Articles by Month: October 2002

Caerphilly Birth Centre in Wales

The Caerphilly Birth centre is a special place in Wales. For the past five years it was operating as a small obstetric unit then it closed, to re-open as a midwifery led Birth Centre in February of this year. They have 29 midwives, who operate pre and post natal clinics for women giving birth in the Birth Centre but also in other units in the area, including the Royal Gwent Hospital in Cardiff.

So far, there have been 140 births in the Birth Centre this year, well above the predicted number for the first year, and their results have been outstanding. Only 11% of women have had to be transferred to the main hospital and they have reduced their use of pethidine to only 7%. More and more women are also choosing a homebirth with the midwives - up to 10% at present and rising.

They have been told they will have to drop staff numbers by about 7 midwives as they are overstaffed. Naturally no-one wants to move - the midwives in this unit love their job and are really enjoy the births they are able to facilitate - all very normal.

At the Royal Gwent, the picture is very different. This is a very high tech unit with high epidural and caesarean rates. They are chronically short staffed, so as an interim measure, “Caerphilly midwives” (as they are labelled by Gwent staff) are being seconded to work shifts there. None of the Birth Centre midwives like this arrangement because they are under constant pressure to work in non woman friendly ways and to justify their reluctance to adhere to the strict protocols in the unit. Whilst these midwives shouldn’t be subjected to the bullying they are obviously getting, they could re-frame their shifts in the Gwent in a different light - as an opportunity to show their colleagues there is another way of working. They are unlikely to be sacked, so this gives them enormous power to state their position clearly and to buck the current system. This may be a very uncomfortable and unfamiliar role to adopt, but it could be the making of them...... they should recognise their talents and start trumpeting their special qualities that enable normal births to occur even in a rather hostile, medically dominated setting. Now there is a real challenge - are they going to be up to it?

Posted by andrea at 04:46 PM | Comments (3)

Fentanyl and the Russian theatre debacle

The news of the release of the hostages in the Moscow Theatre using a gas to subdue the terrorists has been everywhere these past few days. The death of 115 hostages, with another 150 in a critical condition due to the gas has raised a lot of questions and the Russians have been reluctant to reveal the details of the gas that was used.

Today the news is that its general composition is now known - it is an ‘opiate’ drug, chosen because it that sedates and eases pain. The Americans have identified it as Fentanyl. The Russians claim that it was meant to put people to sleep but not to kill them as has happened.

When I read this I couldn’t help making the leap from this poison gas to the Fentanyl and other opiates given to women in labour. They too are supposed to ease pain but are really sedatives. They also have unpredictable results, with some women hardly being affected at all and others almost passing out after a standard dose. People will say that the dosages used in Russia bear little relationship to the amount given to labouring women, but can we be sure these labour drugs are as innocuous as claimed? The fact that research is limited just proves that few people are interested in investigating the safety of drugs given to the unborn baby, it does not prove there is no adverse effect.

It may sound rather harsh, but this catastrophe in Russia may be useful for those of us who are trying to get reform of birth practices in the west. I hope that someone exposes a similarity between the use of this “poison gas” and the drugs that are routinely given to many women during labour and birth. If women knew the risks they were taking with their own health, let alone the health of their unborn babies, I truly believe they would avoid taking opiates (e.g. pethidine, diamorphine, Fentanyl) of all sorts, either as a straight medication or in an epidural mix. Perhaps the stark messages of all these unnecessary deaths in Russia will alert the rest of us (again) to the dangers of medications during labour. It’s perhaps a long bow to draw, but you know where my passion on these issues lies.....

Posted by andrea at 04:38 AM | Comments (2)

Are midwives really "with women"?

What a day I had yesterday! A very long 7 hour train trip starting at 6.00 a.m., across England from the North East to Wales, so that I could speak at a Conference outside Cardiff in the afternoon organised by the Bro Morgannwg NHS Trust.

There has been severe storms the day before, which caused havoc on t he roads and with train services, and the program had to be rearranged and some speakers had trouble getting there. This was fortunate for me, as I was only able to hear the afternoon session myself. Luckily, Mo Harris, Research Midwife from Derriford Hospital had her presentation changed to the afternoon and this was one presentation I really needed to hear.

