Andrea’s Diary

The Caerphilly Birth centre is a special place in Wales. For the past five years it was operating as a small obstetric unit then it closed, to re-open as a midwifery led Birth Centre in February of this year. They have 29 midwives, who operate pre and post natal clinics for women giving birth in the Birth Centre but also in other units in the area, including the Royal Gwent Hospital in Cardiff.

So far, there have been 140 births in the Birth Centre this year, well above the predicted number for the first year, and their results have been outstanding. Only 11% of women have had to be transferred to the main hospital and they have reduced their use of pethidine to only 7%. More and more women are also choosing a homebirth with the midwives - up to 10% at present and rising.

They have been told they will have to drop staff numbers by about 7 midwives as they are overstaffed. Naturally no-one wants to move - the midwives in this unit love their job and are really enjoy the births they are able to facilitate - all very normal.

At the Royal Gwent, the picture is very different. This is a very high tech unit with high epidural and caesarean rates. They are chronically short staffed, so as an interim measure, “Caerphilly midwives” (as they are labelled by Gwent staff) are being seconded to work shifts there. None of the Birth Centre midwives like this arrangement because they are under constant pressure to work in non woman friendly ways and to justify their reluctance to adhere to the strict protocols in the unit. Whilst these midwives shouldn’t be subjected to the bullying they are obviously getting, they could re-frame their shifts in the Gwent in a different light - as an opportunity to show their colleagues there is another way of working. They are unlikely to be sacked, so this gives them enormous power to state their position clearly and to buck the current system. This may be a very uncomfortable and unfamiliar role to adopt, but it could be the making of them…… they should recognise their talents and start trumpeting their special qualities that enable normal births to occur even in a rather hostile, medically dominated setting. Now there is a real challenge - are they going to be up to it?

The news of the release of the hostages in the Moscow Theatre using a gas to subdue the terrorists has been everywhere these past few days. The death of 115 hostages, with another 150 in a critical condition due to the gas has raised a lot of questions and the Russians have been reluctant to reveal the details of the gas that was used.

Today the news is that its general composition is now known - it is an ‘opiate’ drug, chosen because it that sedates and eases pain. The Americans have identified it as Fentanyl. The Russians claim that it was meant to put people to sleep but not to kill them as has happened.

When I read this I couldn’t help making the leap from this poison gas to the Fentanyl and other opiates given to women in labour. They too are supposed to ease pain but are really sedatives. They also have unpredictable results, with some women hardly being affected at all and others almost passing out after a standard dose. People will say that the dosages used in Russia bear little relationship to the amount given to labouring women, but can we be sure these labour drugs are as innocuous as claimed? The fact that research is limited just proves that few people are interested in investigating the safety of drugs given to the unborn baby, it does not prove there is no adverse effect.

It may sound rather harsh, but this catastrophe in Russia may be useful for those of us who are trying to get reform of birth practices in the west. I hope that someone exposes a similarity between the use of this “poison gas” and the drugs that are routinely given to many women during labour and birth. If women knew the risks they were taking with their own health, let alone the health of their unborn babies, I truly believe they would avoid taking opiates (e.g. pethidine, diamorphine, Fentanyl) of all sorts, either as a straight medication or in an epidural mix. Perhaps the stark messages of all these unnecessary deaths in Russia will alert the rest of us (again) to the dangers of medications during labour. It’s perhaps a long bow to draw, but you know where my passion on these issues lies…..

What a day I had yesterday! A very long 7 hour train trip starting at 6.00 a.m., across England from the North East to Wales, so that I could speak at a Conference outside Cardiff in the afternoon organised by the Bro Morgannwg NHS Trust.

There has been severe storms the day before, which caused havoc on t he roads and with train services, and the program had to be rearranged and some speakers had trouble getting there. This was fortunate for me, as I was only able to hear the afternoon session myself. Luckily, Mo Harris, Research Midwife from Derriford Hospital had her presentation changed to the afternoon and this was one presentation I really needed to hear.

