the world if you ask me. It has drawn out the best and the worst in me. It is demanding, pushes all my buttons and takes me beyond the limits I believed I once had. I have always been sensitive to pick up “cues”, to empathise and support, encouraging women to speak up, ask for help, and report violence that has brought physical and emotional harm to them and their unborn child. Some women may not disclose any such events but we can always do our best to create a safe place, following policies, guidelines, and instinct. More on the practical aspects later. A basic bottom line is to always offer your best to each woman, whatever her circumstance. 

We midwives  enter into each appointment / birth experience evaluating what that woman needs to facilitate a good experience for her.

SILENCE - can be a refuge, but it may also be a prison. I spent most of my childhood in silence to the daily abuse I survived. We humans are pretty resilient and we can make it through most adversities, but we carry that stress, the trauma and the memories in our conscious and subconscious being, maybe even epigenetically through generations?  Add the dynamic of pregnancy, hormone changes, physical challenges and life’s daily problems. Women in your care may have already turned to alcohol, drugs, eating disorders, self-harm, or some other self-medication, in order to get through each day, numbing themselves as a self preservation method.  Of course this puts their health and pregnancy at risk, and they need help.

What do you notice when you are “with woman”? Do you notice when someone else is constantly speaking instead of her, keeping her in silence? How about the quiet and shy type? Will she look into your eyes? Does she flynch or jump at sudden noise or movement? Does she “zone out”? Does she come across as passive, agitated, guarded or anxious beyond a typical level?  Do you have women that never come to an appointment alone?

If perinatal mental illnesses go untreated they can have a devastating impact on women and their families. In extreme cases, these illnesses can be life threatening – they are one of the leading causes of maternal death in the UK (3)

mage: http://www.freedigitalphotos.net

Silence is not always a sign of contentment. Try to make an extra effort to find out the reason behind the silence.

More than 1 in 10 women will be affected by a mental illness during pregnancy or after the birth of their baby (4). This means that each year in the UK more than 70,000 families will experience the impact of these illnesses. We midwives are growing in awareness and our aim is to facilitate women's ablitiy to speak up about their unique situations, decisions and personal needs. 

SHAME - is  'the painful feeling arising from the consciousness of something dishonorable, improper, ridiculous, etc., done by oneself or another'.  Brene Browne defines shame as the fear of disconnection, 'Is there something about me, that if people know it or see it, that I won’t be worthy of connection' 

Do you ever read beautiful birth stories online? Birth story surfing is turning into a competitive sport these days with words and images of joy, peaceful and pleasurable birth, fantastic photography capturing the moment, the idyllic and the organic.

But what about the woman who is afraid to birth? Maybe she can’t quite put it into words but she has an unexplainable fear of a breast or vaginal exam. The thought of breastfeeding and skin to skin could be a challenge that makes her feel like she is suffocating? Maybe her life has been a chaotic and confusing, relational and abusive mess, so the mere idea of such unpredictable, uncontollable events such as labour and birth could be horrifying. There is no rational explanation in her head and it’s not the easiest topic to bring up, especially with her own high expectations of “perfoming” and being the best mother she can be.

In her family, or in her culture, issues of sexuality, birthing, problems and relational difficulties may not  be addressed and she has no confidence, or no one she can trust to voice what she has been through, or what she is constantly living. Perhaps you will be the first person in her life to ask questions that dig a little deeper, and provide an opportunity for help, referral, counsel, and medication when needed. The more we work at listening and observing with all our senses, we can become more sensitive to the women we interact with. 

Image:  canstocck.com

After a lot of theory and learning for my midwifery study, the practical part came along. I was in great anticipation of putting all I had learned into practice. I was shocked by some of my responses. When I had to perform vaginal exams I felt horrible, as if I was abusing the woman. I went to my supervisors on several occasions in tears, and stated that I could not be a midwife because I did not want to do vaginal exams. It was a strong emotion beyond my cognitive mind. My supervisors encouraged me not to give up, and that was it, I pushed through, but I would really have prefered to skip that part. I have since learned to observe and to only do vaginal exams upon the woman’s own request or when the pattern of labour is unusual. Of course they are useful to diagnose an aynclytic baby, or a surprise breech etc. 

Courage brings connection, which defeats shame, so enabling a woman to #breakthesilence of her current, or history of, abuse, in her vulnerability, which in turn will also facilitate the crushing of shame, and light the flame of connection. Where there is no longer fear, love dwells.

Often women who have suppressed memories of childhood sexual abuse (CSA) will start to get flashbacks when they become sexually active, or during pregnancy, labour, or birth. For me the process of being a student midwife stimulated those subconcious memories into that present time, with flashbacks, intense feelings of shame, and an inherent impression that I was doing something wrong, or that I was not worthy to be a midwife. The truth was, I was doing nothing wrong, but the exposure to something new had triggered something hidden. It’s important that you find someone you can talk to if you are struggling with your own responses, or a situation in which you feel needs specialised attention and is beyond your scope of care that you can provide. I have always found that asking for help has been both a relief and a solution to my own struggles in my personal and professional development. I had to take time out at times, to deal with my own issues, so I did not carry them into my work, and to learn to be kind to myself, so I could give compassion to others.

Some women have suffered so much trauma that a vaginal birth is out of the question and an elective cesarean would be a kind and relieving option. Some women need to have specialised care, counseling and yet still be the decision makers for their own care. With the appointing of specialist mental health midwives, women will get the much needed support and counsel throughout the UK. 

We midwives give our best, our combined efforts, together with colleagues bring optimal care and support to women and their families. 

Speak – As I grew as a student or as a midwife my skills have been enhanced. There are study days, conferences, social media, and more, to glean knowledge. I have found that reading books, studying, workshops and team learning opportunities have given me insight and assisted me to grow.

