Andrea’s Diary

Yesterday was a long one - we finished the Active Birth workshop in South Shields (Newcastle) and then I travelled for 3 ½ hours down to Kirkby in Ashfield (sounds very quaint!) between Derby and Nottingham. I certainly feel I know UK trains very well by now!

This will be a Teaching Skills program - it will be interesting to see who is in the group and what they are currently doing.

Today’s group are being primarily sponsored by South Tyneside Hospital, near Newcastle. We do have midwives from Dundee in Scotland and Sunderland as well, but most are local. The hosptial here is about to be renovated and the unit will move into temporary accommodation for 6 months while this is done, but they are looking forward to a nice new unit with all the mod cons, where they hope they can get midwifery care well set up.

Several issues came up today - especially the use of Moxa Sticks and moxibustion to turn breech babies. One of the midwives is 34 weeks pregnant and her baby is breech, so it was a very pertinent conversation. I explained how to do moxibustion and that this is something that parents do for themselves - one of its advantages. The success rate (70 - 80% successful in turning babies) makes it well worth a try and the fact that the baby does the work itself reduces the risks and increases the likelihood that the baby will stay that way once turned. It works by stimulating fetal movements and takes about 6 - 8 hours to achieve success following the heat treatment to the outside of the little toes. If anyone wants specific instructions, click HERE for the full story with diagrams, pictures, the research etc.

Given that most breech babies are born by caesarean these days, it sems to me that trying everything to get the baby to turn around is worth doing so that surgery could be avoided.

More tomorrow - then off to Nottingham for the weekend “Teaching Skills” workshop.

Yesterday I had a look around the St Thomas Maternity Unit, or “Birth Centre” as they call it. There are two corridors in the labour ward area - one is the regular labour ward (which they now call the “Birth Centre”) and the other houses the “Home from Home Centre”. It all looked very pretty in an institutional kind of way and that the hospital has lost the plot.

First, they have no idea what a Birth Centre really is. What they have built (and moved into 6 weeks ago) is a regular hospital. Yes, it is painted and bright (primary colours!) and that is certainly a change from the tired, dreary, worn out facilities most women in Britain have to put up with when they have baby in hospital. Apparently other hospitals in London that are being renovated are also calling their maternity units “birth centres” and while I agree they are centres for birth, by debasing the accepted definition used by the rest of the world it seems they are trying to hoodwink British women into thinking they are getting low tech, woman centred care, when in fact it will be “business as usual”.

The “Home from Home” unit is also another con job. It too looks just like a hospital - 12 birth rooms opening off the long corridor, 2 pool rooms, and a yet to be established “common area”that will have lounge chairs and murals on the walls. The decor is “hospital functional”and the only concession in the labour rooms is a sofa bed. The Health and Safety people decreed that women could not use that for either the birth or a post-partum cuddle with the father and baby because it “couldn’t be cleaned” (the mattress is not covered in plastic) so the women must use a regular hospital bed with its electronic controls. Each room has an ensuite, with a small bath and toilet and the shower is over the bath. No way women can move about in the shower and impossible to get the father in comfortably for support. Yes, they are reasonably low tech - no CTG machines, epidurals or forceps etc, but there are Entonox points in the bathroom and beside the bed and the rooms are fitted with scavenger units to suck out the Entonox so that he staff don’t get over exposed to the nitrous oxide. Would you believe that they use Entonox for women in the bath, almost routinely? Pethidine is also available if requested/required. They do have big windows and the view of the Houses of Parliament and Big Ben a few metres away across the Thames would be fantastic on a fine day.

This area is very far removed from most people’s idea of “home”. Belinda Ackerman, the Clinical Midwife Specialist in charge told me that they are hoping to get lots more home births happening and are aiming for 17 community based teams of midwives to provide this service. They can only staff 8 teams at the present time, so home births are likely to be few and far between,. Meanwhile women will come in and have a fairly standard hospital stay in this “Home from Home” area. Belinda said that the whole unit had been designed by administrators/architects who did not consult the staff about what was wanted (nothing changes, does it?) and there are a lot of furniture and some decorating they want to make. I will be interested to see how they are getting on next time I visit.

