Andrea’s Diary

Today I am packing up in the UK ahead of returning to Sydney tomorrow. As I look back on this trip, it’s useful to reflect on what I have learnt from this trip:

The Birth Centre concept is finally being developed in the UK. However, disturbing trends are emerging - for example, I have just spent four days at Birmingham Women’s Hospital, where a new Birth Centre is under construction. It has been commissioned by the obstetricians, who have the majority on the decision making committees that are overseeing the staffing, design, construction and management of the new unit. The unit will be located in the obstetric unit and will have a double door access to the regular labour wards. Staff will rotate throughout all areas. In other words, this is a sham and a complete nonsense that appears to have an expansion of this highly medicalised unit as its primary purpose. I pity the poor midwives who will be trying to make it work for women. This is not an isolated event either, I heard of other examples of this kind of duplicity going on in the UK.

The Occupational Health and Safety people are developing into a police force that is hampering improvements and systematically undermining common sense. I have heard a long litany of ridiculous decisions they have made: women in supposedly home-like facilities not being allowed onto sofa beds (or similar comfy chairs) in labour because they cannot be easily cleaned; fathers not be allowed to make a cup of tea because they may burn themselves on the kettle; all birth balls removed from a unit afer a small mishap with one ball brought in from home by a labouring woman; towels for use with hot water being kept under lock and key; toast not able to be made in labour ward kitchens because it may set off the smoke alarms if someone is distracted and forgets to take it out of the toaster; etc etc. I should have made a list as I went along, but I was so gobsmacked (to use a local expression) that I didn’t write them down. Next time I will compile a dossier - it will make a great basis for an article in one of the midwifery journals!

On the other hand, I heard about dirty units, filthy floors, run down equipment and a general lack of facilities. It seems that the Infection Control Officers are not nearly as diligent as their OH & S colleagues!

The over riding impression that I have, however, is that this is a very “sick” culture, where women expect to be given drugs in labour and midwives offer them routinely because there is no real belief that women have the stamina or will power to labour without props of some kind. When I show birth videos I now make it clear that al the births midwives will see are ones where no drugs are being used of any kind. This is a rarity in the UK, even for home births. I think that this lack of trust in birth is contributing to the poor self esteem and low levels of confidence that are very evident amongst British women, which is hampering political action, personal improvement and change within the maternity services.

So, with a heavy heart at the lack of progress in British maternity circles, I head back home. Sometimes I wonder why I bother putting myself through considerable inconvenience to keep plugging away in the UK with the message about normal and natural births. There are midwives and women here that appreciate what I am saying and who have personal experience that backs my message. I just wish there were a whole lot more of them…..

Today is the last day of my last workshop in the UK for this tour. It is an Active Birth workshop and is being held in the Birmingham Women’s Hospital.

I was delighted to welcome Christine Choong from Malaysia, into the group. Christine is a British midwife, married to a Chinese obstetrician an they live in Kuala Lumpur. She is a graduate of our Graduate Diploma in Childbirth Education and Lactation Consultant, and she offers prenatal classes, support services for parents and acts as a doula when asked. She has been campaigning for better births in Malaysia for many years and her husband, Kho Hsiang, is a keen supporter of natural birth.

When I last visited Kuala Lumpur I was able to visit several hospitals and was dismayed by the birth practices that I saw - shared labour wards with no privacy and routine lithotomy, episiotomy, shaves and enemas and a conveyer belt approach to care. Malaysia was a British colony in its past and there are still echoes of western systems in place. Malaysia does have midwives (unlike Thailand, for example) yet maternity services are mainly staffed by obstetric nurses.

Christine says that in the past few years several obstetricians have begun to support alternative positions for birth, although only if requested. She therefore emphasises that parents make very definite requests of their caregivers, whom they should choose with care if they want something different from the routine production line that normally operates.

Breastfeeding is well supported and the BFHI has been adopted enthusiastically by hospitals and family health care services. I well remember seeing a woman presented with her baby for immediate breastfeeding just after she had suffered the most inhuman birth practices! The connection between fewer birth interventions and easier and more successful breastfeeding is one that few caregivers anywhere in the world are keen to campaign around. It always seems to fall into the “too hard basket”.

I heard one of the silliest stories ever yesterday - it is a great illustration of how bureaucratic and idiotic hospital administrations can become.

One of the midwives in the workshop yesterday (from Taunton, Somerset) had attended an Active Birth workshop that I presented in Taunton a couple of years ago. She was interested in trying the hot wet towels for easing labour pain and found they were a great success. Some women, who had indicated in advance that they would want an epidural, found the hot wet towels were enough and they avoided using medications altogether.