Enhancing my communication skills through observation, reading, workshops, role play, listening, and reflecting have been vital instruments. Consider the language we bring to each conversation. Is it enabling a useful discussion? Is it creating fear or kindness? Women are exploring language and different methods as tools to undergo a gentler birth experience. We can support this by being flexible and giving choice and using alternative words as options. Examples of this are surges, instead of contraction, opening instead of dilation, not putting emphasis on a nuchal cord delaying progress, aiming for the positive rather than bringing a fearful approach. Our verbal language combined with body language and attitude, can make all the difference to how safe a woman in our care may feel.

Image:  canstocck.com

The systems in place in hospitals across the UK have plenty of resources, and referrals to a community midwife, mental health midwife, consultant in mental health, community psychiatric services, depending on severity.

If a service is run in a way that enables a woman to see the same midwife at all or most of her appointments, she is more likely to feel able to disclose concerns about her mental health. However, evidence shows that too many women do not receive continuity of care, and that this makes it harder for women to discuss their mental health with a midwife. (5)

We midwives have the tools, skills and resources,  to speak words that enable the woman to be powerful and positive, no matter what their background or current cirmumstance.

Reclaiming something for yourself is an achievement. Overcoming seemingly impossible obstacles can be a daunting, yet not impossible task. Believe me, I’ve done it several times. A woman who has a phobia of needles (a possible effect from CSA, but not solely related) could have a positive experience by meeting a care provider who specialises in providing sensitive and specialised care. I have witnessed a woman completely at ease during a planned elective cesarean, yet previously terrified. After meeting and asking questions from a kind and experienced doctor to perform needed procedures involving needles, she was able to cope remarkably well and even surprised herself. A gentle approach involving the woman in the decision making can make all the difference.

Another woman voiced that she would prefer absolutely no vaginal exams in labour. It was easy to observe, in labour, that she was progressing well, no vaginal exam was done, she birthed in water and was clearly pleased with the birth experience afterwards.

I hear so many stories of women who had a traumatic birth the first time around. For their next birth, they were proactive to seek a different experience. Some choose a homebirth to avoid procedures that had caused stress in their previous birth. I have witnessed firsthand how women reclaiming their birth and their power, their decision making autonomy and their circumstances, go on to birth in a calm, loving and supported manner. What a beautiful way to enter parenting and what an imprint on the baby, begininning it’s life in perfect love, peace and a safe embrace.

We midwives  hold the potential to positively influence society by bringing compassion and kindness to the forefront of our practice.

References:

1. Price, S, Baird, K and Salmon, D (2007) Does routine antenatal enquiry lead to an increased rate of disclosure of domestic abuse? Royal College of Midwifes 

2. Granville, G and Bridge, S (2010) Summary of findings and recommendations from the independent evaluation. PATHway: An Independent Domestic Violence Advisory service at St Mary’s Maternity Hospital, Manchester. 

3. Saving Mother’s Lives: The Eighth Report of the confidential Enquiries into Maternal Deaths in the United Kingdom (2011) British Journal Obstetrics and Gynaecology. 

4. NICE (2007) Clinical Guideline 45, Antenatal and postnatal Mental Health. http://guidance.nice.org. uk/CG45

5. MMHA SMHMs Report P.6

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

Photo: Midwiferyaction.org

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

Tracey (pictured above):

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

The framework for quality maternal and newborn care

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

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

Key messages

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

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

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

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

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

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

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

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

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

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

For more information see the Executive Summary

Reference:

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

Dr Tracey Cooper can be found on Twitter

Is change is on the way? Place of birth

The National Maternity Review Team in England are working hard to gather evidence, opinion and visionary ideas for the future of maternity services. I have been invited to participate in two separate meetings, but am sadly unable to attend due to pre-booked holidays. I have lots to offer.

My action when participating in #MatExp #FlamingJune activity was to gather views of maternity services from willing individuals, by inviting them to write a post for my blog. Whilst it's now July, I am continuing with the action as contributions keep coming!   Please do get in touch if you want to have your say. I will send the link for the posts to the Team in good time.

So here is post 7. Natalie Meddings, mother, doula and active birth teacher, has a revelation. You can read about it below.

Natalie: 

Something astonishing has happened. Something that has caught me by surprise. A couple of weeks ago, while doing our usual how-are-you ? go-round in my  Active Birth Class, it hit me that more than half of the women in attendance were planning to have their babies at home. For the first time in the seven-year life of my yoga class, the MAJORITY were planning a homebirth.

It’s a microsample, it’s true. But 60% is 60%, especially when year in, year out, it’s been more like ten - one sole mother, keeping quiet in the corner in case her unconventional choice got challenged over tea.

Photo: Hannah 

Last week there was no self-silencing though. Neither was there any noticeable announcement. Quite the opposite, which is why I almost missed it.

As one after the other, they aired their plan to book a community midwife and see how things went, there was something ordinary about it - an almost casually-arrived-at agreement that this was common-sense, the most natural thing in the world to be in the most natural place in the world to give birth.

There were no faces made by those whose preference was hospital, or gasps of ‘you’re brave’.  Like many birthworkers, I’ve been spreading the female idea for years - why a safe and familiar space gives the female body full physiological chance of a straightforward labour . And suddenly here we were. Here we are, with that message starting to mean something.

To be fair, I think the ‘normal’ part of it had been helped by the group’s  avoidance of the word homebirth. Instead we’ve focussed on the all-options-open aspect to booking a community midwife - the in-built safety and control of having someone visit you in labour at home so that you can decide how you feel and what you want to do on the day.

Free of the homebirth heading, the idea was less loaded, less of a leap and as a result, an idea they could envisage.  Without a big, fixed plan, the women could more easily imagine themselves in such a situation, as well as the immersive benefits that setting offered biologically - deep privacy and quiet.

But there was something else behind this new turn too.  These women had heard lots of positive birth stories.

As recently even as three years ago, that wasn’t the case. A mother with a good birth story to share usually felt unable to. Pejoratively pigeonholed by the media as a ‘type’; silenced in NCT groups for fear she’d be crowing.  What could she to do but stay quiet?  Meaning that the stories pregnant women got to hear were overwhelmingly worrying ones - traumatic tales of long labours and apparently inevitable medical rescue.

