Andrea’s Diary

The feedback from my last Diary entries about the workshop in Dublin has been interesting. I gather that there has been some discussion on the Irish Midwifery Egroup discussion list (G’day all my Irish readers!) and that I have raised the ire of some midwives.

If people are talking about the issues I have raised then that is terrific. My intention is not to irritate or annoy people, but to raise awareness and encourage action to improve the maternity services in Ireland. It would be easy for me to walk away, shaking my head and full of pity for the women who must suffer under this system (women and midwives). Shooting the messenger is also a very easy game for people to play and neatly avoids facing the problem or tackling the issues. The fact is, I care about the women here and am willing to do my bit to bring about a change I know that many people in Ireland want, but feel powerless to influence.

For those who want to consider these issues further, I would urge you to read these articles, to print them off and to circulate to colleagues, friends and anyone else you think would benefit:

Fish can’t see the water

The Active Management of Labour

I will be writing more on maternity care in Ireland after I complete the workshop today in Limerick.

Today I am back in Limerick, to present an Active Birth workshop for midwives from the Regional Hospital and surrounding units. This is a follow up visit from one I made last October, when I worked with all the second year students in the current group at Limerick. That visit had been arranged in response to a request from the students for more input on normal birth and how this could be facilitated, because they felt they needed more practical experience in this area. That workshop contained 24 students and a few staff, and was a very interesting two days.

This time, the group will consist of midwives on the staff of the local maternity hospitals. I have already had some feedback from the students, several of whom attended the Perceptive Midwifery program that I ran in Glasgow recently, and it seems that the last workshop here resulted in mixed outcomes. The students were happy but some staff were a little sceptical. My aim will be to turn their thinking around as well, and to re-kindle the midwifery philosophy in this western area of Ireland.

Some lovely feedback came in today, from a midwife who attended my Active Birth workshop in Warwick recently. She and her colleagues from Lincoln had been enthusiastic from the start, and they obviously were ready to be energised around making some changes. This is what she wrote to me:

“I attended Andrea’s workshop last weekend in Warwick with four other colleagues. We have gone back to our unit in Lincoln and taken the place by storm!!! The beds are moved, I have placed a large amount of information relating to active birth on our “Taking normality forward” board, our labour ward tour is changing as from this Sunday, the dates are filling up for a new parent workshop I had alreadt planned and there has been a massive change in moral and practice in just the last five days.

Even the doubting Thomases have had to admit there must be something in it with the increase in either reduced analgesia or drug-free normal births many amongst primips. You can almost feel the excitement and eagerness in the air.

I am currently the leader on a 6 month project to take forward normality and felt that the workshop would be a turning point. I had no idea though what a profound effect it would have on the five of us who attended and how quickly it could grow within the unit. We all feel like different midwives and if the growth and change within our labour ward, unit and community continues then we will truly have made a real move towards women centred care.

Thank you Andrea for relighting our passion and belief in midwifery and the wonder of pregnancy and birth”.

Jane Kania, Midwife, Lincoln Maternity Unit

I am thrilled to hear of the changes that these midwives have made in their unit. I trust they will keep it up, not always an easy task, given the pressures midwives are under, the system itself (which can be resistant to change) and the reactions of other staff, which can be undermining and demoralising. I was impressed by the commitment of this group, however, and know they will appreciate the impact they will have on the women in their care, and that this will sustain them in the long run. Congratulations to you, Jane, and your colleagues, and best wishes for the future of maternity care in Lincoln.

One of the issues that arose during the workshop in Ireland is the way that personal attitudes, beliefs and philosophy affect the content of the program that an educator facilitates.

Women today have been sold the idea that labour is so painful that an epidural will be needed. In providing the full story about epidurals and other ways of handling the pain of birth, a childbirth educator needs to be able to “sell” other options, such as the use of water, movement, creating an effective environment for birth etc. Getting these ideas across is much easier if they stem from the experience of the educator herself, and if she is familiar with the way these alternatives work in practice.

