Andrea’s Diary

The group I am working with in Birmingham are from two hospitals - Solihull and Heartlands. I was aware of this in advance, so to try and find out what experience the group had from working in other hospitals, I asked each person to tell us where they trained and had worked as a midwife. It is often useful when group members have worked in a variety of units, because they bring perspectives and experience from different service providers.

As the group members introduced each other it became clear that this was a very stable workforce. All but a very few had trained in these hospitals and then worked in one or other. This is unusual, and whilst it can mean a very tightly knit, cohesive group of midwives who share common philosophies and practice habits that may not necessarily be the reality.

I then told them that I would try to push their boundaries beyond what they knew from working in this small geographical area because I felt they needed to know of other ways of working. When midwives want to introduce a new service, try a new technique or change a policy, they need to find other units that have travelled that road before. I have never encountered two hospitals who work the same with identical policies, protocols and management strategies, and this diversity (whilst challenging the claim that may be made that “our hospital has the best way of providing service”) can offer valuable feedback to others who want to learn from their experience.

These two hospital in Birmingham, despite being somewhat of a “closed shop” within the Trust, are very different. Both serve a different demographic group, with one having much higher rates of epidural use (the affluent Solihull clientele) and the other a much lower caesarean birth rate. Neither have a midwifery led unit or a birth centre, although they are hopeful one can be established.

I am looking forward to exposing them to other ideas about birth today….. and leaving them with much food for thought.

The necessity for including the topic of “unexpected outcomes” in prenatal programs for parents was explored in the London workshop over the weekend. It is an issue that is often difficult to raise and hard to present in a positive way, yet it is a worry that will concern almost every woman at some point in her pregnancy and to ignore it would be to send a message that this topic is not important.

Labour and birth is an unpredictable event in every respect. Coming to terms with this uncertainty is often difficult for parents, especially in today’s society where organisation, predictability and forward planning are such hallmarks of modern life. Many women, used to carefully constructed diaries and routine appointments with friends, family and the gym can find the chaos of trying to meet the needs of a new baby completely overwhelming. If there are other surprises, such as a sick child or perhaps the death of the baby to factor in (with all the resultant emotional turmoil), depression and anxiety can be major outcomes for both parents.

These topics must be included in the prenatal education program, not necessarily with a heavy emphasis on detail, but with at least enough time to enable reflection and acknowledge the reality of these tragic events. I have written about how this can be achieved with sensitivity and realism in my article “Mentioning the unmentionable”.

It was an interesting weekend and the diversity of the group provided some useful perspectives as we shared ideas and developed plans for improving the variety of prenatal programs currently on offer. For the next two days I will be in Birmingham (Solihull), presenting my last Active Birth workshop for this current tour.

This weekend I am presenting a “Teaching Skills” workshop in London. It is the usual interesting mix of participants - midwives, National Childbirth Trust educators, students and some Yoga teachers.

One of the group members is a midwife who is from Spain, whom I met before in an Active Birth workshop. I shared my experiences of my last week in Spain with her and she agreed that the basic problem in Spain is that the “midwives” that work in many hospitals there see themselves as technicians with skills that give them sought after status within the medical model. They see themselves as specialist nurses, focusing on tasks rather than the needs of the women in their care.

In other western countries, especially those with a strong history of midwifery, there a completely different concept of midwifery. The total care of the pregnant woman, including her spiritual, emotional, psychological and physical health are considered part of their scope of practice and midwives aim to care for the woman through her whole episode of childbearing. This doesn’t always happen, of course, because the maternity services are not always geared to provide these level of personalised service, but the education midwives nevertheless receive enables them to undertake this kind of total care whenever possible.

Although maternity care in Spain leaves much to be desired, this midwife commented that she felt women were starting to demand better services and alternatives to the medicalised, hospital based birth that is currently the norm. She is one of the new generation of midwives, many of whom have sought their education in England. There was a period in Spain when there were no courses in midwifery available at all, and now they are currently only training about 100 midwives a year. The workforce is rapidly ageing because of this gap of about 15 years when no courses were available. There is a looming crisis in maternity care and many of the midwives who have been waiting in the wings in England may well return to Spain. If this happens, the returning midwives will bring with them a different concept of midwifery care. Many women in Spain (according to my informant today) are looking for alternatives, and these midwives may well be able to do this.

