Andrea’s Diary

This was written at the end of the workshop in Spain, the day after my previous entry.

As I mentioned before in a Diary entry, Spain has a very medicalised approach to birth. In many ways this is not so different from other countries, but they have developed some unique routines that are amazing.

I was staggered by some of the things I have been told about by the midwives here. For example, every woman in Spain goes for a CTG each week, starting from 38 weeks (or even earlier if a problem is suspected). until the baby is born! They seem to have the idea that this is done in other countries, and the reason they offer for this service is that women want to know that the baby is OK and also in case the baby dies later - they can say that it was doing well before the birth. Since the rate of litigation is very low in Spain and women are not inclined to sue, even if there is a clear problem with her management, it is hard to justify this routine on legal grounds.

I think this practice is a prime example of setting women up for intervention. How easy to would be to say that there is a problem with the baby and that an induction is indicated! A caesarean could also be offered with ease, should the caregiver wish, and as most women are seeing an obstetrician, this seems a likely possibility. Given the varied interpretations of these traces, almost anything could be read into them. Women, of course, will take up the offer to the CTG because they see this as “care” and every woman craves attention for her pregnancy and baby, especially at the end of her pregnancy.

Imagine what this must be costing the Spanish health system! If every pregnant woman in England lined up for weekly routine CTG s from 38 weeks on , the whole health system would grind to a halt, as it would in other countries. They were surprised when I said that this doesn’t happen elsewhere.

We had a long discussion about unnecessary pregnancy testing and what is means in relation to creating the feeling that pregnancy and birth are normal physical events for a woman. Frequent ultrasound scans are another popular pastime, especially in the private sector, and lots of other tests abound. It is hard to change a culture a fear about birth when there is so much emphasis on testing and technology and it is no wonder that women want it all to carry over into the labour. The midwives in this group had very limited knowledge of many of the issues we explored, probably because they see themselves as servants of the doctors and they assumed that the doctors would know best. Some of the older, more experienced midwives however, who knew what birth was like before all this palaver became entrenched, were able to share some very valuable insights drawn from their own practice and this was enormously helpful for the group. We need ways to celebrate this expertise and to capture the skills for others to draw from, before they retire and it is too late. Spain certainly needs to learn from these wise women.

I have been havng trouble accessing the Internet in Spain, so will include two Diary entries today to catch up…

Working in Spain is proving a fascinating experience. It’s been a steep learning curve - discovering the workings of the Spanish health care system, hearing about the way birth is conducted here and thinking, on the spot, of ways I could adapt the normal Active Birth workshop content to better fit local conditions.

Spain has a three tiered health system. The national health service is similar to those elsewhere - everyone pays through their taxes - and it is apparently fraught with the usual problems: lack of money, long waiting lists, under staffing. Many people take out health insurance as it is cheap and offers the alternative of faster care and a private room in the hospital. The third layer is for the rich - they by-pass the rest and just pay outright for the care they want.

Until around 30 years ago, all births were in the home. The Government then decided to move birth into the hospital (this will be familiar to my British readers as the same thing happened there) and homebirths became an things of the past. The hospitals were staffed with many doctors who then got involved in the births and because there were plenty to go around, more than were really needed, it was decided to cut back on the training of midwives. All of the schools of midwifery were closed and the nurses were given extra training when needed. The doctors took firm charge of the whole birth process.

However, as the midwives aged, and then retired it became apparent there was an acute shortage and there were none being trained. The few midwives left were allocated to the labour wards and nurses were left to undertake the prenatal and postnatal care. After eight years, the midwifery schools were opened again and now there si some new blood entering the scene.

Meanwhile, women, although they may have seen a nurse during their pregnancy for the routine tests etc, started seeing a doctor as well, as he could provide continuity of care. The first and only time a woman would see a midwife was during the labour and even then the doctor would arrive for the birth itself.

The initial breastfeeding rate is very high as Spanish women want to breastfeed their children. While it may be 95% plus after the birth, there is no support in the hospital and by two weeks the breastfeeding rate has dropped dramatically, and by 6 weeks is almost non-existent. Formula feeds are freely available in the hospital and samples are given are given out post partum.

There is no midwifery organisation in Spain and few nurses would consider themselves as “midwives”. Of course there are exceptions, and these will likely be women who have trained elsewhere, probably in Britain. There is an informal network of these people and I am fortunate that this workshop is being organised by one of them, Rachel MacLeod who works at the Acuario birth centre south of Valencia (more about Acuario later).

In the light of all this, birth in Spain is very medicalised. Midwives are firmly under the control of the doctors who dictate all the protocols and demand strict adherence to rigid routines. All women give birth on a narrow table with their legs in stirrups - they will have had a perineal shave and an enema and can expect an episiotomy. There is routine starvation of women during labour and most births as augmented. Needless to say the epidural rate is very high and so are the caesarean, forceps and vacuum rates.

It is all so antiquated, and a real reality check. Two days ago I was debating the finer points of physiological third stage with British midwives, and here I am being told that the doctors insist that if the cord is not cut immediately the baby’s blood will drain back to the mother! As a consequence, I have left out whole sections of my normal workshop program because they are not even at first base with physiological birth.