Mo was reporting on a study that she has undertaken on “one to one” midwifery in practice. With perimission from all concerned, she positioned a black and white video camera high in the corner of several labour wards and made continuous recordings of a number of labours. In all cases, the midwife was responsible for only one woman at a time, meaning that she was able to stay with the labouring woman throughout the whole labour and birth - the “gold standard” that is held up as the ideal situation for midwifery and midwives.

Each video tape was transcribed and the activities being undertaken in each minute were tabulated, then analysed. Mo was able to show us video clips, some with sound, to explain her findings, and they were astounding.

All the women were on the bed and all had the baby’s father present. Some had another person as well, often the woman’s own mother. The midwife was most often seen in the corner, writing up her notes on a table that meant she had her back turned to the woman. Some women had epidurals and one had severe problems that mean she needed special care and close attention. The analysis showed that midwives spent very little time actually “with woman”, even when they were in the room. Most time was spent writing up notes. The midwife allocated to the woman who required close monitoring because she was at very high risk spent 43% of her time out of the room, taking breaks, talking to other midwives, or performing other unrelated tasks!

Several scenes showed the reactions of the fathers - overwhelmed and unable to cope. One woman is literally tearing her hair out (?transition) - the midwife is out of the room and the father puts his head down on his hands, clearly distressed. On several occasions, when the monitor revealed the baby’s heart rate dropping, the midwife still failed to interact with the woman or her partner - just made a few comments from the corner where she was writing up her notes. On one occasion, the woman’s own mother goes for help, when the monitor is registering a low heart rate and the midwife is (again) out of the room. Conversations with colleagues, such as the doctor when he is called in, take place in the corner and excluded the parents. If the handover occurred beside the bed the woman was included, but this was uncommon and the videos showed a huddle in the corner with the woman straining on the bed to hear what was being said.

What does this study tell us? It is very clear that midwives are not interacting with women, not comfortable providing physical support and poor at communicating with the woman and her partner. It is clear that women are still being confined to bed, that they find epidural insertion very stressful and that the needs of fathers are being completely overlooked.

I was shocked and very disturbed by its content and felt desperation that we could ever change this around without a massive change in the culture of midwives and midwifery. Mo still has this study going on and has now filmed in 9 maternity units. She has also taped doctors at work. In summing up her presentation, Mo suggested that perhaps we do need to employ doulas since midwives clearly don’t have time (and perhaps the willingness) to provide the personal, up close comfort that women need during labour. She also wants the system to be overhauled so that midwives don’t have to document everything so closely, or could do it in a more efficient (and less time consuming) way.

I was pleased I could leave the participants of this Conference with some images of a very normal, woman-centred active birth - if we had finished with Mo’s presentation I fear that we would have all gone home is a huge depression. I hope to find out more about this study and that the tapes can be re-jigged somehow to make them into training materials that can be used to sensitise midwifery managers and the midwives themselves into reviewing their practices. My god, it is very much needed!

Posted by andrea at 09:38 PM | Comments (4)

Midwifery in Hull

I’ve been in Hull this weekend, presenting an another Active Birth workshop for midwives from this area and nearby units. Amongst them were two Dutch women and a New Zealander, all enrolled in a Midwifery Course in York. It is always a pleasure to have midwifery students in workshops as they bring a fresh perspective and because two of them were Dutch, and one was pregnant and planning a home birth (of course), they asked lots of useful questions as well as highlighting the cultural differences between The Netherlands and the UK.

The Hull Maternity Unit is being combined with the Castle Hill Maternity Unit in about 6 months. They are only a few miles apart and combining them will create a unit that handles about 3,000 births each year. A Birth Centre is part of the plan and there is some concern about combining the two staffs and forging new workable policies that everyone can be happy with. Castle Hill has been doing water births, for example, and the Hull team have been more used to technology.

The workshop has given everyone a chance to review their basic attitudes and philosophy and as there were several key senior midwives in the group, hopefully they will have caught the enthusiasm of the others for developing a very midwifery orientated unit and take the lead in establishing the new unit’s ways of working. I felt very positive at the end and felt that many issues were raised and explored constructively.