When an educator has had a difficult birth, or has been the victim of a rigid medicalised birth system herself, it could be hard for her to be confident about using these alternatives or convincing in her “selling” of these ideas. Tied up in this could be an unwillingness to be seen as a “failure” herself and a concern about creating expectations that women can achieve a non-medicalised birth when her own experience tells her this is very difficult or impossible. Whilst this approach may be understandable from a personal emotional perspective, there is a risk that with holding information may serve to perpetuate a brutal system that exploits women during the birth process.

In making these comments, I don’t mean to imply that only women who have natural, non-medicalised births should lead prenatal programs. My point is that educators need wide experience, and this can be gained by attending births, acting as a support person, visiting hospitals and birth centres and by talking to women to have had a variety of labour experiences.

Educators who have unresolved feelings about their own births must recognise that they have unfinished business that needs attention, to avoid their feelings unconsciously colouring the messages they give others. Women seemingly delight in recounting horror stories about labour to each other, and this is something an educator must avoid doing at all costs, even in a subtle or subliminal way, when she is facilitating a program for expectant parents.

Some of the comments that were made in Dublin by some of the educators indicated that they had personal issues around their own births that may well be affecting what they are saying to pregnant women. Many had little current experience of labour ward practice and most had never seen anything other than routinely actively managed births. Their attitudes and beliefs were reflected in the language they used, the comments they made and their reactions to my suggestions for teaching strategies. I felt that many found my ideas a little uncomfortable, and therefore they would not be pursuing them.

Parents gather their ideas on labour and birth from many sources and they respect that their childbirth educator as a professional with expertise on the subject. It is therefore the responsibility of the educator to put personal feelings aside and to strive for the best educational opportunities for the parents in their programs. If this means the educator stepping outside of her comfort zone to gain a wider appreciation of birth choices and options, then this is something she has to undertake. It won’t be easy in the Irish context, but every effort needs to be made, if the system is to be challenged as it surely and sorely needs.

My trip to Dublin this week has left me with very mixed feelings. Whilst I very much enjoyed being with this group of Irish midwives and public health nurses, I was dismayed by what they told me about the state of maternity care in Ireland, especially in Dublin. I guess that in some ways I was not surprised by this - Dublin is after all the home of the “Active Management of Labour” protocol that forces women to accept a predetermined management plan for their labours, whether they like it or not.

The most disturbing aspects of the workshop discussion for me were the group’s acceptance of the status quo, their unwillingness to consider the suggestion that this could be challenged to any degree and the outright fear of labour that these educators, on the whole, expressed.

The rigid management of labour, as set down by the Master of each hospital in Dublin, requires that women spend no longer than 12 hours in the first stage of labour and one hour in the second stage. This is achieved by the routine use of rupturing membranes, liberal use of oxytocic drugs and instrumental deliveries if the birth is delayed beyond the given time frame. Whilst there is a pretence of “allowing” choice, “informed consent” is often obtained under duress, such as in the transition phase of labour when a women is required to listen to the anaesthetist explaining the pros and cons of epidurals before requiring her to sign a consent form. If a woman decides that she doesn’t want a standard procedure, or questions a policy in any way, she is labelled a trouble maker and will be subjected to verbal abuse, intimidation and harassment during labour. It is no wonder that given these circumstances, childbirth educators are unwilling to encourage women to speak up for themselves during labour and that preparing for this regime is seen as preferable to leaving women potentially vulnerable in labour.

I was surprised that so many of these educators were frightened of birth. Given that they will have had their babies withing this system themselves, much of this fear will have come from personal experience. Quite a few were public health nurses, and would not have had any direct experience of maternity care for some time, and this places them at a disadvantage, as they have to reply on their colleagues who work in the maternity hospitals to relay information. What they are being told to pass on are the policies and procedures that the hospital want women to accept without question. Very few of these educators were aware of the evidence surrounding birth issues or used the research in their classes as a basis for encouraging informed decision making. Parent education programs were typically 3 or 4 sessions of 2 hours each - far too short to provide any real educational experience for parents, but enough time to explain the procedures they would face.