Some of the midwives at St Thomas will not, of course, welcome any criticism of their wonderful unit. There is a distinct culture amongst the staff there - and they believe that they are definitely the best. I was surprised at the closed minds of many of them and the almost violent reactions I got on some of their workshop evaluations - they don’t like being challenged! The “God syndrome” is alive and well amongst these midwives! I think they should get out more, and have a look at how care is provided in the smaller units and real Birth Centres, both in Britain and overseas. Are they scared they won’t measure up, I wonder? Everyone else in the workshop group were very positive in their feedback and welcomed the chance to review their own practice and consider new ways of looking at things. I fear that you can change the decor in a hospital but unless you change the staff attitudes, women will get the same old care and end up with the same old rates of intervention as ever. St Thomas is certainly a midwife centred, not a woman centred unit.

I am doing a workshop at St Thomas’ Hospital at the moment. It is right across the river from the Houses of Parliament and Big Ben and many of the rooms boast a marvellous view. As usual in these London groups, there is a very mixed bunch of midwives and many have overseas experience. One has just spent two years working in Cambodia, another has worked in Dubia for some time, we have a Danish midwife, a French yoga/exercise teacher and a couple of Aussies and Kiwis.

St Thomas’ has recently renovated its maternity unit and as part of the refurbishment, has opened a “Home from Home” birth unit. The idea of birth centres is finally catching on in Britain and a number of hospitals have opened “birth centres”, which has ignited a debate about just what constitutes a “birth centre”. The accepted definition is that it is an autonomous midwifery unit, offering midwifery care for low risk women. No interventions are offered or allowed and if a woman wants to use pain medications during labour she is transferred to the regular labour ward.

It seems that this definition is being loosely applied in Britain and that women will be able to have pethidine and entonox in birth centres and monitoring may also be available. Today I will have a look at the St Thomas’ unit and I will check this out. We must keep the concept of midwifery care pure and unadulterated and birth centres should uphold these principles. I will be asking some specific questions!

Yesterday I was a speaker at a Home Birth Conference in Chichester. The program was titled “Home Birth - Empowering Women” and there were a number of speakers, including Andrya Prescott, independent midwife (”Birth - A Normal Process”), Jill Hutchings, NHS midwife (”A Parents Guide to Homebirth”) Andrea Simons, obstetrician (”Getting Risk into Perspective”) and Jonathan Montgomery, Professor of Health Care Law (”Does the law empower women?”). My presentation was entitled “Empowering Women to Keep Birth Normal”.

There were about 130 people in attendance, a nice mix of parents, midwives, childbirth educators and students. All the presentations were well received and the day was voted a success by everyone.

Several interesting issues arose during the day. Andrew Simons had some intriguing statistics from the hospitals in the counties of Kent, Sussex and Surrey in the south of England that showed considerable variations it the numbers of homebirths within each region. Brighton had a home birth rate of 10%, whereas most hospitals reported around 2%. There were other figures that showed the vacancy rates for midwives in each unit, and there were large variations from 26% down to 1%. When the two tables were matched up it was clear that those hospitals that had the lowest rate of home births were also the ones with the highest vacancy rates for staff and that those units that provided good midwifery services had few vacancies. It was a stark reminder that midwives don’t want to work in units that are medicalised, non midwife and woman friendly and that offer few choices in the way services are provided.

There were also some very good data on the safety of homebirths. Examination of the birth outcomes for mothers and babies for planned homebirths showed that the risk to the baby was extremely low and that women also had a much safer time at home. Of course, this is to be expected, since if the system is working properly (i.e. midwives are well supported in their decisions to transfer) then those women and babies at risk should, on the whole, the identified in time to be transferred to hospital for appropriate care. Unplanned homebirths, however, proved very risky indeed, for both mothers and babies.

The figures don’t, however, tell the whole story because included in the unplanned homebirth statistics were both those who gave birth unexpectedly before arriving at hospital as well as those who plan to have a birth at home without professional help. If a woman had not booked a home birth, she was deemed to have an “unplanned” homebirth. It was clear from the table showing each hospital’s outcomes that in one unit, there were a large number of “unplanned” homebirths, many more than “planned” homebirths, and yet they had good outcomes. It was not possible to find out why this was the case, but I suspect that in this particular area, midwives don’t ask the woman decide in advance where she wants to give birth, but instead wait until the labour is in progress to make that decision. A birth that occurs at home under these circumstances would be classified as “unplanned”.