There could be exciting changes in the wind in Spain, of these predictions are fulfilled!

I had some lovely feedback today. When I arrived into the office after my trip to Spain, there was a letter waiting for me from a midwife who was at the Burton Active Birth workshop last week. She wrote:

“Just a quick note to say thank you for such an enjoyable weekend. I learnt such a lot and it was great to meet other midwives and share experiences.

I went to work Sunday night, so enthusiastic, and cared for a woman who had the most wonderful birth “drug free”. I felt so proud of us all - mum, dad, baby and me.
The following shift, armed with my new lease of life, I cared for a woman who wanted to get on the bed. I worked so hard to keep her off the bed and didn’t rush to do an internal (much to my colleague’s dismay). She did all the things we talked about on your course, all went well. She pushed spontaneously, in a darkened quiet room with “no doubt” a rush of endorphins (me and her!) Until I looked down and saw - not only her bottom, but the baby’s!! She was on all fours, and sadly a very senior person put her in lithotomy. Nevertheless, she had a wonderful birth, she was delighted, as was the dad. Unfortunately I was greeted with a variety of comments from my colleagues “I’d have examined her on admission”, “I’d have had her on a CTG” (would that have told us it was a breech?, I asked). Still it was a great experience and although I have been a bit tense about other people’s views, my care was woman centred and she was delighted (said she was turned over because she said it only got painful then!) but what a miracle she had a vaginal birth. If she’d have had an internal she’d have had a section and it was a huge 8.5 lb baby. Goes to show you!”

As you can imagine I was thrilled that this midwife had taken the plunge and tried some of the ideas we explored during the workshop. It can be hard to ignore the comments of doubting colleagues, but in the end it is the woman having the baby who counts.

I hope that other midwives will take heart from this feedback. I am always thrilled to know that my work is proving useful and even more excited to hear of midwives really embracing their role and discovering the pleasures for themselves and parents of enabling natural births to occur. Congratulations to this midwife and thank you for the wonderful birth story.

I am back in Spain, presenting another program at the Acuario Birth Centre. This small private clinic is about an hour’s drive south of Valencia and as I was driven down by Rachel Macleod, the program facilitator, we got talking about women’s motivation for home births. Rachel works at Acuario and also offers a home birth service, using the Centre as a back up in case of transfer.

One recent transfer involved a woman who was following a strict macrobiotic diet during her pregnancy. She was of slight build and in good general health, although her baby was not growing as well as Rachel anticipated. She had booked for a home birth, and when labour began, it was clear it would be a long, drawn out event, as the baby was in a posterior position. The mother was well supported by her family and everything seemed to be on track. After a day of regular contractions, the membranes finally broke about 9.30 p.m., hopefully signalling the start of a more active phase of labour. Rachel visited her and found her to be 3 cms dilated with contractions every 3 minutes. Six hours later she was still 3 cms and making no progress at all. The decision was made to transfer to Acuario as the woman was exhausted and wanted help. An epidural was organised and a syntocinon drip, but the baby didn’t react well to the stronger contractions and a caesarean was the eventual outcome at 9.00 a.m.

In discussing this case, Rachel noted that this was not a strong, robust woman, with good reserves that she could draw on in the event of a long labour. When the baby is positioned like this, movement, walking, rocking etc will be important to get the baby to position itself and to move down. This woman was unable to keep this up, and it was clear she didn’t have the required stamina. The size of the baby was of concern as well. The question was whether the macrobiotic labour was a factor - this diet can be low in protein unless care is taken and whilst the woman was apparently well, the effect of such a diet on her baby was less clear. The baby was 2.8 kilos, small, but otherwise healthy, but one wonders if it too was unable to find the reserves it needed to weather a long slow labour. Of course, the longer labour may have been protective of such a tiny infant, and it may have done well if the epidural and syntocinon had not become necessary.