Mo was reporting on a study that she has undertaken on “one to one” midwifery in practice. With perimission from all concerned, she positioned a black and white video camera high in the corner of several labour wards and made continuous recordings of a number of labours. In all cases, the midwife was responsible for only one woman at a time, meaning that she was able to stay with the labouring woman throughout the whole labour and birth - the “gold standard” that is held up as the ideal situation for midwifery and midwives.

Each video tape was transcribed and the activities being undertaken in each minute were tabulated, then analysed. Mo was able to show us video clips, some with sound, to explain her findings, and they were astounding.

All the women were on the bed and all had the baby’s father present. Some had another person as well, often the woman’s own mother. The midwife was most often seen in the corner, writing up her notes on a table that meant she had her back turned to the woman. Some women had epidurals and one had severe problems that mean she needed special care and close attention. The analysis showed that midwives spent very little time actually “with woman”, even when they were in the room. Most time was spent writing up notes. The midwife allocated to the woman who required close monitoring because she was at very high risk spent 43% of her time out of the room, taking breaks, talking to other midwives, or performing other unrelated tasks!

Several scenes showed the reactions of the fathers - overwhelmed and unable to cope. One woman is literally tearing her hair out (?transition) - the midwife is out of the room and the father puts his head down on his hands, clearly distressed. On several occasions, when the monitor revealed the baby’s heart rate dropping, the midwife still failed to interact with the woman or her partner - just made a few comments from the corner where she was writing up her notes. On one occasion, the woman’s own mother goes for help, when the monitor is registering a low heart rate and the midwife is (again) out of the room. Conversations with colleagues, such as the doctor when he is called in, take place in the corner and excluded the parents. If the handover occurred beside the bed the woman was included, but this was uncommon and the videos showed a huddle in the corner with the woman straining on the bed to hear what was being said.

What does this study tell us? It is very clear that midwives are not interacting with women, not comfortable providing physical support and poor at communicating with the woman and her partner. It is clear that women are still being confined to bed, that they find epidural insertion very stressful and that the needs of fathers are being completely overlooked.

I was shocked and very disturbed by its content and felt desperation that we could ever change this around without a massive change in the culture of midwives and midwifery. Mo still has this study going on and has now filmed in 9 maternity units. She has also taped doctors at work. In summing up her presentation, Mo suggested that perhaps we do need to employ doulas since midwives clearly don’t have time (and perhaps the willingness) to provide the personal, up close comfort that women need during labour. She also wants the system to be overhauled so that midwives don’t have to document everything so closely, or could do it in a more efficient (and less time consuming) way.

I was pleased I could leave the participants of this Conference with some images of a very normal, woman-centred active birth - if we had finished with Mo’s presentation I fear that we would have all gone home is a huge depression. I hope to find out more about this study and that the tapes can be re-jigged somehow to make them into training materials that can be used to sensitise midwifery managers and the midwives themselves into reviewing their practices. My god, it is very much needed!

I’ve been in Hull this weekend, presenting an another Active Birth workshop for midwives from this area and nearby units. Amongst them were two Dutch women and a New Zealander, all enrolled in a Midwifery Course in York. It is always a pleasure to have midwifery students in workshops as they bring a fresh perspective and because two of them were Dutch, and one was pregnant and planning a home birth (of course), they asked lots of useful questions as well as highlighting the cultural differences between The Netherlands and the UK.

The Hull Maternity Unit is being combined with the Castle Hill Maternity Unit in about 6 months. They are only a few miles apart and combining them will create a unit that handles about 3,000 births each year. A Birth Centre is part of the plan and there is some concern about combining the two staffs and forging new workable policies that everyone can be happy with. Castle Hill has been doing water births, for example, and the Hull team have been more used to technology.

The workshop has given everyone a chance to review their basic attitudes and philosophy and as there were several key senior midwives in the group, hopefully they will have caught the enthusiasm of the others for developing a very midwifery orientated unit and take the lead in establishing the new unit’s ways of working. I felt very positive at the end and felt that many issues were raised and explored constructively.