Not booking women for a birthplace early in the pregnancy but waiting until the labour to make the final decision is a very good way of boosting home birth rates. The Albany Practice (part of Kings Hospital) has certainly proven this and boasts a 43% home birth rate, easily the best in the UK, and this has been achieved with a caseload of whom 85% are classified as “high risk”. There are lessons to be learned from this approach, and ones that would not only enable better choices for women to be offered, but ones that would enable midwives to get increased job satisfaction. A solution to the chronic shortage of midwives, perhaps?

The first day in the Dundee workshop was surprising in some ways. The issue of language was a theme I raised, as usual, and it was quite an eye-opener for the group. Some new terms came up in general discussion that I haven’t come across before.

Here, midwives talk about women feeling “sore” during labour e.g. - “when she’s starting to feel sore, we get something for her” and “we tell women they will feel sore during labour”. I have yet to find out just what level of pain “sore” refers to, but perhaps that will come today.

One midwife described the labour ward as a “lock down area” which was pretty shocking. She was referring to the fact that most labour wards in the UK have stringent security, the result of a baby being snatched from a labour ward some time ago. Therefore, a code is now required to gain access to the labour ward, with visitors often restricted, women unable to wander about freely and limited numbers of companions being the norm. To refer to this as a “lock down” area, accurate as it may be, conjures up gaol conditions. I pointed out that women are already tagged (wrist bands), given hospital clothing to wear and pretty soon may be photographed at this rate! The days of women being “confined” are still very much with us.

Several of the midwives referred to homebirths as “confinements”. It will be struggle for these midwives to change the way they talk about women and to them. I am more and more convinced that language is a key to the whole relationship between midwives and women. If women are to regain any confidence in their own ability to give birth, and midwives their trust in women’s abilities, beliefs and attitudes are key elements that must be addressed. The “self talk” we use, the discussions with colleagues and direct communications between women nd midwives all revolve around actual terms and vocabulary. If attention is paid to those, and make an effort to chose women-centred and midwife friendly terminology then we can change basic attitudes.

I left the group with much to think about on this score, and one senior midwife said that she had really taken this issue on board and realised she needed to think carefully about her own use of language. It is a start - we will see what the reactions are this morning when I give the group a chance to reflect on yesterday’s program.

Today I begin work in Dundee. Yesterday was my day off for this week and I spent it in Edinburgh, doing some “touristy things” for a change. The weather was fine and it is a lovely city, all Georgian terraces built of stone, hills and valleys, magnificent public buildings and of course, the Castle.

I did manage to finish my next article for MIDIRS (December issue), this time explaining NMAP and the campaigns building up to change midwifery in Australia. One things I really notice in the UK is the profile that midwives have attained - this morning on the BBC news there is a story about pay rates in the public service and nurses and midwives are specifically mentioned as being 10 and 12 percent below teachers and policemen. The issue of pay rates for midwives is always raised in workshops here (unlike OZ, where it is never mentioned at all) but the point for me is that everyone recognises that midwives are a separate entity from nurses……

Off to find out about midwifery in Dundee, specifically in Ninewells Hospital.

The workshop in Kilkenny finished on a high note, with everyone having had fun and with lots of requests to come back to do another one soon. The Irish are so hospitable and it is a lovely country. There is no doubt that change is underway here, but midwives have a tough battle on their hands, considering the stranglehold that theobstetricians have on their maternity care system. I will be back next March for a workshop In Cork, an area with a large population of “alternative lifestylers”, so that will offer some different perspectives.

Today I am travelling to Edinburgh and have a 24 hour break before going on to Dundee. Scotland has a reputation for great midwifery, but in my experience so far, almost all women are given diamorphine (synthetic heroin) in labour, something that is unheard of in other countries. I can never understand how a woman would accept giving her unborn baby a dose of a drug she hopes that child will never become addicted to in later life. It is probably a measure of how a woman in strong labour, particularly around transition, will accept anything without thinking of the consequences, if they think it will ease the pain of labour.

I am looking forward to finding out what they do in Dundee.

Ah, Kilkenny, Ireland!