Tomorrow I have been asked to give them some practical pointers about how they improve birth for women who are on the beds as there is no way they can enable women to give birth on a floor mat. Although it goes against all my basic teachings (as many of you will know) I will be as creative as I can and give them some suggestions so that they can try putting some of the basics (such as upright birth) to the test with the women on the beds. It will be a challenge!

More on how this turns out tomorrow.

Today I am off to Spain for a few days. I don’t know much about the birth scene there, except that it is very medicalised and doctor centred. There is a Birth Centre, in Acuario, between Alicante and Valencia and it is there that I will be presenting an Active Birth workshop.

I will be working with a translator and that always presents some challenges. It will be fun to meet some Spanish midwives and I am sure I will learn much, perhaps more, than they will learn from me!

More in the next few days…..

Today is the second day of an Active Birth workshop in Bristol, England. Many of the participants in this group have a lot of experience with home birth, which is not surprising, given that we are not far from Bath, an area well known for its midwifery led units and home birth.

We canvassed quite a few issues related to home birth during the day. We also talked about the problem of litigation, which has midwives running scared in this country. Midwives are adamant that they must “document, document, document” to avoid litigation and this is regularly drummed in by management and the obstetricians.

I would have thought that poor practice and lack of communication with women were the underlying factors that trigger litigation and that no amount of documentation will cover this up. As someone pointed out yesterday, there is nothing to stop midwives from “filling in the gaps” after a birth, especially when the labouring woman requires actual hands-on midwifery care rather than a pen-weilding baby sitter.

I threw in the comment that the NICE (National Institute for Clinical Excellence) guidelines that the baby be monitored using pinards or sonicaid every 15 minutes during first stage and after every contraction in second stage, is an intervention in a normal birth. These guidelines were put in place as an alternative to routine CTGs, which NICE have now said need not be used as a routine, especially on admission. The underlying reasoning for this recommendation seems to be that if there is litigation, extensive documentation of the baby’s heartbeat will somehow make a difference to the outcome. The issue of the effect of disturbing the woman labouring normally every 15 minutes was dismissed by my group yesterday as unimportant - they claimed that women “like to know how the baby is doing”. I wonder how they divine women’s feelings on this? Perhaps they have asked her in this way “you want to know how your baby is doing, don’t you?” when in fact the real reason for meddling with her concentration is that the midwife is terrified that she will be carpeted for a gap in the records for the fetal heart rate.

The state of midwifery in this country is dire. Fear of litigation is shaping midwifery practice, the obstetricians (who know virtually nothing about normal birth) are dictating midwifery practice and trust in birth as normal process is slipping away. If women in Britain were more forthright and less pathetic, if midwifery leaders appeared from somewhere to offer solutions and take strong public positions in support of normal birth and everyone learned how to celebrate those successful midwifery practices that do exist, perhaps something could be done. I will not be holding my breath!

This is my last workshop in the UK for this trip. Tomorrow I go to Spain for a program there and then I will be off home, where I hear that the NSW Government is finally rolling out the first programs under the NMAP. Great to hear of progress being made somewhere!

I really enjoy working with Welsh midwives, although there are a fair few from Britain in this group as well. Many of the Welsh midwives work in a variation of caseload practice (which they call “integrated midwifery”) which gives them a lot of flexibility. They carry a birth kit in the car and go to the woman in labour. The decision about birth place is made during labour, and of course, this means that the home birth rate is climbing steadily in many parts of southern Wales.

We explored the impact that “coaching” could have on morale in the workforce, given that moaning and complaining are fairly common amongst midwives when they feel undervalued and stressed. This is a topic that I am very interested in and one that I am exploring in more depth myself at the present time. I feel it has great potential for improving morale and supporting innovation in midwifery and it will form a significant part of the new workshops we are planning for Australia on “Team Building” and “Managing Change”. How to develop coaching skills will be part of these programs. We may consider offering them in the UK later as well - they could use them too!

I was a speaker at the All Wales Midwifery Conference near Cardiff yesterday - the theme was “In it Together” and it celebrated the new initiatives being taken in Wales to strengthen midwifery and improve maternity services for mothers and midwives.

A series of new strategic frameworks have been released that set out the basic principles that will underpin midwifery services into the future. They set targets for the implementation of various reforms that will ensure choice and improved care for women. One key strategy is to raise home birth rates to 10% by 2007, and they are well on their way up, with some areas well over this target already. The reforms being planned will put Wales well ahead of other areas in the UK and the energy and enthusiasm amongst the Conference participants was palpable and exciting.

Today I am in the Brecon Beacons (fabulous mountainous area of Wales) and will be presenting an Active Birth workshop over the next two days. I hope to have a day off on Sunday to do a bit of walking in the area, before travelling to Bristol for my next event.