One concern had been the lack of interest amongst midwives for working in the Birth Centre. Nine midwives are needed and to date only 4 have expressed an interest in working there. I discussed this issue with Julie Green, the Practice Development Midwife and suggested that she talk to the students that she lectures and perhaps set up a programme for new graduates to join the Birth Centre staff. Many students are not completing their training because they are disillusioned by the gulf between their theory and practical experience. If they could come out of their Courses and join a supportive staff in a Birth Centre where they could immediately reinforce their passion for true midwifery, many might either stay on to complete their studies or not leave as soon as they graduate. I hope she is able to consider this suggestion. I know that such a program exists at St George Hospital in Sydney where new graduates are specifically sought for the staff at their very successful Birth Centre. Surely it could work in the UK as well?

On October 18, the Australian Government has announced at that the National Institute of Clinical Studies has negotiated a license to provide free access by all Australians to the data held in the Cochrane Library. As most people working in the field of maternity will know, the Cochrane Library is THE repository of Randomised Controlled Trials concerning many aspects of health care. It began, over 20 years ago, by looking into maternity and obstetric care because this was the area of medicine least evaluated and most in need of reform. Since then it has expanded into other areas of medicine.

Although only 10% of interventions and treatments in medical care have been assessed, it is expanding quite quickly and there are currently 1,500 completed reviews and another 1,000 in progress. 60 reviews are being added to each quarterly update.

This is an initiative that will enable consumers as well as health professionals to keep as up to date as possible in terms of appropriate care. It is particularly relevant for those of us concerned with birth, because as a normal process and a wellness condition, it flourishes best when interventions are kept for those few mothers and babies who need them. The old excuses of meddling to “save the baby” and installing routine procedures without any or adequate testing should now be over. We are starting to amass the science - now all that is needed is to use it!

The current issue of “The Practising Midwife” contains an interesting report on the pay negotiations being undertaken by the Royal College of Midwives on behalf of midwives across the UK. The message from the RCM is that if you pay midwives more, they will stay in work. I don’t think this is the real issue at all. I have written to the Editor in an effort to get this issue on the table:

Dear Editor,

The suggestion being made by the Royal College of Midwives that higher pay rates will result in more midwives either staying in their posts or returning to work ( Practising Midwife October 2002) is only a small part of the story. As I travel around the UK presenting workshops, I hear many stories from midwives that clearly indicate that it is working conditions that is the real issue.

Midwives tell me they want flexible working hours, more part time work and more family friendly shifts. However, what they find intolerable and frustrating is not being able to practice their midwifery skills and are dismayed by the resultant poor care that women are receiving. It is a Catch 22 situation: the rising rates of interventions are leading to a loss of midwifery skills and as midwives resign in disgust or despair, the shortages of staff are forcing those left to work as nurses, rather than midwives.

The Royal College of Midwives should address these issues as well as pay rates. I note that those hospitals that do have good team or caseload practices, midwifery-led units and high home birth rates have few vacancies compared with the centralised, high tech units. Perhaps training courses for Midwifery Managers, more direct talks with employers (Trusts, PCT etc) and Government would help to highlight these problems.

I fear that midwifery in the UK is in rapid decline, and that unless these basic issues are tacked, midwifery, in its traditional form, is likely to disappear.

Andrea Robertson

Not sure if they will print it and I will be interested to see if anything results. Perhaps I need to write an article about this…. “observations of a visiting Aussie workshop facilitator”!

Anne Cifuentes, a midwife/childbirth educator from Queensland mailed me today. She had been contacted by one of the women from her classes, seeking another copy of an article she had been given at her prenatal classes. This is what she said:

“I must tell you a story that I know will delight you. The other day at work, I received message to ring a woman who had given birth to her first baby at Allamanda 2 years ago. Susan had attended the prenatal classes with her first baby and was now pregnant again and due in 2 weeks.

When I rang her back, she was so pleased to here from me and we had a lovely chat. The reason she wanted to speak to me was to ask for a copy of your article “The pain of labour a time for growth”. Several years ago I sought your permission to hand this article out at the classes and I remember you saying, “Gosh, I wrote that years ago Anne”. Well, it may be a few years old now Andrea, but the message it carries is still as true and as valid as the day it was written. Susan told me that your article helped her immensely as she prepared to have her first baby and that she had passed it on to many of her girlfriends. Like many things you lend to people, she didn’t get it back and wanted to read it through again before she had her next baby.