But the word-of-mouth miracle that is social media has changed that. Instead of negative birth experiences installing fear and that fear going on to inform more negative experiences, the cycle is reversing. Women are now hearing lots of positive birth experiences, getting inspired and encouraged, and going on to have positive experiences too.

Support networks like my own tellmeagoodbirthstory.com and Milli Hill’s Positive Birth Movement  saw the super-powerful resource women could be for other women - and created an outlet for it.

Tellmeagoodbirthstory connects pregnant women with women who’ve had positive birth experiences by email; the now countless Positive Birth Groups around the country are a place where pregnant women can hear stories and share wisdom first hand. And from our kitchen tables, we keep the fire burning beneath it all with a busy and very buzzy presence on facebook and twitter.

‘I think about my birth every day of my life.’

‘At home, I understood what I had to do and the part I had to play – which was to let my body get on with it. It was much easier doing that at home, where I didn’t have to make any decisions to make or to think about anything else at all.’

 ‘In labour, there’s more rest than work – no one ever tells you that.’

These are the kind of comments women are hearing now – on their feeds, at groups, by connecting – so that it’s not so much the choosing to homebirth  that’s significant, but the increase in confidence.  Those women in my class being calm and in command of their experience.

Louise saying:  ‘I want to be able to listen to my body without distraction, to allow it do what it instinctively knows how to do.’   

Claire saying: ‘When I first found out I was pregnant a home birth was the last option on my mind. But having heard from other mums about labour, I’ve realised it’s being in the comfort of my own home, in my personal space that’s going to help me relax and let go.’

A few years ago, I questioned Mavis Kirkham, professor of midwifery at Sheffield Hallam University about the relationship between mothers and the maternity service.

‘The organisation of maternity services encourages women to take the attitude towards labour and birth that they would have towards a plane journey,’ she said.

‘Just as we buckle ourselves in and hope for the best on a flight, women are encouraged to do the same in labour. We feel there is nothing we can do to influence holding the plane up in the sky and so we switch off completely. Birth is a bit the same. Women can feel there is little they can do to affect the unfolding of the labour, that it is out of their hands, so they give responsibility to the pilot and trust they’ll get them to where they are going.’

But uninvolvement is on the wane. Women are starting to take charge, realising they can affect how their labour unfolds – and by listening to and learning from others, working out ways in which they can do that.

Self-assurance is growing from the ground up – and what the Maternity Services Review might consider are ways to foster that.

When tellmeagoodbirthstory first began, one hospital got in touch, interested in the difference a free mother-matching network might make to their birth outcomes. But they quickly grew hesitant when they realised they had no control over the information women were sharing. My local GP surgery was the same. When we asked to put up posters, the practice manager said: ‘how can we know what they are saying to each other?’

Though a degree of caution is understandable in a litigious society, paternalism like this misses a trick.  By trusting women, you engage women - they take part in and responsibility for their birth experience, and this in itself is a way to increase safety.

Mavis Kirham may have highlighted how disengaged the pregnant population has been in recent decades, but she is also the first to stress how easily reversible that is – through mother-to-mother education. Through community.

In particular, she has pointed to an estate in the north of England where a homebirth project was piloted. At first it was slow to take. But it only took a few mothers telling their neighbours what having a baby at home was like – and minds quickly opened. In no time, everyone was wanting one.

I think there’s a similar knock-on happening now. Slower to spread perhaps, but a chain of confidence nevertheless and this time the  community is country-wide.

Natalie Meddings

Natalie Meddings is mother to Constance, 13, Pearl, 11 and Walter 9 and lives in London. Natalie trained as a doula with Michel Odent and Liliana Lammers in 2003 and has been supporting women in birth ever since. Natalie became an Active Birth yoga teacher around the same time and have been running classes in Barnes, South-West London since 2008. Natalie set up 'Tell Me a Good Birth Story' a few years ago and ran it voluntarily with the help of hundreds of lovely, amazingly generous mums nationwide.

Thank you so much for this post Natalie! I refer lots of women and families to your site, and frequently mention you at conferences. You are an inspiration - Sheena 

You can follow Natalie on Twitter 

What I want the National Maternity Review team to know: Hugo's Legacy

I 'met' Leigh via social media, over a year ago. We became connected due to our common interest in improving women's experience of childbirth. Leigh is passionate in her quest to maximise the potential for women to be listened to, for the language health care workers use to be sensitive and appropriate, and for open, respectful communication.  I am grateful to Leigh for her time writing this blog post as part of my #FlamingJune action for #MatExp, to inform the National Maternity Review team of important issues. I hope Leigh's words help to make a difference. 

Leigh:

The National Maternity Review is going to be assessing current maternity services, and consider how services across the country should change to meet the needs of women and babies.

My son Hugo was born in February 2014 when I was just 24 weeks’ pregnant because I had the rare, life-threatening pregnancy complications HELLP syndrome and preeclampsia. The day before Hugo’s birth, I had been transferred to a specialist hospital two hours away from my home. Hugo died in my arms aged 35 days.

I have written about my experiences extensively in other posts on my blog. To very briefly summarise, there is nothing I can fault in the clinical care either Hugo or I received. However, there were many issues surrounding communication that could have prevented further stress in an already heartbreaking situation.

Hugo’s Legacy is about helping other women who suffer birth trauma, other families with a baby in neonatal care, and parents who lose a baby. Anyone who experiences any of these things deserves compassionate care, and a streamlined system that enables people to get the support they need, rather than battle against it.

So this is what I would like the National Maternity Review to know:

That every woman is individual.

That evidence is vital in the context of providing safe care. But to recognise that evidence cannot tell you everything. Each woman, each situation needs to be considered according to its own merits.

Postnatal care – Hospital

That any new mother separated from her newborn baby for clinical reasons, as Hugo and I were, should be reunited as soon as it is clinically possible.

That no new mother should be left in an intensive care bed, her baby in the neonatal unit fighting for his life, feeling that she is the least important patient on that ward.

There should never be a delay due to interdepartmental squabbling about beds, and to which department the responsibility of taking the mother to see her baby belongs. (This happened to me in intensive care).