The workshop here has been interesting. A number of midwives from Waterford had to pullout because of the “vomiting virus” that has struck their hospital. This is a virus, apparently endemic in Ireland at certain times of the year, with symptoms that sound a lot like food poisoning. It is highly contagious and when people come to hospital because of dehydration from the vomiting etc it can then be spread throughout the hospital. If it is found in the hospital, staff are not allowed to attend programs elsewhere for fear of carrying the virus with them and in extreme cases, hospitals have to be closed down temporarily until free of the virus.

It is clear that prenatal education has still a long way to go in Ireland. The whole maternity system here is very much dominated by obstetricians (the old “active management” extends beyond the woman to the midwives as well) and midwifery is just starting to establish itself as an entity in some places. Waterford has the only midwifery led unit in this part of the country, but there are some stirrings in other places as well. Many women have to travel to give birth in centralised hospitals, so classes have to cater for women to will give birth away from their home town.

The formats of the classes varies a lot but several people in the group explained they do only two sessions which is hardly adequate. Most programs cater for women only with perhaps a fathers night at the end, and the idea of doing small group work (or interactive exercises and activities) is new and a bit daunting for them.

Private care is very common in Ireland, and when I explained Sally Tracy’s research on the outcomes for women with private care they were a bit shocked and adamant that they couldn’t mention this kind of research in their classes because it would upset the doctors! I initiated a discussion about informed consent and the role of the educator as the member of the team who makes sure women have the necessary information to inform their decisions. This was a new concept and one which caused a degree of discomfort. The Irish are used to authority figures ruling the roost and there is a general pattern of strong beliefs and opinions that people are keen to express. If someone has an opinion that is different from the prevailing views, it could be very hard for them to get a hearing, so change is slow, especially when it involves challenging medical practice.

There is no midwives association or organisation in Ireland, and this will need to change if midwifery is to get the recognition it deserves. Midwives here are very much a part of nursing, and it is interesting that there seems to be no movement to establish a separate identity. The relationship between doctors and nurses is as hierarchical as ever…..

It’s been a hectic week (as usual!).

Thursday was the conference in Birmingham: “Antenatal Education, but not as you know it”, which was billed as the first conference for antenatal educators in Britain. The event was the brainchild of Julie Foster, the Parent Education Coordinator at Birmingham Womens Hospital, who, with the help of NCT on the administrative side, put together a program of presentations from a long list of people, including Mavis Kirkham, Jean Sutton and Judith Schott. There were 400 enthusiastic educators in attendance and it is likely to become an annual event, perhaps moving around the country to give everyone a chance to attend.

One of the most interesting papers was from a member of Fathers Direct, a new organisation that evolved out of an NCT postnatal coffee group. He talked about ways of involving fathers and gave some interesting perspectives on the role fathers do play and would like to play. He said that men don’t really se themselves as “parents” and respond more readily to the term “fathers” or “dads”, so to increase participation rates publicity could include these words, for example” Programs for Expectant Mums and Dads”. Their group is expanding rapidly and are now looking at ways they can become politically involved, for example, by seeking better legislation for paternity leave etc.

I was asked to present a one hour workshop, before the main program and again at the end. I chose the topic “Informed choice or pot luck - making prenatal education relevant” but somehow this was changed to “Empowering women to have a natural birth”. Still, for an hour it didn’t really make much difference! It was really just a taster for my longer workshops and they were well attended - even those who came at the end of a long day (when we were all feeling a bit brain dead after an intense day in a very hot venue) managed to participate and find some energy.

One of the main benefits of these events is that it gives a lot of educators the chance to catch up and network. It was great to meet a lot of people I’ve had in workshops over the past 10 years and to get some amazing feedback. One midwife told me that after attending my Active Birth workshop she enabled her daughter to give birth to a 10lb baby at home, when she was under pressure to be in hospital “because the baby was going to be big”.

The only problem I had with the day was the word “antenatal”. As you know, this is a term I have real problems with, given that it creates a negative impression, even though it is supposed to just mean “before birth”. That’s why I use the term “prenatal” and every time I hear “antenatal” I flinch. Did a lot of that on Thursday!

Yesterday I spent all day travelling to Kilkenny in the south of Ireland. Today I am presenting a weekend workshop for educators and I will definitely be raising this issue of language with them!