I posted the article to her the next day and expect to see her arrive in the unit any day now. Those are the little inspirational moments we all need from time to time and I am sure you are smiling now.”

I was smiling and it made my day. I am always impressed by the Dutch midwives mantra “if you want to keep birth normal, you have to have the pain” but also know that women will need more than this to really feel confident that they can bear the pain of labour and even benefit from it.

The article that Anne mentioned is very similar to this one, which is an expanded version that I wrote a bit later. If anyone wants to copy this and hand it out in their classes - please go ahead. You can print it off from our web site.

I have just been catching up on my September MIDIRS Digest - breakfast reading when I am eating in Hotels during my travels. It contains the usual array of research articles but there are also several original pieces focussing on the state of midwifery in the UK.

These comment on various aspects of midwifery practice and lament the fact that it is being completely dominated by medicine and is in a gradual process of decline, with extinction on the horizon. Many people in other countries look to the UK as an example of midwifery at its best, yet the reality is completely different. The profession is supported by Government laws (for example, a midwife must stay with a woman if she decides not to go to hospital for the birth, even if it is against the midwife’s advice), regulation (the Nursing and Midwifery Council oversees many regulations that strengthen the midwife’s personal practice and protect her standing), Government enquiries such as the Winterton and Cumberlidge Reports, and enjoys a high profile in the community. Yet each year the number of births in the sole charge of a midwife is falling (now around 68%, down from 75% five years ago), the caesarean section and interventions rates are rising rapidly, midwives are in chronic shortage (some units are 30% down on the numbers they need) and many students fail to complete their education, dropping out in despair.

Lots has been written about this - books, in fact. It does concern me though, that if this si the state of affairs in a country that has such a strong midwifery culture, how will other countries, where there are no supportive laws and regulations fare? In Australia we are fighting to get a new style of maternity care (NMAP) adopted as policy in a country where we have 7 Governments to negotiate/fight with, no legislation that support or protects midwives and no overall regulations that govern and shape midwifery practice. I hope that this lack of regulation will prove a strength rather than a downfall. In New Zealand, midwives managed to get themselves well positioned from a similar base as Australia, so I will remain optimistic.

Britain is a country that is often described as a “nanny state” and there is no doubt that life here is closely monitored, controlled, organised, regulated and dictated. Everything is covered by some rule or another and people are often treated as incapable - signs warn of potential disasters (“beware uneven surfaces”, “mind the gap”) apologies abound (“we apologise for the delay of 3 minutes in the later running of this train”, “we regret any inconvenience caused by this alteration to your …….” etc)
and there is an air that the taking of personal responsibility is a thing of the past as “someone” will take care and provide for you. Apologising for the lack of services now replaces the actual service itself.

Perhaps this is partly why the health care system is in such crisis and that midwives are falling behind. By over regulating and offering to “take care” of people from cradle to grave, the State has effectively stifled initiative and produced a population is prepared to be cowed in return for not having to think for themselves. This is no doubt a harsh and simplistic view, but I despair when I see the lack of action by midwives and their inability to get themselves organised on a national level to address issues of primary importance to their existence. There is a lot of talk about these issues, such as the excellent articles in MIDIRS, but where is the fervour, passion and collective action to change things?

Perhaps it will take a major crisis ( the current situation does not yet seem to be bad enough) to precipitate collective action amongst midwives. Yet I fear that the culture amongst women here, the vision of themselves as “poor things” that need to be looked after, the prevailing view that “someone else” will fix it and their lack of personal backbone will spell disaster and that midwifery may yet be lost. I feel like shaking the lot of them and telling them to wake up before it is too late!

After few weeks in the UK, I always seem to feel like this - frustrated and amazed. You don’t realise how different the Australian culture and way of thinking is until you stand it beside the British way of life!