There was also the question of her motivation for a homebirth. Many women see a home birth as a “good idea”, without any real understanding of the benefits of labouring at home or any real commitment to the basic principles. It can also be seen as “appropriate” for a particular lifestyle”. In the event, sometimes these labours just don’t proceed until a transfer to hospital is made and the woman is at last able to let go and get on with the necessary work. The emotional and psychological state of a woman is a key factor in any birth, perhaps especially for those planning birth at home.

Much of this is speculation, but talking these events over and observing labours closely is how we learn more about birth and its many variations. There are always so many strories to tell!

This afternoon I head to Spain again, to present a workshop for the Acuario Birth Centre in Beniarberg, near Valencia. This will be my third visit to this wonderful centre and I am again looking forward to catching up with my friends there.

This time I am hoping to talk to the people who come to the workshop, and the organisers, about setting up a network of like-minded midwives etc in Spain. From the feedback I have had from midwives in workshops (both in Spain and from Spanish midwives in Britain) and the numerous enquiries that my previous Diary entries, there seems to be a need for a support network to keep moral high and lead a process of change.

There are a number of Spanish people who would like to see more options for birth, fewer interventions, a more holistic and humanised approach to maternity care and better outcomes for mothers ans babies. In short, a midwifery alternative to the current obstetrically dominated services. Changing entrenched programs is hard and difficult, but not impossible and it will take commitment and effort to get such a process moving. A network, probably based around an email discussion list, would be a good place to start. I’ll be talking to everyone that I can during this trip about this possibility and if we can geta group established I will put the details into a future Diary entry.

In the meantime, if you would like to join such a group, please put a comment on this Diary entry and we can be in touch with you.

Sometimes when I am in Spain it can be difficult for me to access my emails regularly and to write my Diary entries as often as I would like. It may be a few days before you receive the next installment, but I will have several days to report on by that time and will post these entries at the same time, as soon as I can.

This workshop in Burton on Trent (yesterday and today) is on the theme of “Teaching Skills for Educators” and it makes a good change of pace from the Active Birth workshops I have been presenting over these past weeks.

Several group members are from Goodhope Hospital in Sutton Coldfield near Birmingham and I was delighted to hear of the progress they are making in their efforts to keep birth normal and to incorporate the ideas we had explored in the workshops I have presented there in the past. They are running their own Active Birth programs now for parents and also for staff - which is a wonderful development. It is so encouraging to have this feedback and to know that what I am offering is having some impact.

We cover a lot in this Teaching Skills program - starting with some of the foundations for developing parent education (working with adults, aims and objectives, teaching and learning styles etc), program planning and of course, lots of different presentation ideas. My main goal is to shift thinking from the emphasis that is usually placed on cramming in information and facts, towards enabling parents to gain skills they will need to manage their changed lives during pregnancy, birth and parenting. Many programs are so short these days (often only 3 or 4 sessions) that attempting to make sure parents “know everything” is clearly futile. It makes more sense to help parents feel confident solving problems, learning how to use the health care system effectively and to evaluate the options and choices they will be offered. A good dose of consumer rights and negotiation skills are also useful.

The activities I include are all designed to enable these skills to be developed by group members, whilst they have fun, get to know each other and build their confidence. When I present these workshops I realise how much I miss being able to work with expectant parents. One day when I am unable/unwilling to continue with all the travel, I will again be able to offer programs for parents on a regular basis. It is such fun and so rewarding - a real community service.

The “what will people think” syndrome popped up yesterday, during the second day of the Nottingham workshop. In a punitive environment, or one where there is very little mutual support from colleagues or management, midwives will no doubt worry about what will happen if they step outside the accepted practices or try something different. This kind of climate saps confidence and undermines autonomy and should be stamped out by midwifery managers, who are responsible for the overall philosophy of a maternity unit.

The only real barriers for trying new approaches, using innovative ideas and experimenting, are in people’s minds. In maternity care, where meeting the needs of pregnant and labouring women should be the central aim, midwives have the opportunity to work with a degree of freedom that offers excitement and enviable possibilities for professional development. As long as a midwife practices with good intent, safely and with the full permission of the woman, she is protected by law and should receive the support of her superiors. She must be able to justify what she does and provide evidence for her actions, but at the end of the day, she is primarily responsible to the women for whom she is caring.