One concern had been the lack of interest amongst midwives for working in the Birth Centre. Nine midwives are needed and to date only 4 have expressed an interest in working there. I discussed this issue with Julie Green, the Practice Development Midwife and suggested that she talk to the students that she lectures and perhaps set up a programme for new graduates to join the Birth Centre staff. Many students are not completing their training because they are disillusioned by the gulf between their theory and practical experience. If they could come out of their Courses and join a supportive staff in a Birth Centre where they could immediately reinforce their passion for true midwifery, many might either stay on to complete their studies or not leave as soon as they graduate. I hope she is able to consider this suggestion. I know that such a program exists at St George Hospital in Sydney where new graduates are specifically sought for the staff at their very successful Birth Centre. Surely it could work in the UK as well?

Posted by andrea at 04:52 AM | Comments (6)

The Cochrane Library

On October 18, the Australian Government has announced at that the National Institute of Clinical Studies has negotiated a license to provide free access by all Australians to the data held in the Cochrane Library. As most people working in the field of maternity will know, the Cochrane Library is THE repository of Randomised Controlled Trials concerning many aspects of health care. It began, over 20 years ago, by looking into maternity and obstetric care because this was the area of medicine least evaluated and most in need of reform. Since then it has expanded into other areas of medicine.

Although only 10% of interventions and treatments in medical care have been assessed, it is expanding quite quickly and there are currently 1,500 completed reviews and another 1,000 in progress. 60 reviews are being added to each quarterly update.

This is an initiative that will enable consumers as well as health professionals to keep as up to date as possible in terms of appropriate care. It is particularly relevant for those of us concerned with birth, because as a normal process and a wellness condition, it flourishes best when interventions are kept for those few mothers and babies who need them. The old excuses of meddling to “save the baby” and installing routine procedures without any or adequate testing should now be over. We are starting to amass the science - now all that is needed is to use it!

Posted by andrea at 04:48 AM | Comments (2)

Midwives' working conditions

The current issue of “The Practising Midwife” contains an interesting report on the pay negotiations being undertaken by the Royal College of Midwives on behalf of midwives across the UK. The message from the RCM is that if you pay midwives more, they will stay in work. I don’t think this is the real issue at all. I have written to the Editor in an effort to get this issue on the table:

Dear Editor,

The suggestion being made by the Royal College of Midwives that higher pay rates will result in more midwives either staying in their posts or returning to work ( Practising Midwife October 2002) is only a small part of the story. As I travel around the UK presenting workshops, I hear many stories from midwives that clearly indicate that it is working conditions that is the real issue.

Midwives tell me they want flexible working hours, more part time work and more family friendly shifts. However, what they find intolerable and frustrating is not being able to practice their midwifery skills and are dismayed by the resultant poor care that women are receiving. It is a Catch 22 situation: the rising rates of interventions are leading to a loss of midwifery skills and as midwives resign in disgust or despair, the shortages of staff are forcing those left to work as nurses, rather than midwives.

The Royal College of Midwives should address these issues as well as pay rates. I note that those hospitals that do have good team or caseload practices, midwifery-led units and high home birth rates have few vacancies compared with the centralised, high tech units. Perhaps training courses for Midwifery Managers, more direct talks with employers (Trusts, PCT etc) and Government would help to highlight these problems.

I fear that midwifery in the UK is in rapid decline, and that unless these basic issues are tacked, midwifery, in its traditional form, is likely to disappear.

Andrea Robertson

Not sure if they will print it and I will be interested to see if anything results. Perhaps I need to write an article about this.... “observations of a visiting Aussie workshop facilitator”!

Posted by andrea at 05:55 PM | Comments (4)

Pain in labour

"I must tell you a story that I know will delight you. The other day at work, I received message to ring a woman who had given birth to her first baby at Allamanda 2 years ago. Susan had attended the prenatal classes with her first baby and was now pregnant again and due in 2 weeks.