Buoyed by this success, the midwife asked for the hospital to order some flannels that she could use for this simple treatment. Eventually they arrived and were locked away in a cupboard. Now, if she wants to use them for a labouring women, she has to get special permission from the unit manager to remove them from the cupboard! As she pointed out, the various drugs that midwives can use for labouring women are freely available without any trouble - they can be used without special permission being needed!

Have you ever heard anything so silly? These are not gold plated flannels, or specially manufactured small towels that are hard to come by - they are cheap, ordinary terry towelling squares that cost a few pence each. Someone here has comprehensively lost the plot!

Nevertheless, this midwife continues to use these towels because they are so effective and cheap. Eventually someone must get the message that this is a situation worthy of a student revue skit!

I am half way through a Teaching Skills workshop at Birmingham Women’s Hospital. As always, it is interesting to have a mix of NHS and NCT educators in the group and to hear how they organise their parenting programs in various parts of the country. Here they have cut back the classes to three sessions of 2 hours, just as has happened elsewhere. This is a very retrograde step, and we will explore ways of clawing back some of their funding, which is the usual underlying reason for the cut backs. Lack of educators is also a reason, and it is easy to see why midwives might not want to work in this area - several members of this group talked about their discomfort at public speaking and their lack of initial training.

I know that there are several topics that will come up today, that educators invariably find difficult to tackle. For those of you who want to know what we will be examining in more detail, you can read what I have written before in this article on Unexpected Outcomes and also on Pregnancy tests. This last issue came up yesterday when everyone did an activity that focuses on the usefulness of early pregnancy programs, and issue I must write more about on another occasion.

One of the issues that came up in the London Active Birth workshop that I have just concluded was the concept of a “Birth Centre” as interpreted by the British. In the rest of the world, a birth centre is an autonomous midwifery unit that offers normal, natural birth with a small team of designated midwives. These centres are usually located within a hospital precinct, although many of the American centres are completely freestanding (I have visited US birth centres in office blocks) and in New Zealand, many midwives have clubbed together to convert residential houses into a birth centres.

Wherever they are physically situated, the basic principle is that women who choose that care are aiming for a completely natural birth, with no electronic monitoring (CTGs), drugs for pain, epidurals, inductions, ARMs, episiotomies etc and optional oxytocics for 3rd stage. Women will be offered baths and showers for easing pain, complete freedom of movement, open access for families and friends as birth companions and no limitations of food and drink in labour. Both the women using the unit an the midwives staffing it have a deep belief in the positive nature of birth and women’s capacity to handle it well without interventions of any kind.

In Britain there is a new movement gathering strength to establish birth centres across the country. It seems to be a re-badging of the “midwifery led units” that were a central plank of the Cumberledge Report that initially gave midwifery such a boost 10 years ago, but which has faltered since. These “birth centres” are springing up in many hospitals, but the way they are operating and the basic principles underlying their operation appears to be quite different from the kind of service defined by this term elsewhere in the world.

Firstly, there appears to be no commitment to drug free, natural births. Women can have pethidine and nitrous oxide (Entonox) on request and the majority use these medications freely. TENS machine are also encouraged. Whilst baths and showers are on hand, and water births are an option, these are sometimes being used togther with medications, a dangerous practice and poor midwifery as well.

The London workshop venue was in Guy’s and St Thomas’ Hospital, where they actually call their regular labour ward the “Birth Centre” and their “low risk unit” the “Home from Home Unit”. This is appalling and is a deliberate attempt to con women into thinking that they will be getting midwifery care when they will be subjected to regular obstetric management. I understand that the same tactic has been used at Kings Hospital as well, and this shameful situation needs to be exposed so that women are not being duped into accepting medicalised birth when they are expecting a birth centre approach. This duplicity will become more obvious as there is more publicity about birth centres and women begin to specifically seek out this alternative.

Other workshop participants told us about their attempts to get a “birth centre” established at Southend Hospital. After many years of struggle, they have been able to obtain 4 rooms within the labour ward area that will be designated as a birth centre. It will attempt to provide midwifery care, but they face considerable opposition to the midwifery guidelines they want to introduce, and a lot of retraining of the midwives who are not used to working without CTGs, for example. I have no doubt that these midwives have the women and their own profession at heart and will do their best in obviously difficult circumstances, but to call this service a “birth centre” is, I believe, a travesty of the concept that will undermine its effectiveness and debase the nature of this type of service.