That postnatal wards need to have a greater awareness of the needs of mothers whose babies are being cared for in a neonatal unit. It is difficult enough for us being on a ward with women who have their babies with them. Please don’t delay us visiting the neonatal unit to see our babies because of a lack of coordination between maternity and neonatal about timing of rounds. Please don’t force us to make our own meal arrangements because the food that is provided sits getting cold on a tray next to our postnatal bed, while we are spending precious time with our baby.

Me and Hugo

Postnatal care – Community

That better consideration needs to be given to the postnatal care needs of mothers whose baby is in neonatal care, especially when the woman has been transferred to a specialist hospital away from home. The pathways need to be clear, sensible, and appropriate staff aware of them. For example, at first I was told I would need to make the four-hour round trip to see my own GP – impossible. Then I was told I would need to register with a local GP – challenging. Eventually I was able to see a community midwife at the hospital.)

Support for Birth Trauma and Bereavement

That no bereaved parent should return home with empty arms and feel cast adrift from the hospital. To have to find their own support. To have to make telephone call after telephone call explaining an illness they do not yet quite understand and have to say the ‘D’ word again and again. To feel like such a failure as a woman and as a mother. To have to relive everything that happened again and again because services in the 21st century seem not to find the capability to communicate with one another.

That there is support for women who have experienced birth trauma, and for bereaved parents, but people need to know about it – professionals need to know about it so they can direct parents accordingly. Let’s use some of that 21st century communication capability to close those circles, make those connections.

That when a woman makes a complaint about her care, (or feeds back about her care in any way) they are listened to respectfully. That they are made to feel like a human being with emotions with a response that includes words like ‘sorry’ where appropriate. That they do not receive a response that feels like a report to the trust board, a box ticked. That they are reassured learning has been made so no other woman has to suffer the same upsets, the same heartbreak, the same trauma. The same nightmares.

That Language Matters

No mother should ever be told by a panel of consultants their recommendation to ‘withdraw treatment’ for their child while that same panel of consultants stands, mouth agape as the mother lies crumpled on the floor, sobbing as though her heart has been ripped out of her chest. Which it has.

No mother should have to be told dismissively “all mothers feel guilty”, as if that is a salve on their pain.

No mother should have to read in a referral letter inaccuracies about the details of her son’s life and death, and for the GP who wrote it to phone her to apologise with the excuse that they did not read her notes because they were ‘too busy’.

No mother should be made to feel like she is abnormal because of what the trauma of her own life-threatening illness and grief over the death of her son has done to her mind. Instead, she should receive compassionate support to help her understand, and live with the trauma.

This is part of my story, a snapshot of my life and experiences since February 2014. There is nothing that can be done to undo what happened to me, or to Hugo. There is nothing that can be done to bring Hugo back.

But there are things that can be done to prevent other women suffering such unnecessary additional upset and torment.

That is why I would like the National Maternity Review to read, to listen, and to take account of my experiences.

In Hugo’s memory.

Contact Leigh via her website, or Twitter 

What one group of mothers feels the National Maternity Review Team should know

I am delighted to introduce Helen Calvert, mother, play-group leader and campaigner, who positively supports parents and maternity services. Helen's post is number 5 of my #FlamingJune action for #MatExp, to inform the National Maternity Review team of key issues, and she actively sought out the views of parents using social media.  Thank you Helen! 

For the last 3½ years I have been running a Facebook group for mums.  What began as a way of talking privately to my “mum” friends has turned into a group of over 1,500 mothers across the country. 

 A desire to share some of the birth stories from my group was what first drew me to #MatExp and I have since become more involved in the campaign.  As one of her ACTIONS for #FlamingJune Sheena Byrom is publishing a series of blog posts about what the National Maternity Review Team should know, and she asked me to contribute.

 Last week I asked the group “what would you like the National Maternity Review Team to know so that they can improve maternity care for UK families?”  The group has no particular emphasis when it comes to birth plans or feeding choices – the only things we have in common are that we are mothers and we have Facebook accounts.

 What is important to us?  What makes a difference?

• Continuity of Care
• Individualised Care
• Presentation and Provision of Information
• Listening, Respect, Control
• Compassion and Communication
• Collaborative Working
• Postnatal Care
• Breastfeeding Support

 Continuity of Care

This theme was probably the strongest.  Women want to know the people who are delivering their babies, they are unhappy with having to explain their story over and over again and with receiving conflicting advice and opinions from a number of different birth professionals.  Group members talked about building relationships with their midwives, knowing the professionals helping them to give birth and getting to know a small team.  This is currently not the reality, with one mum commenting “I didn't recognise anyone at the birth”.  Some families are choosing homebirth precisely because the homebirth team available is a smaller team and it is more likely that they will know the community midwife who attends their labour.

 Continuity throughout pregnancy, birth and the postnatal period is what women are so keen to experience, but even continuity and consistency whilst in hospital would be a step forward.  One group member explained:

“I feel continuity is a major factor too!  I was on a lot of strong painkillers postnatally and every time there was a new shift they questioned why & wouldn't give them to me until they checked (I was in agony by the time they came around again crying in pain!). Then they’d realise a consultant had ok'd it. I felt like they didn't read notes well & looked at me like I was a druggy! So knowing your patient prior to seeing them could be a good one / better handovers?”

With birth being such a personal and individual experience, and with very few women feeling comfortable discussing their mental and gynaecological health with a stranger, continuity of care can only improve outcomes.  As one woman commented:

“Without continuity it's so hard to build a decent relationship with your midwife, and therefore it's just not easy to be open with them and they with you. I think it's vital for mums.”

 Individualised Care  

As a partner to continuity is the idea of care being provided with the individual in mind.  The current feeling is that there a “boxes” pregnant women are forced into, and once you are in a “box” your care is structured accordingly, with little thought to your individual circumstances, personality, fears and wishes.  An understanding of what is important to that particular family can make a huge difference to their maternity experience.

 “...the midwives there (Ashford Hospital) knew that I was gutted I'd not got my home birth and so they basically recreated a home birth atmosphere for us (dimmed lighting, blankets, left us alone together) it was an altogether lovely experience and didn't feel high risk at all.”