Midwives gain valuable experience when women ask for something different, or labour in ways that appear to step outside the boundaries of current practice. This is the way to learn about the many variations ion the birth theme, and to discover the mysteries and strengths of women’s bodies.

When midwives shy away from supporting women, when they back the protocols and policies at the expense of women’s needs, they not only let the women down but they undermine their own positions and professionalism. Who cares “what others think”? It is the woman who matters most, and keeping her birth normal and supporting her physiological needs is a midwife’s primary goal. When colleagues snigger and finger point, when others make snide remarks and sarcastic comments, it is their inflexibility, lack of imagination and basic humanity that is being exposed. Women will support a midwife’s efforts in improving her birth experience, and this is the place to look for the most valuable rewards.

The issue of risk assessment came up in the Nottingham workshop yesterday. Many midwives in the UK believe that they are required to follow protocols and policies closely or else they will be at legal risk, resulting in women being subjected to unnecessary procedures and risky interventions, just because the policies state that these must be routinely carried out. Inductions, rupturing membranes, applying electronic fetal monitoring routinely and giving syntometrine for third stage as standard procedure are a few examples that spring to mind.

In contrast, women are told that having a home birth is decidedly risky and many are being denied this option for very spurious reasons. This issue was canvassed in a wonderful article in the June issue of MIDIRS, and drew on responses from the ukmidwifery email list to compile a list of “excuses” for denying women their rights to a home birth.

The article also included a list of criteria for accepting a hospital birth that women might want to consider. It was produced by Laura Abbott, a British independent midwife and makes interesting reading. Here is the list - you might want to include this in your prenatal program, so that women can make a truly informed choice about a birth place:

Criteria for eligibility for hospital birth

Must not be scared of needles

Must not be claustrophobic or uncomfortable in confined spaces

Must be able to fast for long periods of time

Must be happy to share one toilet with 30 others

Must accept that said toilet may be a considerable distance from the bed area

Must enjoy sleeping on a mattress covered in plastic

Must not have rebellious or questioning nature

Must fully accept that may contract MRSA [a serious hospital acquired bacterial infection resistant to all antibiotics]

Must fully accept that may contract any infection: uterine or perineal

Must be happy to share one midwife with three other labouring women at the same time

Must also be happy that said midwife has been fasted for many hours

Must like and trust in electric equipment

Must be happy that has a 1:4 chance of having major surgery for no good reason.

This non exhaustive list has been included in your medical records and must be discussed and signed by you (the mother), a registered midwife and a supervisor of midwives. If this has not been discussed or signed by all of the above staff you will not be allowed to have a hospital birth and will unfortunately have to stay at home to have your baby.

The 500th baby was born at the Hemel Birth Centre yesterday, while we were workshopping away in another part of the hospital. The unit has only been open for around 18 months, and has proven very popular - the number of women choosing it has exceeded expectations.

The midwives had organised a raffle to be drawn when this milestone was reached, so yesterday, after we finished the program, I was invited to draw the winning ticket. There were 16 prizes in all, so I took turns with Caroline Duncombe (on the left) and Nicky Wilkins (on the right) to choose the winners. The photo was taken by Jenni Farrell, the workshop organiser.

This Birth Centre is a lovely unit - as a stand alone centre it is 20 minutes from the nearest referral centre and the autonomy of practice that it offers midwives is excellent. They have a “snoozle room” too - a lovely dark room, with soft beanbags, a mattress and floor cushions, lava lamps, other mood lighting and peaceful music. Anyone in the unit is able to use it, to chill out, relax, recover or rest. Women often use it in early labour and midwives can also take time out to restore energy after a busy shift. There have been a few babies born there as well - it is a very comfy and inviting intimate space.

The statistics for the first year of operation of the Unit are being compiled now, and I have encouraged them to publish them in an appropriate midwifery journal. Successes such as these need publicity, so that others can learn how it can be done, and to strengthen the case for more of these kinds of services.

It was a terrific weekend, and a pleasure to be among a group of dedicated and enthusiastic midwives. This afternoon I am off to Nottingham for another in an ongoing series of programs fot the midwives in that area.