There is to be a conference on Birth Centres presented by MIDIRS in April. I hope that this can at least establish some basic definitions of this type of care so that the British efforts can be brought into line with the approaches that have been used overseas for over 20 years. Consistency of purpose and the adoption of accepted definitions will strengthen their cause and provide a real alternative in hospital based birth, particularly when using the evidence from the many research studies undertaken in overseas birth centres to underpin their push for these centres.

If maternity services choose to accept the current watered down version of the birth centre that is being developed in Britain then there is a risk that these services will be no more effective than the midwifery led units they seem to be replacing, where women continue to use drugs, breastfeeding rates are still very low and a lack of continuity of both care and caregiver are often the norm.

Today I am off to present a workshop at Guys and St Thomas’ Hospital in London. This hospital is straight across the Thames River from the Houses of Parliament and Big Ben, and in today’s sunshine all their touches of gold will be glittering - a reminder of the power of Parliaments shape people’s lives (but not necessary a shining reminder of the sparking debate that goes on amongst politicians!).

The war in Iraq has been in progress now for several days. It is hard to know what is going on as the media are giving us a very massaged version of events. As the saying goes: “the first casualty of war is truth”. One outcome for me has been that 4 Israeli midwives who had registered for this workshop have had to pull out because there are no flights out of Israel for the time being. I hope I will be able to meet them another time.

In all the gloom about war it is nice to have good news. One of our Graduate Diploma in Childbirth Education students has just launched a childbirth website for Filipina women living away from their homeland. This is an exciting project and one I know she has worked very hard to achieve. Congratulations Rocellita on a fantastic effort!. Reaching out to your compatriots in this way is a wonderful community service and I hope it is widely used and appreciated.

Despite the warnings I had been issued about not mentioning water birth or home birth during my workshop in Jersey, the midwives here turned out to be similar to those everywhere else - keen to promote normal birth and wishing that they could offer more midwifery care (including water and home births) to women on this island.

Jersey is 11 miles by 7 miles and has a population of 88,000. It is closer to France than Britain, and the southern most island of the United Kingdom. The economy revolves around banking and tourism - Jersey is not a part of the European Union, has no VAT and is a tax haven with very low rates of personal tax. They are trying to limit immigration, as you can imagine!

The health system here is interesting. All medical care is private, and people pay £18 (approx AUD$54 ) per visit to see a GP. Those who cannot afford it are able to get care at the hospital. The GPs are keen to do most of the prenatal care (lucrative!) yet they are happy to let the midwives manage the births. This means that the midwives rarely know the women whom they will meet for the first time during labour. There is a midwives clinic at the hospital, so some women get midwifery care all along, and others are specifically asking for this, even though they could afford to see a doctor.

The rates for interventions are similar here to those elsewhere - caesarean section rates around 25% , high rates for epidurals and too many inductions. The familiar story from midwives everywhere I travel.

One midwife pointed out that the potential for litigation makes providing informed choice very important and that this could be useful in forcing change: if women know that services are available elsewhere (e.g. water births) they may well demand that they be offered here too. A very good idea - the need to make sure that women are aware of all the alternatives can be used not only to push changes, but also to protect midwives from censure and women from unnecessary intervention. It is a subtle idea and one that midwives are not always willing to adopt, but it is nevertheless an effective strategy.

I am looking forward to learning more about Jersey tomorrow. It is one place I would like to visit again, next time with a bit pf spare time to have a good look at the lovely old buildings and the countryside. It is a very attractive place!

There is an interesting article in the current issue of The Practising Midwife ( March 2003) titled “Women’s Experience of Waterbirth”. It describes the feedback that was received from 189 women in five different birthing centres who gave birth in water.

One of the main findings was that women demonstrated a strong desire for using water during labour and that they saw it as therapeutic. However, one astounding figure was that 88.3% used Entonox (nitrous oxide) during their waterbirth. There were even a couple of women who were given Pethidine or Meptid while using the bath.

I find this astonishing. Practitioners in other countries would find this high rate of drug use associated with waterbirth quite disturbing. There is always a potential for complications arising from the use of any drug and it could be difficult to manage a woman in a tub or bath should such an event occur. Some women, for example, become quite drowsy and even nauseous on Entonox, and a drowsy woman in a bath could pose quite a risk.

All this begs a basic question in my mind, however. The use of water is widely considered, and promoted, as an alternative to drug use in labour. This is certainly the message that women in countries outside Britain are given and it is understood by the woman as well. However, it is not an expectation amongst midwives in Britain. For example, I was shown the scavenger system for removing Entonox from the ambient air in the new Guys and St Thomas’ “Home from Home” Unit in London last year. They even had outlets for the system beside the bath!