Individualised care is even more important when a family have been told that their baby is seriously ill:

“I didn't fit into any box with my first born due to his antenatally diagnosed exomphalos (and postnatally diagnosed diaphragmatic hernia). Antenatal classes were all relevant but I felt so aloof. Who is giving birth at x? Who is giving birth at y? If complications arise you'll go from x to y so if you want to have a look around y then book that in (then we were shown round hospital x). But poor old me couldn't put my hand up as I was being induced at hospital z. Also in the breastfeeding class, no consideration was given to breastfeeding a baby in NICU. I had to speak to them at the end. And they didn't know much. We didn't fit in. Maybe specific antenatal classes for people in our boat at specialist centres would be better than the ordinary ones?”

Presentation and Provision of Information

Mothers talked about having to seek out information for themselves, and having to ask “am I allowed...?”  Antenatal classes were discussed and it was suggested that they focus more on birth as a normal bodily function and how hormones and environment play their part.

One message that came through strongly was that families would like to be given their birth notes as standard.  It is so important that parents can understand what has happened to them and to their baby.  Finding out that baby was back-to-back, that you had a PPH, that there were complications that made physiological birth unlikely – all of this is important for women and surely it is their right to know these details?

“For me the one thing I'd like to see change is for everyone to be given the option of having a copy of their notes when they are discharged from hospital. In hindsight, I felt like a bit of a failure after the birth and I was so fearful of giving birth again. If I'd known more about what had actually happened I'd have realised that I did blooming well under the circumstances. It was only after support from others on this group that I pushed to get access to my notes and I finally gained a bit more confidence.”

Listening, Respect, Control

Many women discussed feeling as though the midwives had not listened to them – had dismissed their pain, had questioned their stage of labour, even questioning whether their waters had really broken or whether they had wet themselves.  These women felt patronised, belittled and ignored.  There were also examples of women's concerns being dismissed leading to serious health complications for them and their babies.  Feeling as though they are listened to and are in control of their own birth experiences is very important to women. 

“I know both my pregnancies and births were full of complications, but there were still opportunities that I feel were missed, that could have given me more control and allowed me to lead my labours more effectively.”

Compassion and Communication 

The experiences where compassion was lacking were, for me, the hardest to read.  The language used, the way that some women are spoken to, the way that some are treated – at this vulnerable and important time – never ceases to shock me. 

“When I threw up I got told off for not using the sick bowl which was in the bathroom. To clean it up she took the sheet from the bed and swirled it round with her foot and left it all on the floor.”

All women deserve compassion and understanding, but this is never more true than when a woman's notes include the information that she has been a victim of abuse

“The matron I had post-delivery was very damaging - especially as I've been abused and find physical contact difficult. She would literally pinch my nipple into my baby's mouth and leave me not caring when I said it hurt.”

When care HAS been compassionate and communication effective, this is what the family remembers.  Women spoke about their midwife putting them at their ease, being someone they could talk to about anything, being patient and giving hugs and reassurance.

 “I know it’s a day-to-day thing for midwives to see women in labour but it isn't a day-to-day experience being in labour.”

Collaborative Working

There was some discussion of how midwives and consultants work together, and how this can be improved.  Women want to see the knowledge of these two groups combined, rather than used as a tug of war between professions.  What is most concerning is those women who appear to be caught in the middle of professional disagreement:

“My midwife and consultant openly disagreed on my treatment, to the point where the midwife told me she didn't agree with him and he was wrong and she refused to carry out the treatment plan he had recorded on my notes.”

Postnatal Care

Very few women had poor experiences antenatally, but postnatal care is the area most cited as being problematic.  The lack of time that midwives have to help with feeding and to give advice, especially to first time mums who will be anxious about things the midwives might see as “minor”, e.g. how to cope with the cord stub whilst changing nappies.  Many mums felt abandoned postnatally – after all of the preparation for birth, classes and discussions, once baby arrived they were alone. 

Two issues came through strongly:

 ·       The problem of fathers and partners being sent home from postnatal wards

·       The handover between midwives and health visitors

 “On the first night of OUR baby being in the world he had to miss it coz he wasn't allowed to stay.”

“I was solely responsible for baby after going through labour and I needed his support.”

“The handover to health visitors needs to be much slower and more gradual. With my first, I felt I'd barely given birth before I was shunted over to some other service that I had barely heard of and certainly didn't understand. I didn't have any faith in myself and was in no condition to form a trusting relationship with some new random professional.”

Mental health was also discussed, with one mother explaining that the noise on the postnatal ward made it impossible for her to sleep, and this sleep deprivation coupled with anxiety led to postpartum psychosis.  “Someone should have noticed my deterioration and tears.”

Breastfeeding Support

As always, breastfeeding support was said to be lacking.  Families are sent home too soon without a full feed being observed, and are then often readmitted or switch to formula feeding due to weight loss, nipple pain or a lack of understanding of what are normal breastfeeding patterns.

“All I wanted was for someone to just stop and really talk to me and address the issues, someone who ACTUALLY knew what they were talking about in terms of breastfeeding, not someone who was just going to come in to try and patch over the issues and tick me off as job done.”

I hope that these views from a range of geographical areas and different types of women are of use to the National Maternity Review Team.  I hope that ordinary, extraordinary and everyday maternity experiences can help to change childbirth in the UK.

Helen Calvert 2015

Follow me on Twitter! @heartmummy

The power of two: what the national maternity team need to know....

Blog post number four of my 'What the national maternity review team needs to know' #MatExp action, gives us a sobering nudge. The national maternity review team are offered a perspective on how to reduce perinatal deaths. 

Victoria Morgan is currently on sabbatical, developing the 'Every Birth a Safe Birth' methodology. Here she reflects on the MBRRACE-UK Perinatal Deaths and the London Maternity Strategic Clinical Network conferences:  and asks if they shed light on a way forward for clinical quality improvement in maternity care. 

