Andrea’s Diary

It was the last day today for our General Manager, Jason Tunbridge, who has been head-hunted for a job elsewhere. As I pointed out my last Diary entry, you can learn a lot from working here, and sometimes find yourself talking about things you never dreamed you would be discussing.

Over our farewell lunch for Jason, the Epi-No came up in conversation. At the ACMI Conference in Perth, Jason had one of these devices on display and was asked about it by many of the people who visited our stand and it seems that people either like it or hate it. Explaining how it works, however, led to several hilarious discussions - one of the hazards of being a man in a woman’s world is having to deal with this kind of task. Jason, with his wicked sense of humour, handles this kind of thing really well, as I am sure the midwives concerned discovered.

We will miss him in our office. As he pointed out, when he joined Birth International he knew nothing about childbirth, apart from being present for his son’s birth, and now he can provide basic information on a whole range of topics, including the Epi-No! We wished him well with his new venture, and hope that he can find some ways of using all this new found knowledge, gained over the last four years. He’ll be a hard act to follow…..

I am often impressed by the trouble some women will take to avoid hazards during their pregnancies. The desire to have a healthy baby is a powerful motivator for women and many will go to sometimes extraordinary lengths to protect their unborn baby.

A woman phoned me today wanting to know who she could contact to have her microwave oven checked for any leakage of microwaves that might pose a danger to her as yet unconceived child. This was a question I had not been asked before and I had to quickly think of possible leads for her. In the end I suggested she contact the Australian Consumers Association because they test all kinds of household products, especially electrical appliances, and surely one of their technical staff could answer this question for her.

I would think the risk from microwave ovens would be negligible and there would be far greater concern about exposure to the chemicals that we ingest in various ways every day. Recent reports in the UK suggested that aerosol air fresheners and deodorants etc could be behind the rise in several childhood illnesses, including allergies. We live in a potentially toxic world and avoiding hazards can be difficult, given our lifestyle choices and living environments.

Good luck to the woman who called me - I hope she is reassured by the information that she is able to obtain. To be really sure of keeping her unborn baby safe however, she may have to consider living in an isolation bubble, avoiding many foods, contact with other people and lead a spartan, basic existence. On the other hand, babies are remarkable resilient and exposure the chemical cocktail in which we live, even if filtered through to the womb, may help them better prepare for life on this planet. I’m sure that this mother will do her best and that her baby will achieve its potential according to Nature’s grand plan.

As I said to my newest staff member - working for Birth International can be a challenge when we try help people with all kinds of questions. Working here will definitely broaden your outlook and encourage lateral thinking!

There have been several interesting reports in the British press over this past week concerning midwifery. There was the announcement that starting in January next year, midwives will be required to ask pregnant women is they are being physically abused by their husbands/partners. It is known that many women suffer from domestic violence for the first time when they become pregnant and for many others, the level of abuse increases when they are expecting a baby.

It is not clear what midwives will do with this information, or indeed, if there will be training in how to handle this delicate subject so that useful discussion can take place. This is an area of concern that has been on the agenda here in Britain for some time, with several articles and books being written about it, and a number of studies undertaken. Whether the reporting and documentation of this kind of abuse has any impact on reducing its incidence remains to be seen, but I guess asking the relevant questions is the place to begin.

The Observer newspaper carried a report of a study by Cambridge University researchers of 785 obstetricians in the UK and Ireland (as yet unpublished) that canvassed the reasons behind the increasing caesarean section rate. The main reason given by77% of those surveyed, was “patient’s choice” with “fear of litigation” cited by 67% as a key reason. This is very interesting, especially in light of government figures that reveal that last year there were 60,000 fewer claims for compensation from insurers than the year before, and that the number of claims against the NHS fell by 20% in the last year.

Of those caesareans being undertaken as a result of the “patient’s choice”, only 7% were for non-medical reasons, which suggests that complications (genuine or manufactured?) were the underlying factor for so many women opting for surgical births.

It seems that doctors think they will be sued, even when the chance of this happening are low, and falling. The doctors are clearly frightened, but by whom - the women, or their insurance company? The companies stand to lose a lot if there is a successful claim brought against a doctor, giving them ample reasons to frighten the doctors into doing unnecessary surgery to forestall any later claims. No-one has been sued for performing a caesarean it seems, yet many are perceived to be at risk if they don’t. Surely one day there will be a landmark case where a woman wins damages for an unnecessary caesarean that caused her ongoing pain and suffering. It was a highly publicised court case that changed the way that patients are now informed of their risks for any medical procedure. We need one or two similar high profile stoushes in the courts to stop the doctors, and their insurance companies, in their tracks and force the cessation of unnecessary surgery for birth.