It is hard to know what will stimulate change in the Irish system of maternity care. Given the subjugated position of pregnant women, I think it is unreasonable to expect them to force change through their questioning or requesting of alternatives - they fear very real retribution, and no woman wants to risk this when she is at her most vulnerable during labour. The midwives have seemingly given in as well - no doubt because of similar threats - and appear to have lost touch with their professional role as the protectors of normal birth. They don’t seem to have appreciated the fact that they are colluding with the doctors in the shameful exploitation of pregnant women when they fail to challenge what is going on.

The doctors will not force change - they are making squillions of Euros each and sit very comfortably at the top of a chain of command that bestows huge power over women (both the pregnant and the professional) and the health care system. My good friend Doris Haire, American birth activist extraordinaire, suggests that the best solution is to “sue the pants off them” as money si the only language obstetricians understand. Given the amount of emotionally and physically damaged women will be leaving these birth factories, perhaps this is a likely solution. The litigation rate in Ireland is certainly very high.

I am returning to Dublin in June to present another Teaching Skills workshop for a further group of educators. I wonder if there will be any fall out from my visit this time, and whether the next group will have many of the same characteristics as this one. I am not blaming these women for their approach to parent education, I am just sad that they have not been given any opportunity to embrace and pass on the joys of birth to the women they serve and to use the influence they have to encourage and stimulate change. I will try and get these messages across with my next group.

Today I am off to Dublin to present a Teaching Skills workshop for the Irish Nurses Association. It is the first of two programs (the next one is in June) and I note from the list of attendees that many different hospitals will be represented.

I am looking forward to using this opportunity to find out what is happening in the Irish maternity services, especially now that midwives are starting to develop a higher professional profile. Health care in Ireland has long been dominated by the obstetricians, and it is the only country where the chief obstetrician in the major hospitals of Dublin are known by their title of “Master”. Not Doctor, not Mister (as they do in the UK) but “Master”. It says a lot about the way they, and others, see their role.

One of the main themes of this workshop will be enabling parents to develop their skills in dealing with this kind of health care system. The issue of informed consent will be a major topic for discussion and exploring women’s rights, responsibilities and capabilities will no doubt feature.

The Irish can be a feisty lot, full of fun and willing to take a chance. I wonder if these qualities will come out in this group of midwives/nurses?

During the last day at the Warwick workshop, I was given some of the birth outcome statistics for the unit. These were really encouraging, and demonstrate how midwives can work together to achieve better births for women. The Caesarean section rate has fallen from 24.5% tp 22.7% in the last year (the national average is 23%), the assisted birth rate is down from 13.1% to 11.8% and the normal birth rate, as a result, has risen to 65.6%, up from 62.4%. Homebirths are also increasing, with 3% of women giving birth in their homes, up from 2.6% the previous year.

The midwives in Warwick can be proud of their efforts, and I hope that they will be spurred onto even better outcomes, now that they have seen the impact they can make. The Caesarean rate is till way too high, but could be reduced by avoiding elective repeat caesareans, supporting VBAC and reducing inductions and augmentations. If they can use water and heat as substitutes for epidurals and limit the use of pethidine, both Caesarean and instrumental delivery rates will fall further.

I look forward to meeting some midwives from Warwick again in the future, and to seeing what they have achieved for this coming year. Perhaps a home birth rate a few percentage points higher?

Last time I presented a workshop at Warwick Hospital near Leamington Spa (October 2004) , I wrote in My Diary that the midwives here were working in a rather medicalised model of midwifery care. When I arrived this time, I was naturally keen to learn what had happened after my last visit - were things different?

I was told there had been some fall out. Some of those attending had been rather negative and so they had challenged my right to make any comments, using the well worn argument “and she’s not even a midwife!”. I always find this an interesting remark, as it reveals a lot more about the person making it than it does about me. My feedback had started some useful discussions however, and some of the ideas we had explored in the workshops are now being used. I was heartened to hear this, and I hope that after this weekend program, further innovations will occur.

The group in this workshop come from a number of different hospitals. Some are still medicalised and others are trying to implement a midwifery model to differentiate low risk women from those deemed high risk.