Perinatal deaths in the UK

The Perinatal Mortality Surveillance Report was recently published by MBRRACE-UK (which runs the Maternal, Newborn and Infant Clinical Outcome Review Programme).  At the launch event, hosted by the Royal College of Obstetricians & Gynaecologists, two key findings struck me.

Key finding 1:  the UK mortality rate for babies is 6 stillbirths and neonatal deaths per 1,000 births

“Between 2003 and 2013, the rate and the number of stillbirths and neonatal deaths fell in the UK.  The fall equates to more than 1,000 fewer deaths, despite the fact that the birth rate has risen by 12% in the same period.”

But is this good enough?  The report went on to say:  “If the UK could match mortality rates achieved in Sweden and Norway…the lives of at least 1,000 babies could be saved every year.”

Key finding 2:  local rates vary from 5.4 – 7.1 stillbirths and neonatal deaths per 1,000 births

This variation is not explained by differences in the poverty, ethnicity or age of the mother – the rates have been adjusted to account for that.

This variation is not the variation which is part of any process – the rates have been stabilised.

When reviewing statistics, it is tempting to say the variation is due to factors outside our control – the demography of the population or normal variation.  However, the MBRRACE-UK team has addressed this in their analysis.

A call to improve the quality of maternity care

The MBRRACE team called for trusts with rates that are 10% higher than the UK average to “review both their data quality and the care they provide”.  Trusts were encouraged to get an outside person to help them look at clinical practice by David Field, Professor of Neonatal Medicine and the Perinatal Programme co-lead for MBRRACE-UK, at the University of Leicester.

However, as no organisation had rates matching the lowest mortality rates in Europe – in the Nordic countries (Norway, Sweden, Denmark, Finland and Iceland) of 4.3 extended perinatal deaths per 1,000 births – Prof. Field encouraged all trusts to consider if they were happy with the present situation and whether they had a desire for further improvement.  He asked if we were willing to aim at the Nordic countries’ rates.

London Maternity Strategic Clinical Network

On the same day, the London Maternity Strategic Clinical Network of midwives, general managers, commissioners, GPs, obstetricians, service users and those from education and quality improvement organisations met to learn from one another’s experience about how to improve maternity care.

In 2013, two months after the Network was formed, the CQC maternity services survey results revealed 6 of the 13 worst performing trusts were in London.  Network members chose to believe that improvement was both desirable and possible and have set about making it happen.

User experience

Florence Wilcock, consultant obstetrician and Chair of the Network’s Maternity User Experience Sub Group, is a driving force in improving maternity user experience and has a very personal take on the difference to wellbeing that compassionate care makes to mothers (see her on YouTube).

The Whose Shoes? approach is one Florence champions.  Five trusts have held user experience Whose Shoes? workshops.  The workshops bring together a wide range of maternity service users and staff from all disciplines (including CEOs, heads of midwifery, obstetricians, support staff and parents).  The benefits of the workshops were broad:

• Spending time on reflection helped clinicians and service users understand one another’s perspectives; common themes emerged.
• It helped staff to bond after a recent merger.
• Gave added impetus to change underway.
• The format of hand held notes was reviewed to make them more user friendly for mothers and clinicians.
• A service was provided for women with a previous traumatic birth experience.

You can read more about Flo and Gill's work here! 

The power of two

So what if we could bring the two approaches together?

• The approach to data exemplified by the MBRRACE-UK report, sharing outcomes data in rate form, so that comparisons – in this case, between Clinical Commissioning Groups - can be made; and
• the approach to quality improvement of the London Maternity Strategic Clinical Network - the meeting of multi-disciplinary teams from discrete geographical areas to examine other approaches and implement change to improve quality.

The Northern New England Cardiovascular Disease Study Group are a case in point.  The group saw a 24% improvement in six hospitals’ mortality rates for coronary artery bypass surgery (Peck 2005).    Improvements came through 'examining other systems of care and questioning your own system' (Malenka and Connor, 1998).  In my next blog I shall look at the lessons learnt from this Group and how they might help us answer the question:  how can we improve the quality of maternity care?

Thank you Victoria....

Victoria morgan

You can find Victoria on Twitter @VictoriaRM6

Student perspective: moving evidence into practice

This is the third post in the series 'What the national maternity review team should know' blog posts, my action for #FlamingJune #MatExp.

Hannah Tizard is an exceptional student midwife, and has already made her mark by highlighting the importance of optimal cord clamping at birth, in response to research evidence. You can find Hannah on Twitter, and below read her insightful perspective. 

For the best part of thirty years evidence based medicine has been an important and expected part of midwifery practice and it provides a way of integrating clinical expertise with the best evidence from research. Government strategies (Midwifery 2020) and standards for ethics and practice (The Code, 2015) provide an underpinning framework. UK midwifery sits within the structure of the NHS which is of course bound by governance, hierarchical relationships, policy and guidelines. That is not to insinuate these things are bad, they are necessary and signify our responsibility to safe practice, however, they also often present one of the challenges to moving practice forward in line with evidence.  

Student context

As budding student midwives entering the world of midwifery we also enter the world of medicine, some of us for the first time. For me this is significant and whilst it represents a challenge it is also defines our commitment to provide care in a diverse and ever changing field of work, adapting practice to suit. In my opinion there is no room for complacency, we accept through practice we develop experience but that experience must never over shadow a requirement to continually develop skills and understanding. The way we are taught today will be different from those who enter the profession following us. Indeed that’s part of the appeal – new research innovates, illuminates understanding and highlights improvements for the future – it’s exciting!

As students we are fortunate in our position to be privy to this plethora of new research, we have access to well respected informed lecturers, university research clusters and expensive databases full of papers, some of which cement previous understanding while others challenge practice. We do take for granted the accessibility of knowledge, having the internet at our fingertips, flicking through threads on social media, stumbling across a new article that blows your mind. For us the ‘light bulb’ moments happen on a weekly basis! And we have a desire to share.