As I pack up in readiness to return home from the UK, I’ve been reflecting on the workshops in this round and the experiences that I have had. The programs have offered a wide variety of groups and levels of midwifery care: very medicalised maternity care in Italy and Belfast, enthusiastic woman centred care in Inverness and Leamington Spa and great students in Limerick.

Again it struck me how insular these various hospitals are and how unaware midwives are of developments in their field in nearby towns, let alone other parts of the country (or overseas!). Many are struggling to change policies or want to develop new programs to extend options for women, yet they have not looked around for evidence they could use to bolster their case or strengthen their arguments. As I often point out in workshops, every hospital has a different approach to service provision, so there are many variations on the theme. It is likely that any new development a hospital wishes to pursue will have been tried already in another unit, and drawing on their feedback can save a lot of time and heartache.

Many midwives are frustrated with the tight control the doctors have over their practise and the inevitable increase in interventions that comes from over medicalising maternity care. In Wales, the Clinical Pathway for Normal Birth has had a dramatic effect in lowering caesarean rates, increasing the rate of home births and giving midwives confidence to practise their skills.

This Pathway, which puts the emphasis on keeping birth normal through adopting a midwifery model of care, provides clear guidance for caregivers, setting out parameters for “normal” that enables many women to achieve physiologic births. One example is that the usual standard of “one centimetre and hour” for dilatation has been extended to “two centimetres in 4 hours” which gives leeway to those women who dilate unevenly, with perhaps a lull after they arrive into the hospital.

In time, no doubt the requirements of this Pathway will be reviewed and the criteria re-evaluated, in the way of all such documents. It has certainly given midwifery a new lease of life in Wales and the results have been very pleasing. Yet so few people in the rest of the UK have heard of these developments. I have mentioned the Pathway many times in workshops and suggested that midwives have a close look at producing something similar for their units. I understand that Scotland is pursuing the development of an all-encompassing guideline of a similar nature, and I hope that this is the case. I wonder in Britain will follow suit?

Meanwhile, there is nothing to stop individual midwives or maternity services from developing their own pathway for their own local practices. I suggest you click on the link above and have a look at this Pathway and the associated documentation (evaluations etc) contained on the Welsh site. There is plenty of food for thought there!

The maternity hospital in Limerick has no bathtubs and only two showers available for women to use during labour. This is typical of many hospitals, especially those built before the benefits of warm water for easing labour pain had been fully appreciated.

I suggested that one solution might be to buy a couple of portable pools, which could be set up as required and stored when not in use, by either standing them on their side, or dis-assembling them. The comment was made that perhaps the hospital’s engineers would raise objections that the floors were not strong enough to support the weight of a full tub of water, and of course this needs to be checked out. There is also the issue of space within the room to set it up, which might be overcome if some of the extraneous equipment was removed (perhaps even the bed could go - now there’s a radical thought!). Access to taps for hose attachments and a drain where the water can be pumped to empty the pool will also have to be available. Disposable pool liners (inexpensive plastic sheeting can be used) will be necessary for each woman as well. Families planning home births manage these arrangements, so it can’t be all that hard to organise.

It is easy to see how these kinds of potential problems could be used to discourage serious consideration of a portable pool, especially by unsympathetic or over worked managers that just don’t want to be bothered. One way around this might be to ask the engineers to investigate the room structures, floor joists etc as part of an overall assessment of the facilities, rather than as part of a “pool installation” program. A pool of water weighs around half a ton, so they could be asked to indicate where equipment of this weight could be safely located in each room, if necessary. Armed with such a report in advance, it would be harder to find valid structural arguments to refuse the request for such a pool.

The next step would be training the staff in the necessary procedures. There are many ways this can be done, and workshops that cover the basics of health and safety can be arranged through various agencies.

As a short term measure to compensate for a lack of facilities, I think buying a portable pool is an option worth considering. I have known hospitals where this has been done successfully and where labouring women were therefore able to enjoy facilities available in other newer hospitals.

Back in Ireland this week, this time in Limerick in the Republic. I was delighted to learn that this group will be all the students in their second year (24 of them) plus some physiotherapists and a few midwives from the Maternity Hospital.