When I rang her back, she was so pleased to here from me and we had a lovely chat. The reason she wanted to speak to me was to ask for a copy of your article "The pain of labour a time for growth". Several years ago I sought your permission to hand this article out at the classes and I remember you saying, "Gosh, I wrote that years ago Anne". Well, it may be a few years old now Andrea, but the message it carries is still as true and as valid as the day it was written. Susan told me that your article helped her immensely as she prepared to have her first baby and that she had passed it on to many of her girlfriends. Like many things you lend to people, she didn't get it back and wanted to read it through again before she had her next baby.

I posted the article to her the next day and expect to see her arrive in the unit any day now. Those are the little inspirational moments we all need from time to time and I am sure you are smiling now."

I was smiling and it made my day. I am always impressed by the Dutch midwives mantra “if you want to keep birth normal, you have to have the pain” but also know that women will need more than this to really feel confident that they can bear the pain of labour and even benefit from it.

The article that Anne mentioned is very similar to this one, which is an expanded version that I wrote a bit later. If anyone wants to copy this and hand it out in their classes - please go ahead. You can print it off from our web site.

Posted by andrea at 05:27 PM | Comments (3)

The state of midwifery in Britain

I have just been catching up on my September MIDIRS Digest - breakfast reading when I am eating in Hotels during my travels. It contains the usual array of research articles but there are also several original pieces focussing on the state of midwifery in the UK.

These comment on various aspects of midwifery practice and lament the fact that it is being completely dominated by medicine and is in a gradual process of decline, with extinction on the horizon. Many people in other countries look to the UK as an example of midwifery at its best, yet the reality is completely different. The profession is supported by Government laws (for example, a midwife must stay with a woman if she decides not to go to hospital for the birth, even if it is against the midwife’s advice), regulation (the Nursing and Midwifery Council oversees many regulations that strengthen the midwife’s personal practice and protect her standing), Government enquiries such as the Winterton and Cumberlidge Reports, and enjoys a high profile in the community. Yet each year the number of births in the sole charge of a midwife is falling (now around 68%, down from 75% five years ago), the caesarean section and interventions rates are rising rapidly, midwives are in chronic shortage (some units are 30% down on the numbers they need) and many students fail to complete their education, dropping out in despair.

Lots has been written about this - books, in fact. It does concern me though, that if this si the state of affairs in a country that has such a strong midwifery culture, how will other countries, where there are no supportive laws and regulations fare? In Australia we are fighting to get a new style of maternity care (NMAP) adopted as policy in a country where we have 7 Governments to negotiate/fight with, no legislation that support or protects midwives and no overall regulations that govern and shape midwifery practice. I hope that this lack of regulation will prove a strength rather than a downfall. In New Zealand, midwives managed to get themselves well positioned from a similar base as Australia, so I will remain optimistic.

Britain is a country that is often described as a “nanny state” and there is no doubt that life here is closely monitored, controlled, organised, regulated and dictated. Everything is covered by some rule or another and people are often treated as incapable - signs warn of potential disasters (“beware uneven surfaces”, “mind the gap”) apologies abound (“we apologise for the delay of 3 minutes in the later running of this train”, “we regret any inconvenience caused by this alteration to your .......” etc) and there is an air that the taking of personal responsibility is a thing of the past as “someone” will take care and provide for you. Apologising for the lack of services now replaces the actual service itself.

Perhaps this is partly why the health care system is in such crisis and that midwives are falling behind. By over regulating and offering to “take care” of people from cradle to grave, the State has effectively stifled initiative and produced a population is prepared to be cowed in return for not having to think for themselves. This is no doubt a harsh and simplistic view, but I despair when I see the lack of action by midwives and their inability to get themselves organised on a national level to address issues of primary importance to their existence. There is a lot of talk about these issues, such as the excellent articles in MIDIRS, but where is the fervour, passion and collective action to change things?

Perhaps it will take a major crisis ( the current situation does not yet seem to be bad enough) to precipitate collective action amongst midwives. Yet I fear that the culture amongst women here, the vision of themselves as “poor things” that need to be looked after, the prevailing view that “someone else” will fix it and their lack of personal backbone will spell disaster and that midwifery may yet be lost. I feel like shaking the lot of them and telling them to wake up before it is too late!

After few weeks in the UK, I always seem to feel like this - frustrated and amazed. You don’t realise how different the Australian culture and way of thinking is until you stand it beside the British way of life!