Emotion work

We are very privileged but equally bringing new research to the table can pose difficulties. In 2005 Billie Hunter wrote a paper about emotion work of midwives in hospital based settings, it emphasized the importance of colleague relationships in midwifery which provided feedback on individual practice, but also highlighted these relationships were often difficult to manage and a major source of emotion for midwives and students. Hunter (2005) found senior and junior midwives frequently held contradictory models of practice, resulting in competing claims for occupational authority and senior midwives attempted to maintain their position through unwritten rules and sanctions. We are now ten years on but I believe Hunter’s claims are still relevant today, differing paradigms of practice and professionalism create conflicts, cause barriers and are part of the maternity workplace, perhaps they will still be relevant 10 years from now, but I sincerely hope not.

Tenacity

Certainly, there is much going on in midwifery today which attempts to change culture, to give everyone a role, working together with service users and practitioners to promote communication and collaboration rather than foster unhealthy competition and barriers. It is always fantastic to hear about midwives and students helping to change routine, inspire each other and develop more efficient ways of working – social media is the best place to find these stories.

At a recent conference consultant midwife Tracey Cooper discussed her midwifery journey characterised by her determination to challenge boundaries to try to improve outcomes for women. Tracey has been confronted, her practice has at one time or another been scrutinised but Tracey says “using the evidence makes us strong”. I’m always impressed by her ability to use quiet questioning and her advice, which is, when unduly challenged ask politely for the statistics which are proposed to contradict your work, as often there aren’t any!

Effectiveness

Obviously all new research must be independently reviewed and extensively critiqued before being accepted into practice and institutional structures should operate efficiently to ensure the newest evidence is included into policy before it becomes out of date. Practice development midwives must also ensure evidence based guidelines are implemented effectively so health outcomes are achieved. Michie (2005) states a lack of theoretical understanding of the processes involved in changing the behaviour of healthcare professionals may be to blame when this fails. Midwives need to understand why new policies exist, be informed about the evidence and be able to translate that to the women we care for. It’s a complicated process.

Possibilities

Questioning our current delivery of care, day to day ingrained practices and interventions, some of which cause harm and are used without a sound evidence base is of the utmost importance and easily overlooked. Sheena Byrom explores the use of language in care, Amanda Burleigh has challenged the lack of evidence behind the practice of immediate cord clamping and its damaging effects, Denis Walsh proposed birth centre model and Sheila Kitzinger fought against the medicalisation of childbirth. These are just a handful of individuals who have shaped a profession, developed and enhanced women centred care and improved outcomes for women and babies. They listened, questioned and sought answers, they are importantly passionate about ensuring maternity care is protected and delivered with compassion. It only takes one enquiring mind and a little courage to set the wheels in motion, find those who will support you, collaborate and enjoy celebrating achievements, no matter how big or small.

As discussed by Mary Steen (2012) in her paper, teamwork and motivation make systems work and together we can make a difference, enjoying the adventure and having creative ideas and vision along the way helps - “the journey is the reward”.

References

Hunter, B. (2005). Emotion work and boundary maintenance in hospital-based midwifery. Midwifery,21(3), 253-266. doi:10.1016/j.midw.2004.12.007

Michie, S. (2005). Making psychological theory useful for implementing evidence based practice: a consensus approach. Quality And Safety In Health Care, 14(1), 26-33. doi:10.1136/qshc.2004.011155

Midwifery 2020 Delivering Expectations. (2010) (1st ed.)

Steen, M. (2012). Pushing boundaries and making it happen | RCM. Rcm.org.uk. Retrieved 16 June 2015

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

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

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

Women want to be treated as individuals.

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

Women want to be listened to.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

You can follow Michelle on Twitter @QuashieMichelle 

What the national maternity review team should know: action for June

Baroness Julia Cumberlege

The news that a national review of maternity services in England was going to take place, led by Baroness Julia Cumberlege, was more than welcomed. The process is now underway, and information of the progress is filtering through, and more is eagerly awaited. 

I am hopeful for the future, given the growing body of evidence, data from surveys, national policy documents, and feedback from those who use and deliver maternity services. Being an avid user of social media, I am regularly in the centre of discussions about childbirth, and most importantly, I find myself reading blog posts of detailed stories and accounts of childbirth written usually by women who feel compelled to share their experiences. I also read about wonderful maternity care celebrated by staff working in nurturing environments, and other less positive revelations of over-worked demoralised maternity workers, usually midwives. I’ve written before about the ever-increasing opportunities of social media, and the virtuous circles that can emerge when childbearing women and their families, and all those involved in providing maternity services come together to enable change. But action is needed, and those members of the maternity review team, tasked with collating evidence and opinion, will be looking for ways to enable this to happen with efficiency.  There are processes in place for individuals and organisations to provide feedback to inform the review process, and the team are planning more ways of engaging with interested parties. 

So, in the month of June, I invited guest posts for my blog from individuals who felt they have information or ideas to offer the team. The first post was by the dynamic duo Gill Philips CEO of Whose Shoes?, and obstetrician Florence Wilcock, who together have developed an ever expanding and inclusive #MatExp dialogue via workshops and social media. Gill and Flo are working so hard to try to influence the way maternity care is delivered....here is a reflection of their first year! 

 

WHAT ARE FOLKS SAYING?

Then came the rest... one post by mother Michelle Quashie, who had a vaginal birth after Caesarean section, inspirational student midwife Hannah Tizzard's views of evidence and practice, Victoria Morgan, who is developing the 'Every Birth a Safe Birth' methodology,  Helen Calvert asked lots of mothers what there views were, mother and campaigner Leigh Kendall, who tragically lost her baby boy Hugo aged 35 days, and Natalie Meddings, doula, has given us an insight into her antenatal group choices for place of birth! 

If you would like to write a post too, please contact me here and I'll get back to you....

What the national maternity team should know: action for June #MatExp

The news that there was to be a national review of maternity services in England, led by Dame Julia Cumberledge, was more than welcomed. The process is now underway, and details of progress is filtering though.  So, in the month of June, I am inviting blog posts from individuals who feel they have information to offer the team. I hope this will be a helpful resource for all. Read here for more information.