We had the usual discussion about the language, and the way changing the vocabulary can not only alter perceptions but form a starting point for creating a new approach to maternity services. The new models of care, usually labelled “midwifery led” still puts the emphasis on the midwife rather than on the woman, where it belongs. Many midwives struggle with substituting “birth” for “delivery” and talk frequently of how they “allow” women various concessions. Frankly, I believe that until midwives take changing their language on board, nothing much will change. When midwives follow the woman, which will be reflected in their language, it makes avoiding routines, getting around the protocols and policies and providing real choice very much easier. Midwives will also be fully practising their craft, as their “Rules” require, and will enjoy the protection of the law.

We will see how we go today. It’s the practical session, and the topics of being truly “with women” will be the main focus. I wonder how many times I will hear the words “delivery” and “allow” today?

The end of this week has me in Milton Keynes, a new city that is only 30 years old. It reminds me a lot of Canberra, but without the hills.

The hospital here is also relatively new, and resembles a collection of porta-cabins on the outside, although inside it has the usual NHS appearance. I had a quick look through the maternity unit after the first day of the workshop yesterday and although very functional, and not very comfortable, it did have a friendly air of bustle. They have a water birth pool in one room and a triangular bath in another, but I gather that despite a water birth training day, these pools are not used very much. We will tackle this issue today, as using water is a very good alternative to the use of pain killing drugs, all of which have implications and consequences for mothers and babies.

A topic for discussion yesterday was whether or not to cut the cord when it is tightly around the baby’s neck. In the past, feeling for the cord was a ritual carried out as soon as the baby’s head was born. Quite often, the cord will be found looped around the baby’s neck, loose enough to be lifted over its head, or for the body to slip through it. If the cord was very tight, delaying the birth, the practice has been to clamp and cut the cord. The consequences of this is that the baby needs to be born quickly as its oxygen supply has been severed. If further problems occur, such as tight shoulders (or shoulder dystocia) then the baby may suffer from a prolonged period without oxygen.

These days, the thinking has changed. It is no longer recommended that the cord be cut at all, and if left, even when it is tightly wrapped around the baby, the baby will perform a somersault manoeuvre, tumbling out rather rapidly. Its head will stay close to the mother’s perineum, while the baby’s legs end up away from her body. The cord can then unwrap from above. As soon as the pressure is released from the cord, the blood will start flowing again, providing the baby with oxygen while it recovers from its traumatic arrival.

Midwives have told me that they see this from time to time at waterbirths, where the water facilitates this action. A very tight cord is a rare condition, and most midwives will only see it a few times in their careers. Not jumping in with the scissors will be hard for many midwives, given their training, but if left alone, Nature takes over and the baby will be born, often very quickly.

For the last two days, Lynne Staff and I have been presenting “Perceptive Midwifery” workshops, the first one in Wales and today, in Glasgow. This program encourages midwives to explore their practice in depth, focusing on their ability to really get into rapport with women, especially when pregnancy and birth contain complexities. A large part of the morning session also deals with communication skills, because without these, a midwife may make assumptions about what women want, or may fail to really provide care that is woman-centred. Lynne asks the group to consider the woman’s needs in terms of her sexuality, her relationship with caregivers, the impact that technology will impose and the implications and consequences of the obstetric procedures she may be subjected to when her labour becomes complicated.

The two groups we have been working with could not have been more different. The group in Wales was made up almost entirely of midwives with many years of experience, mostly hospital based, but some community based as well. There were also two homebirth midwives in the group, both direct entry trained, and one with no hospital experience at all.

The group in Glasgow were mostly students, including five who had travelled from Ireland to attend. These were feisty, passionate women, keen to do the best for women, and all were struggling to handle the conflict between the academic teaching and the practical application of what they were learning.

It has been an enjoyable two days. Firstly because I always enjoy working with my colleague Lynne, who is a midwife with an incredibly strong belief and trust in women and a passion that has enabled her to facilitate all kinds of births in a very woman-centred way. Secondly, I have enjoyed being able to present some different material from the Active Birth or Teaching Skills programs that I am usually asked to do - not that I don’t love that work, but it is good for me to have a change.