Posted by andrea at 07:48 PM | Comments (2)

Midwifery in Uganda

I had a wonderful phone call this afternoon from Julie Green at the Hull Maternity Unit. She is one of the Midwifery Managers there and came to an Active Birth Workshop that I ran last May in Hull. She phoned to confirm some details for another program I am presenting there next week and she told me about her wonderful holiday from which she had just returned.

The last two weeks she had spent in Uganda, working with the midwifery staff in a hospital that catered for 5,000 births each year. She told me that she had learned an enormous amount and had put everything that we have explored in the Active birth workshop to use. She was astounded to see how easily women gave birth when left to do it themselves and it enabled her to see how far we had strayed from “natural” birth in the west. The baby’s heart beat is rarely listened to, yet the babies have high Apgar scores. Meconium abounds but is left to drain and the babies do fine. Women deal with the pain without drugs and “get on with it”. They only had 3 delivery packs with which to manage these 5,000 births, so Julie said to not worry - all they needed was a sterile razor blade, which were in plentiful supply.

Julie was surprised that episiotomy was very commonly done (with those razor blades!) and that women were giving birth on the beds. She hopes that she has encouraged them to avoid doing episiotomies but the bed is another problem - giving birth on all fours, or on a mat on the floor was seen as a retrograde step because women didn’t want to give birth “like they do in the villages”. She showed them how to encourage a left lateral position for birth and hopes that this new fangled idea will be seen as the “next fad” from the west and therefore desirable.

Western medicine has done such a lot of damage to traditional birthing practices around the world. It is heartbreaking seeing women in these developing countries trying to emulate our fancy hospitals, with their limited or non-existent equipment and supplies. Yet they have a lot to teach us. Seeing how women given birth especially in those conditions proves that nature has got it right and that we meddle at our peril. The poor outcomes that do occur in countries like Uganda are the result of things like poor transport to hospital, poor nutrition, and local cultural practices that are not always helpful.

I don’t think we have much to boast about in the west. Our birth practices are appalling by most standards and we could learn a lot from women in these developing countries. I am glad that Julie has had the chance to see for herself how it works and that I have a colleague who can spread the word both here and in Uganda. Good luck to her!

Posted by andrea at 01:56 AM | Comments (2)

NHS Preparation for Parenthood classes

The state of prenatal classes in the NHS is, on the whole, pretty poor. Many of the midwives in the group I am facilitating here near Nottingham talk about programs of 2 sessions of 3 hours plus a labour ward tour! Most classes are for women only, although the few evening couples classes that are offered are very popular. There have been some attempts at innovation, such as aquanatal programs, drop in programs for teenagers (not very successful) and weekly, shorter sessions of a “rolling” nature.

Fathers seem to be regularly excluded. The typical program is 3 or 4 sessions: one on labour, another on “pain relief”, one on “infant feeding” (that always includes bottle feeding so that women can make an “informed choice”) and another on post natal. It is run as a lecture session with questions at the end.

The midwives are usually told they have to “do the classes” , usually with no training, or even warning in some cases. Many said they didn’t like doing them, but it was part of the job and they were obliged to put in appearance. In this group of 30 midwives there were only a few who had expressed any real passion or even interest in childbirth education - most did it as a duty, with reluctance.

On the other side of the equation, the women often only came because they were paid to come. Apparently women can get paid time off work to attend pregnancy care, and it seems that some take full advantage. Stories were told of one employer who puts on a company bus to take the women to their antenatal clinic check-up, aquanatal classes, parent education etc and with a bit of organising women can get 16 paid hours a week off work for pregnancy related appointments!

I get the feeling that here, although there is recognition of the role of education and some midwives are keen and anxious to do a good job, the model that I am proposing is so far ahead of their thinking that it will be a struggle to make any changes. I can see the reactions: “there is no time for this group work; how will I fit this into the current program; the women won’t want this; I don’t want to have to deal with fathers” etc. At the end of the day I get the strong impression that many won’t want to be bothered with making any changes - too much like hard work.