To start us off, who better than the originators of #MatExp…a grassroots community established to maximise opportunity for improved maternity care. Gill Philips and Florence Wilcock started the campaign. Gill is the creator of Whose Shoes?, and a chapter author for our book, The Roar Behind the Silence: why kindness, compassion and respect matter in maternity care, and Florence Wilcock, is an obstetrician and clinical leader.  

Please welcome Florence and Gill...they wrote the post below!

Hi!

We would like to kick off Sheena's June blogging series with a strong call for the Maternity Review Team to engage with our fabulous #MatExp grassroots community. We need to build on all the amazing work that has been happening over recent months through this passionate inclusive group.

So what is #MatExp and how did it come about?  Well, Florence wrote about it here.  

AND

we made this short video when, due to the phenomenal grassroots energy it had inspired, #MatExp was included as a major campaign in NHS Change Day, 2015. 

Users of maternity services came forward not only to join the various actions but to initiate and lead them themselves. You can check out the actions here but they cover everything from appropriate language, postnatal support, best practice and experiential learning – including many male obstetricians spending time in the lithotomy position!

Florence is a passionate obstetrician and clinical leader, who was asked by the London Strategic Clinical Network to find ways to improve maternity experience in response to a poor CQC report identifying that six of the seven worst trusts in the country for maternity experience were in London. Florence approached me, Gill, the creator of Whose Shoes?,  to co-produce some challenging Whose Shoes? maternity scenarios and run a series of workshops, getting users and professionals and all other interested parties – NCT, MSLCs, everyone! - to work together as equals and come up with imaginative solutions. 

With support from NHS England, five very successful and fully subscribed workshops were held across London.

 Queen’s Hospital session in action

The combination of the face-to-face workshops and the social media network have been extraordinary, with lots of overlaps. For example Helen Calvert and Leigh Kendall, two of the mums now helping lead the campaign, came down to London to join the workshops and they also contributed to the #MatExp NHS 6Cs webinar.

The Whose Shoes? Workshops, supported by a full leadership and facilitation toolkit kit developed in partnership with the London SCN and NHS, are now planned at other London hospitals and spreading to other parts of the UK, including a session in Guernsey at the end of June. There is a lot of cross-fertilisation of ideas between localities and between hospitals, with a strong emphasis on building relationships and collaborations. Each workshop culminates in pledges and a local action plan, formulated by the people at the workshop and encapsulated in a powerful graphic record. Inevitably the themes are similar between the different sessions but with a strong local emphasis and most importantly local ownership, energy and leadership.

It would be easy for the NHS Change Day campaigns to lose momentum after the big day itself, (11 March 2015). #MatExp has done the opposite, continuing to build and bring in new people and actions. #MatExp #now has 110 million Twitter impressions. We have just finished the '#MatExp daily alphabet', a brilliantly simple idea to get people posting each day key issues related to the relevant letter of the alphabet. This has directly led into the month of action starting today....see below. 

Mother Helen Calvert set up and ran a survey of health care professionals. She had 150 responses within about 10 days and analysed and reported the results – an extraordinary contribution.

We have a vibrant Facebook group (please apply to join) and the brand new website, set up by the #MatExp team of mums who are incredibly focused, working long hours - all as volunteers. We are all absolutely determined to keep working together to improve maternity experience for women everywhere. In the month of June we are calling for ACTION, starting TODAY on 1st June, and we have lots planned-including Sheena hosting this series of informative blog posts...

Come and join us!

Gill Phillips and Florence Wilcock

The dark side of Social Media

It’s been a long time since I have felt so distressed about work related issues. The bleakest moments are known by so many, as they are detailed in Catching Babies. And I’m not an apprentice when it comes to being in the media spotlight in a negative way, indeed I wrote about it for the March edition of Essentially MIDIRS.

Lots of you will know that I am also an advocate for social media and the amazing benefits it brings, I regularly give talks on the subject and have written about it extensively.  During the sessions and in my written work, I always mention the ‘dark side’, when social media has a negative impact, and how it's important to protect yourself. There is an abundance of clear guidance  to help with this.

But nothing prepared me for the events recently, and I am still processing the effects it has had on me personally. I won’t be mentioning any names. Firstly, I don’t want to draw attention to individuals who make it their life’s work to damage the lives of others. Secondly, I am clear about my professional boundaries, and personal integrity. But for those who continue to intimidate, harass and bully individuals and professional groups, and to undermine evidenced based models of maternity care, I have one message.

I have wobbled, but your actions have made me stronger.   

Postscript:

After writing this post, my supportive and inspirational friend @JennyTheM sent me this. What more can I say?

Another attack - when will it stop?

6th November 2015

Those of you who know me won't need to hear this. But for those who don't, please let me tell you that I've never bullied anyone in my life, let alone bereaved parents. I don't know what pleasure individuals get from being slanderous and cruel to others - it's beyond me. I suppose it's fuelled by the same emotions and hatred that starts wars.

Ignoring libellous allegations is all I can do, but I am saddened and perplexed how my name can be used maliciously with no recourse. It seems unjust, but I will not respond. I will not succumb to negative exploits with more anger, instead I will show compassion - which is more than the pity I feel. That's not to say I don't suffer in my silence. 

I am privileged that my career has been totally dedicated to serving others, and for many years when working in the NHS, my role was focused on those in need, bereaved, or traumatised. I retired from my employed midwifery position with the NHS in 2010, to study, travel and to help with my grandchildren.  Because of an incessant drive and passion to improve maternity services, based on decades of experience, I continue to work mostly voluntarily, supporting and encouraging maternity care workers, and parents.  I gift my time and energy to others, and I love it. 

Nadia and Paul tragically lost their beautiful baby son Ellis, when he was stillborn. Nadia sent me this, earlier this week.

Compassion, love, kindness and respect are the foundations of life. 

May, 2017.

She's done it again. Why does anyone have so much hate of someone they don't know at all, enough to spend time writing lies and vitriol? It is bizarre. This time I have declared the attack on my Facebook wall, and I've been absolutely overwhelmed with positive comments, support, and love. 

So of course I won't respond, there's no point.

I will continue to spread the sunshine.