It is always good to work with students. There have been dramatic and rapid changes in Ireland around midwifery education and instead of the old hospital based training, students are now based in universities, where they cover the theory, while working in the hospital for their clinical components. In some ways it seems the training has not changed all that much - students are still working in the hospitals as part of the staff complement and there are few opportunities to see and learn from other ways of working (birth centres and home births are not available options in this part of the country).

A couple of midwives and students in the group had seen a home birth, but most are seeing women labour and birth with epidurals and the caesarean section rate stands at 30%. Not a good basis for learning about midwifery care, so I re-arranged the program and showed the film “Inner Strength” early in the day. As I have described before, this film is an eye-opener and is sometimes viewed as a bit shocking (all that raw emotion, verbalisation, close involvement of partners and spontaneity can be confronting for those used to anaesthetised labouring women). The comments afterwards revealed that these were the first really physiological births many had seen and they pointed out the very different birth experiences of women in Limerick. The hospital here has two showers and no baths available, and other basic equipment such as birth balls and mats are in short supply. The maternity unit is, however, being extended - another operating theatre is being built!

I am sure that these students will be disappointed in the quality of their Course and the education they are receiving. We talked about the shortcomings and then I asked them what they were going to do about them, suggesting a number of possibilities.

Students are expected to ask questions, and this can be a useful spur to re-evaluation of policies, routines etc. There will be midwives working in the unit who are more in tune with active birth ideas, so they should seek these out as mentors - working together with them can be a big help for all parties - midwives, women and students. Looking for ways of educating pregnant women about alternatives to epidurals and making sure they know about the effects of epidurals on themselves and their babies can encourage women to try other approaches in labour. Women having second (or subsequent) pregnancies are often keen to have better experiences - these are women that may be prepared to work with a student during labour and experiment with different strategies. There were other ideas as well - students can do a lot to encourage change and at the same time help themselves.

We’ll work on these strategies tomorrow and explore a whole range of simple things they can do to make immediate improvements for individual women. I hope to motivate these students to stick with their studies until they graduate and can take complete responsibility for their own practise.

Another topic for discussion amongst the group on Friday was the use of TENS in labour. I’ve written about this several times before, so I won’t expand on my views again, suffice to say that I agree with the Cochrane Library reviewer who stated that it was a technology that was of such little value that no further money should be spent in researching it.

I made this statement when I was asked about it by the physiotherapists in the group. They have used it a lot and are quite convinced of its effectiveness for relieving pain inlabour. They said that the Cochrane Review is quite old, published in 2000 (which it is) and that since then quite a lot of research has been done on this device in Ulster. On further enquiry, I gathered that this research was not done in pregnant women because of “ethical considerations” but that the studies completed to date suggested that the claimed efficacy of this gadget in other settings could be translated to pregnant women, at least in theory, if not in practice.

I am not so sure about all this. Somehow, the nature of labour pain, as far as I can see, is different from pain caused by a disease or injury. I am not convinced that eliminating pain in labour will be beneficial in a biological (or even an emotional or physical) sense. I am also not convinced that TENS is the answer to raising endorphin levels - and I was unable to get confirmation from these physios that this was a proven outcome of the various studies done in Ulster.

The “ethical considerations” also seem suspect to me. This is reminiscent of the obstetric anaesthetists claim that to subject epidurals to randomised controlled trials would be ethical on the grounds that some women in the trial would have to be denied access to an epidural, a move they considered was unethical and unreasonable. It is a neat way to avoid close scrutiny of a technique or procedure that may give unwelcome results.

I still maintain that TENS is a gimmick designed to make a lot of money for its manufacturers and keep women believing that they cannot give birth without technological assistance. The physios did not provide me with any hard evidence to change my mind and until I see the results of these trials in Ulster published and evaluated, I’m sticking to my views.

Today I found the reactions of the Belfast midwives I am currently working with a bit depressing. Although they are very keen to explore the concepts of Active Birth and half of their staff complement are in this group, I was left with a distinct feeling that many of them felt the ideas could not be implemented “with their kind of client”.

The hospital is located in the north of the city, in an area that is socioeconomically disadvantaged, withe the highest rate of teenage pregnancy and unmarried mothers in the UK. The welfare state provides well for young mothers and provides some incentive to have babies when young, and this has become a tradition in many families. I was also told that contraception can still be hard to obtain, as even though doctors may write prescriptions for the pill, many chemists will not stock them for religious reasons. Many teenage women make great mothers and I am not being critical of their decision to have babies, if this is what they want to do.