Parenthood education is so important for changing attitudes, increasing confidence in parents, developing their skills and giving them hope - if the health professionals they meet are just going through the motions, it is no wonder that so many expectant parents either fail to turn up or don’t come after the first session. A wasted exercise all round. I will try and enthuse them today......

Posted by andrea at 06:01 PM | Comments (3)

Kirkby in Ashfield

Yesterday was a long one - we finished the Active Birth workshop in South Shields (Newcastle) and then I travelled for 3 ½ hours down to Kirkby in Ashfield (sounds very quaint!) between Derby and Nottingham. I certainly feel I know UK trains very well by now!

This will be a Teaching Skills program - it will be interesting to see who is in the group and what they are currently doing.

Posted by andrea at 04:47 PM | Comments (2)

Moxibustion to turn breech babies

Today's group are being primarily sponsored by South Tyneside Hospital, near Newcastle. We do have midwives from Dundee in Scotland and Sunderland as well, but most are local. The hosptial here is about to be renovated and the unit will move into temporary accommodation for 6 months while this is done, but they are looking forward to a nice new unit with all the mod cons, where they hope they can get midwifery care well set up.

Several issues came up today - especially the use of Moxa Sticks and moxibustion to turn breech babies. One of the midwives is 34 weeks pregnant and her baby is breech, so it was a very pertinent conversation. I explained how to do moxibustion and that this is something that parents do for themselves - one of its advantages. The success rate (70 - 80% successful in turning babies) makes it well worth a try and the fact that the baby does the work itself reduces the risks and increases the likelihood that the baby will stay that way once turned. It works by stimulating fetal movements and takes about 6 - 8 hours to achieve success following the heat treatment to the outside of the little toes. If anyone wants specific instructions, click HERE for the full story with diagrams, pictures, the research etc.

Given that most breech babies are born by caesarean these days, it sems to me that trying everything to get the baby to turn around is worth doing so that surgery could be avoided.

More tomorrow - then off to Nottingham for the weekend "Teaching Skills" workshop.

Posted by andrea at 05:49 AM | Comments (32)

Are St Thomas' Hospital duping women?

Yesterday I had a look around the St Thomas Maternity Unit, or “Birth Centre” as they call it. There are two corridors in the labour ward area - one is the regular labour ward (which they now call the “Birth Centre”) and the other houses the “Home from Home Centre”. It all looked very pretty in an institutional kind of way and that the hospital has lost the plot.

First, they have no idea what a Birth Centre really is. What they have built (and moved into 6 weeks ago) is a regular hospital. Yes, it is painted and bright (primary colours!) and that is certainly a change from the tired, dreary, worn out facilities most women in Britain have to put up with when they have baby in hospital. Apparently other hospitals in London that are being renovated are also calling their maternity units “birth centres” and while I agree they are centres for birth, by debasing the accepted definition used by the rest of the world it seems they are trying to hoodwink British women into thinking they are getting low tech, woman centred care, when in fact it will be “business as usual”.

The “Home from Home” unit is also another con job. It too looks just like a hospital - 12 birth rooms opening off the long corridor, 2 pool rooms, and a yet to be established “common area”that will have lounge chairs and murals on the walls. The decor is “hospital functional”and the only concession in the labour rooms is a sofa bed. The Health and Safety people decreed that women could not use that for either the birth or a post-partum cuddle with the father and baby because it “couldn’t be cleaned” (the mattress is not covered in plastic) so the women must use a regular hospital bed with its electronic controls. Each room has an ensuite, with a small bath and toilet and the shower is over the bath. No way women can move about in the shower and impossible to get the father in comfortably for support. Yes, they are reasonably low tech - no CTG machines, epidurals or forceps etc, but there are Entonox points in the bathroom and beside the bed and the rooms are fitted with scavenger units to suck out the Entonox so that he staff don’t get over exposed to the nitrous oxide. Would you believe that they use Entonox for women in the bath, almost routinely? Pethidine is also available if requested/required. They do have big windows and the view of the Houses of Parliament and Big Ben a few metres away across the Thames would be fantastic on a fine day.