I had a wonderful phone call this afternoon from Julie Green at the Hull Maternity Unit. She is one of the Midwifery Managers there and came to an Active Birth Workshop that I ran last May in Hull. She phoned to confirm some details for another program I am presenting there next week and she told me about her wonderful holiday from which she had just returned.

The last two weeks she had spent in Uganda, working with the midwifery staff in a hospital that catered for 5,000 births each year. She told me that she had learned an enormous amount and had put everything that we have explored in the Active birth workshop to use. She was astounded to see how easily women gave birth when left to do it themselves and it enabled her to see how far we had strayed from “natural” birth in the west. The baby’s heart beat is rarely listened to, yet the babies have high Apgar scores. Meconium abounds but is left to drain and the babies do fine. Women deal with the pain without drugs and “get on with it”. They only had 3 delivery packs with which to manage these 5,000 births, so Julie said to not worry - all they needed was a sterile razor blade, which were in plentiful supply.

Julie was surprised that episiotomy was very commonly done (with those razor blades!) and that women were giving birth on the beds. She hopes that she has encouraged them to avoid doing episiotomies but the bed is another problem - giving birth on all fours, or on a mat on the floor was seen as a retrograde step because women didn’t want to give birth “like they do in the villages”. She showed them how to encourage a left lateral position for birth and hopes that this new fangled idea will be seen as the “next fad” from the west and therefore desirable.

Western medicine has done such a lot of damage to traditional birthing practices around the world. It is heartbreaking seeing women in these developing countries trying to emulate our fancy hospitals, with their limited or non-existent equipment and supplies. Yet they have a lot to teach us. Seeing how women given birth especially in those conditions proves that nature has got it right and that we meddle at our peril. The poor outcomes that do occur in countries like Uganda are the result of things like poor transport to hospital, poor nutrition, and local cultural practices that are not always helpful.

I don’t think we have much to boast about in the west. Our birth practices are appalling by most standards and we could learn a lot from women in these developing countries. I am glad that Julie has had the chance to see for herself how it works and that I have a colleague who can spread the word both here and in Uganda. Good luck to her!

The state of prenatal classes in the NHS is, on the whole, pretty poor. Many of the midwives in the group I am facilitating here near Nottingham talk about programs of 2 sessions of 3 hours plus a labour ward tour! Most classes are for women only, although the few evening couples classes that are offered are very popular. There have been some attempts at innovation, such as aquanatal programs, drop in programs for teenagers (not very successful) and weekly, shorter sessions of a “rolling” nature.

Fathers seem to be regularly excluded. The typical program is 3 or 4 sessions: one on labour, another on “pain relief”, one on “infant feeding” (that always includes bottle feeding so that women can make an “informed choice”) and another on post natal. It is run as a lecture session with questions at the end.

The midwives are usually told they have to “do the classes” , usually with no training, or even warning in some cases. Many said they didn’t like doing them, but it was part of the job and they were obliged to put in appearance. In this group of 30 midwives there were only a few who had expressed any real passion or even interest in childbirth education - most did it as a duty, with reluctance.

On the other side of the equation, the women often only came because they were paid to come. Apparently women can get paid time off work to attend pregnancy care, and it seems that some take full advantage. Stories were told of one employer who puts on a company bus to take the women to their antenatal clinic check-up, aquanatal classes, parent education etc and with a bit of organising women can get 16 paid hours a week off work for pregnancy related appointments!

I get the feeling that here, although there is recognition of the role of education and some midwives are keen and anxious to do a good job, the model that I am proposing is so far ahead of their thinking that it will be a struggle to make any changes. I can see the reactions: “there is no time for this group work; how will I fit this into the current program; the women won’t want this; I don’t want to have to deal with fathers” etc. At the end of the day I get the strong impression that many won’t want to be bothered with making any changes - too much like hard work.

Parenthood education is so important for changing attitudes, increasing confidence in parents, developing their skills and giving them hope - if the health professionals they meet are just going through the motions, it is no wonder that so many expectant parents either fail to turn up or don’t come after the first session. A wasted exercise all round. I will try and enthuse them today……