Yesterday I had a classic case of “shoot the messenger” syndrome. We were discussing the ways that the topic of pain is covered in classes and exploring how we could be sure that women are given all the information about the various effects and consequences of taking drugs during labour. It was clear that there were a couple of midwives who felt very uncomfortable about this session, and afterwards on the feedback one of them wrote that she was “sick and tired of non-midwives telling midwives what to do” when women clearly wanted to take drugs for easing the pain.

It has been a long time since anyone levelled the charge that I was a “non-midwife” meddling in the affairs of midwives. The fact that I am not a midwife has always been a great advantage to my work and I have never found it to be a problem. In fact, I know a lot about midwifery and have learn much from the many women whose births I have shared. No-one can claim to be an “expert” anyway, given that there are so many possibilities when it comes to the way women manage their labours.

Perhaps this midwife was feeling embarrassed by her lack of knowledge on the topics we were exploring ( I am often surprised that midwives are not aware of the effects of these drugs on the baby and also the research that has been done on the long term effects of pethidine and nitrous oxide) and I realise that these can be uncomfortable subjects for a midwife who has been happy to provide women with any drug that either she or mother thinks fit.

Being confronted with a gap in one’s knowledge and the unpalatable fact that some of the information being given to parents may be lacking, or even inaccurate, is difficult for an educator. We all must try to keep up with the research and be ready to change our story as new evidence comes to light. It is clear that many practitioners are unaware of the research, and it is part of our role to keep everyone informed. I certainly see my job in this light.

I had some lovely feedback today - last year I presented a workshop in Dumfries (Scotland) where they have a small midwifery unit. They have now appointed a midwife to co-ordinate a number of educational programs across the area, including a revamp of the prenatal programs, and she has come down to London to attend the Teaching Skills workshop I am currently presenting at Kings College Hospital.

She reported that after the workshop, the midwives got really busy with the ideas we explored and have been happily incorporating many of them into their practice. They have even been out and bought a number of plastic buckets, so they could easily provide hot wet towels to women for easing labour pain! The new ideas have proven highly successful and the midwives have enjoyed using them.

It was great to hear of their success - it is important for me to know that the ideas I am suggesting in workshops are of practical benefit and that midwives are trying them out. So often I wonder if I am making any progress at all because it is not always possible tp get direct feedback from workshop participants some time later. I was therefore very heartened to know that things are actually happening as a result of all the tripping about I am doing in the name of encouraging natural birth!

We’ve been discussing issues surrounding privacy at the last few workshops. It is obviously an important ingredient for the labouring woman, but some associated concerns have been raised as well.

One that was mentioned is the fact that some maternity units still have those big whiteboards in their central area used to display the name and labouring status of the women currently in the unit. If this is on view to everyone who passes, it means that other women (or more importantly, their support people) can see the details of other women in labour and this amounts to an invasion of their privacy. It could be a particular concern in, for example, a small town, where everyone knows everyone else.

These boards are used to keep everyone informed of what is happening to the women in the unit and are often a focus for the ward rounds and handovers. They can also be used to encourage “throughput” by managers, for example “why haven’t you ruptured Mrs X’s membranes yet?”. If the unit also uses centralised CTG monitoring, a bizarre scene could unfold, where no-one needs to spend time with the woman, as her progress is being plotted by the monitor and the midwife just checks regularly so the board can be updated. It may sound unlikely, but I have heard of some units that are fast developing such a “production line”, similar to those used in industry to achieve targets and maximise productivity.

The whiteboard have got to go. There must be a more humane way of passing on vital details from one shift of midwives to another without relying on this blatant display of personal details. Privacy and confidentiality are issues that are central to a feeling of safety in a unit, and that goes not only for the women giving birth but also for the staff.

The important role of fathers during pregnancy, labour and birth was a topic we discussed yesterday. Twenty years ago, when we first started promoting the “active birth” concept, we realised that fathers needed support during labour, almost as much at the mothers at times.

As Michel Odent has pointed out, if anyone is anxious during the birth process, this contagious emotion will be picked up by the labouring woman and this can have an adverse effect on her ability to labour well. Fathers could easily be frightened by the events of labour and their needs must be recognised and appropriately supported.

In Australia, hospitals responded to these needs by opening their labour wards to all comers (sometimes they regretted this, as large families and multiple friends arrived!) and the prenatal classes were rescheduled to nights so that fathers could attend and learn practical measures so they could be useful birth partners. On the whole, it has worked well, and it is clear that the men have appreciated being involved. Being present at the birth not only enhances the bond between the father and his baby, but also better supports ongoing breastfeeding.

Some of comments following our video yesterday (Giving Birth: Challenges and Choices) highlighted the active involvement of the father. I will be showing a video clip from The Art of Birth today, where the father enthusiastically praises the concept of home birth, as another reminder of the importance of fathers at birth.

The Southern General Hospital in Glasgow, where this workshop is taking place, still has a policy of only one support person at the birth. It is hard to imagine how such an antiquated policy could still be in place and I will be challenging the midwives in this group to press for changes to bring this hospital into line with others elsewhere. It is a discriminatory policy and also a social intervention in birth and it needs to be changed without delay.