This area is very far removed from most people’s idea of “home”. Belinda Ackerman, the Clinical Midwife Specialist in charge told me that they are hoping to get lots more home births happening and are aiming for 17 community based teams of midwives to provide this service. They can only staff 8 teams at the present time, so home births are likely to be few and far between,. Meanwhile women will come in and have a fairly standard hospital stay in this “Home from Home” area. Belinda said that the whole unit had been designed by administrators/architects who did not consult the staff about what was wanted (nothing changes, does it?) and there are a lot of furniture and some decorating they want to make. I will be interested to see how they are getting on next time I visit.

Some of the midwives at St Thomas will not, of course, welcome any criticism of their wonderful unit. There is a distinct culture amongst the staff there - and they believe that they are definitely the best. I was surprised at the closed minds of many of them and the almost violent reactions I got on some of their workshop evaluations - they don’t like being challenged! The “God syndrome” is alive and well amongst these midwives! I think they should get out more, and have a look at how care is provided in the smaller units and real Birth Centres, both in Britain and overseas. Are they scared they won’t measure up, I wonder? Everyone else in the workshop group were very positive in their feedback and welcomed the chance to review their own practice and consider new ways of looking at things. I fear that you can change the decor in a hospital but unless you change the staff attitudes, women will get the same old care and end up with the same old rates of intervention as ever. St Thomas is certainly a midwife centred, not a woman centred unit.

Posted by andrea at 09:10 PM | Comments (5)

A "Birth Centre" by any other name

I am doing a workshop at St Thomas’ Hospital at the moment. It is right across the river from the Houses of Parliament and Big Ben and many of the rooms boast a marvellous view. As usual in these London groups, there is a very mixed bunch of midwives and many have overseas experience. One has just spent two years working in Cambodia, another has worked in Dubia for some time, we have a Danish midwife, a French yoga/exercise teacher and a couple of Aussies and Kiwis.

St Thomas’ has recently renovated its maternity unit and as part of the refurbishment, has opened a “Home from Home” birth unit. The idea of birth centres is finally catching on in Britain and a number of hospitals have opened “birth centres”, which has ignited a debate about just what constitutes a “birth centre”. The accepted definition is that it is an autonomous midwifery unit, offering midwifery care for low risk women. No interventions are offered or allowed and if a woman wants to use pain medications during labour she is transferred to the regular labour ward.

It seems that this definition is being loosely applied in Britain and that women will be able to have pethidine and entonox in birth centres and monitoring may also be available. Today I will have a look at the St Thomas’ unit and I will check this out. We must keep the concept of midwifery care pure and unadulterated and birth centres should uphold these principles. I will be asking some specific questions!

Posted by andrea at 05:01 PM | Comments (2)

Home birth statistics

Yesterday I was a speaker at a Home Birth Conference in Chichester. The program was titled “Home Birth - Empowering Women” and there were a number of speakers, including Andrya Prescott, independent midwife (“Birth - A Normal Process”), Jill Hutchings, NHS midwife (“A Parents Guide to Homebirth”) Andrea Simons, obstetrician (“Getting Risk into Perspective”) and Jonathan Montgomery, Professor of Health Care Law (“Does the law empower women?”). My presentation was entitled “Empowering Women to Keep Birth Normal”.

There were about 130 people in attendance, a nice mix of parents, midwives, childbirth educators and students. All the presentations were well received and the day was voted a success by everyone.

Several interesting issues arose during the day. Andrew Simons had some intriguing statistics from the hospitals in the counties of Kent, Sussex and Surrey in the south of England that showed considerable variations it the numbers of homebirths within each region. Brighton had a home birth rate of 10%, whereas most hospitals reported around 2%. There were other figures that showed the vacancy rates for midwives in each unit, and there were large variations from 26% down to 1%. When the two tables were matched up it was clear that those hospitals that had the lowest rate of home births were also the ones with the highest vacancy rates for staff and that those units that provided good midwifery services had few vacancies. It was a stark reminder that midwives don’t want to work in units that are medicalised, non midwife and woman friendly and that offer few choices in the way services are provided.