I think that this study, and its results on the use of drugs in combination with water, is an example of the wimpish attitude of British women and midwives towards labour and dealing with pain. I see it as another manifestation of the “nanny state” that is such a feature of people’s expectations here. Women have such low expectations of their abilities in this country that they insist that they have as much help as possible in labour and whilst water is a useful tool for easing pain, they don’t consider it enough. It also reflects a widely held view that “Entonox is harmless” to the baby (although clearly a risk to the staff, hence the need to actively remove it from the labour room!).

I get so frustrated that midwives here are unwilling to encourage women to labour without any external props. If the midwives don’t think women can handle labour pain without “a little something” then women will never believe it of themselves. The result is that women get their drugs and never discover the powerful insights and strengths they could gain from labouring using just their own resources, and midwives fail to experience the true nature of midwifery.

People overseas see Britain as a bastion of midwifery practice. I wonder if it really is….. perhaps they still have a lot to learn about women’s abilities and inner strengths when it comes to birth. They are certainly busy devaluing the concept of Birth Centres that has been accepted in other countries.

Meanwhile, today I am travelling to Jersey for another Active Birth workshop,. I have been given strict instructions by the organisers that I am not to mention waterbirth or homebirth during the program. We shall see about that!

Back in the UK office today for a quick catch up before heading off to Jersey for an Active Birth workshop tomorrow. I really enjoyed the Leicester program and will be back there in October for another group, which is already about half full from the waiting list!

Once again language was a bit issue for these midwives. Its not just recognising that “confinement” and “trial of labour” are very un-woman friendly, there are the subtleties of how information is phrased and the non-verbal cues that are part of the communication. Even when I flag the obvious “delivery” for excision, it is impossible for them to take it out of their conversation. Changing habits is such a hard task, yet if we are to move to appropriate, individualised care that is precisely what we need to do - shake off the old routines and develop and awareness of our personal behaviours and how they are meeting our client’s needs..

I’ve written about this in the past and one of these articles on language is now on the web site. See what you think of my suggestions - could you change the way you communicate with women so that you are promoting woman rather than midwife centred care?

It is Leicester today and another Active Birth workshop. Once again I am meeting midwives from a variety of maternity services, but most are either from the Leicester General Hospital or the Leicester Royal Infirmary.

At the General they are planning to open a Birth Centre and the at the Royal moves are afoot to re-establish the midwifery led programs that had were recently disbanded. This unit, with its various teams (the famous BUMPS team was a named centre of excellence in the “Changing Childbirth” report of 1991) had been a model for other units around the country and had achieved some enviable outcomes.

I well remember presenting a series of workshops for all its midwives (facilitated by Denis Walsh) many years ago now. The outcome of the workshop was audited, and they were able to increase their rate of women giving birth in upright positions from 18% to 43% in 12 months, once most of the midwives had attended the workshop. I was very pleased to have this kind of feedback on my work and chuffed that they were so keen to put it into practice.

Sadly, administration decided that due to shortages of staff all these teams would be disbanded and the whole unit revert to more traditional care. Now, the midwives are once again setting up more woman friendly options. Pregnant women will be graded as being low, medium or high risk and then cared for by a dedicated team assigned to each group. Whilst this is a step in the right direction, the need to categorise women at the outset with a risk factor is a shame, because it will lock women into a designated mode of care with little option for swapping. How can anyone foresee how a labour will develop, or whether a particular risk will become a reality? Women wanting a vaginal birth after previous caesarean, for example should really be seen by the midwifery team, but I suspect they will be banished to the high risk team and will therefore be more likely to end up with another caesarean.

I am against classifying or labelling women during pregnancy. I much prefer the approach of “wait and see” especially for place of birth. This is the big challenge for those trying to normalise birth: avoiding the making of assumptions about women’s abilities around labour and birth. As soon as we label a woman we set her up for a self fulfilling prophecy. No one will be surprised that a woman described as “high risk” has a complicated birth or a caesarean. What will be most unexpected is if she defies the outcome pre-determined for her and gives birth without trouble. I suspect that her only hope of this outcome is to avoid the whole system entirely and chose a home birth.

I hope that the midwives in Leicester are able to get their midwifery unit operating as well. I suspect that the need to second guess a woman’s birth prospects in advance will work well for those who are deemed to be of low risk, but will mean a lack of choice for those who don’t meet the rigid guidelines the midwifery service will be required to work under. This is a sad indictment of a health service that espouses “informed choice”. It will be the caregivers that get the choice and the women who will have to live with it - again.