The welfare mentality can prove problematic and this was raised in another context by midwives in the group. Everyone in the UK contributes to the health care system through their taxes, and in return they expect access to all available health services throughout their life. This was the promise made in 1948 when the National Health Service was introduced - that with a universal health care service, paid for by all taxpayers, no-one would be denied health care whenever they needed it.

These days this promise has created problems of its own. Women are arriving into labour wards expecting that they can have an epidural on demand and maybe even a caesarean section if they desire. Women are not seeking full information about these options and it is convenient for the system to encourage their use as it makes for better control over births in busy hospitals. The lack of informed consent is a potential time bomb, which could also prove expensive if women decide to take action over outcomes they didn’t expect.

Here in Belfast, I think the high caesarean rate (29%) may be due, in a large part, to the high rate of epidurals and inductions. I got the strong feeling that many midwives were willing to offer epidurals because they believed that women should get what they are entitled to, and of course they have little else to offer (warm water, positions, hot packs etc). I hope to shift some of their thinking on these issues today and give them some alternatives they can try instead of just offering the menu of drugs. Few of these midwives have any experience of home births and some seemed uncomfortable with normal physiological labour. Their reactions to the noises of normal births (as shown in the film “Inner Strength”) indicated that they were personally unsettled, dismissing the messages of the film as “impossible with our women”.

It is a very conservative area, that was made clear, yet some are open to new ideas and the fact they so many are attending this program is a positive indication of interest in new ways of working. We will see how we go today…..

The topic of waterbirth was on the agenda yesterday with the group of midwives in Leeds. One if the videos I showed was a home water birth, “The Art of Birth”, and I was primarily using it to remind us of the profound effect that birth can have on fathers.

After it was shown, the comment was made that it was nice that this woman was able to use the bath in her own home - that in her Trust, the policy was that any home water births had to occur in a specially hired pool. It was forbidden for a midwife to assist a woman birth in her own bathtub. This was very surprising - I had never heard of this regulation before. The reason given for this policy was the issue of infection control…..!

I wondered about the rationale for this policy. Surely the home bathtub would not pose a problem for the woman - after all, any bacteria that were present would belong to her and her family. Perhaps the safety of the midwives was the issue here - exposing midwives to someone else’s bacterial flora could present a problem, but midwives wear gloves and the water will dilute any bacteria, reducing any risk (water births for women who are HIV positive, for example, are quite safe for the midwives, according to the research). Handling issues would be no different - a midwife would have to bend just as much for a bathtub as she would for a pool.

Perhaps it is a move to make sure that the pool hire people will stay in business. It will certainly cost the family money to get a pool in place and require them to find a suitable area with strong floors, access to drainage etc. If the family bathroom cannot be used and there is nowhere else suitable for installing a pool, then some women might miss out on their wish for a home water birth.

Is this another example of silly bureaucratic measures designed to run our lives for us?

The workshop I am facilitating in Leeds has a large number of midwives who are involved in prenatal education, and there are also five physiotherapists in the group.

Given their interest in parenthood education, I have put more emphasis on communicating with women and boosting their confidence in normal birth through various exercises and activities. I also raised the issue of early pregnancy classes and their value in giving expectant parents a chance to explore issues that are relevant at that time, such as nutrition, emotional aspects of pregnancy, taking care of yourself and the baby during pregnancy, sorting out the various diagnostic tests they will be offered etc.

The possibility of meeting a midwife and being exposed to the midwifery philosophy about birth is also an important attribute of these classes. Many women have their pregnancies turned into an illness through the fundamental structure of pregnancy care, with its focus on numerous tests, regular check-ups and repeated surveillance techniques. Midwives and childbirth educators have a wonderful opportunity through various kinds of prenatal programs to shift women’s views about birth and every chance must be grasped.

This is especially important for women with a previous “obstetric history” who have often been left with many unresolved feelings than can impact on their approach to future pregnancies. We also talked about the usefulness of VBAC classes and today I will give some time to programs aimed at parents who already have children. Refresher classes, as they are often labelled, not only have the potential to enable parents to work out strategies for achieving a better outcome in the current pregnancy, they are also useful in bringing change to the system.

Every “Active Birth” workshop that I present is different, and this one has had a special emphasis on education for parents.