There were also some very good data on the safety of homebirths. Examination of the birth outcomes for mothers and babies for planned homebirths showed that the risk to the baby was extremely low and that women also had a much safer time at home. Of course, this is to be expected, since if the system is working properly (i.e. midwives are well supported in their decisions to transfer) then those women and babies at risk should, on the whole, the identified in time to be transferred to hospital for appropriate care. Unplanned homebirths, however, proved very risky indeed, for both mothers and babies.

The figures don’t, however, tell the whole story because included in the unplanned homebirth statistics were both those who gave birth unexpectedly before arriving at hospital as well as those who plan to have a birth at home without professional help. If a woman had not booked a home birth, she was deemed to have an “unplanned” homebirth. It was clear from the table showing each hospital’s outcomes that in one unit, there were a large number of “unplanned” homebirths, many more than “planned” homebirths, and yet they had good outcomes. It was not possible to find out why this was the case, but I suspect that in this particular area, midwives don’t ask the woman decide in advance where she wants to give birth, but instead wait until the labour is in progress to make that decision. A birth that occurs at home under these circumstances would be classified as “unplanned”.

Not booking women for a birthplace early in the pregnancy but waiting until the labour to make the final decision is a very good way of boosting home birth rates. The Albany Practice (part of Kings Hospital) has certainly proven this and boasts a 43% home birth rate, easily the best in the UK, and this has been achieved with a caseload of whom 85% are classified as “high risk”. There are lessons to be learned from this approach, and ones that would not only enable better choices for women to be offered, but ones that would enable midwives to get increased job satisfaction. A solution to the chronic shortage of midwives, perhaps?

Posted by andrea at 11:44 PM | Comments (2)

The language of birth in Dundee

The first day in the Dundee workshop was surprising in some ways. The issue of language was a theme I raised, as usual, and it was quite an eye-opener for the group. Some new terms came up in general discussion that I haven’t come across before.

Here, midwives talk about women feeling “sore” during labour e.g. - “when she’s starting to feel sore, we get something for her” and “we tell women they will feel sore during labour”. I have yet to find out just what level of pain “sore” refers to, but perhaps that will come today.

One midwife described the labour ward as a “lock down area” which was pretty shocking. She was referring to the fact that most labour wards in the UK have stringent security, the result of a baby being snatched from a labour ward some time ago. Therefore, a code is now required to gain access to the labour ward, with visitors often restricted, women unable to wander about freely and limited numbers of companions being the norm. To refer to this as a “lock down” area, accurate as it may be, conjures up gaol conditions. I pointed out that women are already tagged (wrist bands), given hospital clothing to wear and pretty soon may be photographed at this rate! The days of women being “confined” are still very much with us.

Several of the midwives referred to homebirths as ”confinements”. It will be struggle for these midwives to change the way they talk about women and to them. I am more and more convinced that language is a key to the whole relationship between midwives and women. If women are to regain any confidence in their own ability to give birth, and midwives their trust in women’s abilities, beliefs and attitudes are key elements that must be addressed. The “self talk” we use, the discussions with colleagues and direct communications between women nd midwives all revolve around actual terms and vocabulary. If attention is paid to those, and make an effort to chose women-centred and midwife friendly terminology then we can change basic attitudes.

I left the group with much to think about on this score, and one senior midwife said that she had really taken this issue on board and realised she needed to think carefully about her own use of language. It is a start - we will see what the reactions are this morning when I give the group a chance to reflect on yesterday’s program.

Posted by andrea at 04:30 AM | Comments (2)

A day off in Edinburgh

Today I begin work in Dundee. Yesterday was my day off for this week and I spent it in Edinburgh, doing some “touristy things” for a change. The weather was fine and it is a lovely city, all Georgian terraces built of stone, hills and valleys, magnificent public buildings and of course, the Castle.

I did manage to finish my next article for MIDIRS (December issue), this time explaining NMAP and the campaigns building up to change midwifery in Australia. One things I really notice in the UK is the profile that midwives have attained - this morning on the BBC news there is a story about pay rates in the public service and nurses and midwives are specifically mentioned as being 10 and 12 percent below teachers and policemen. The issue of pay rates for midwives is always raised in workshops here (unlike OZ, where it is never mentioned at all) but the point for me is that everyone recognises that midwives are a separate entity from nurses......

Off to find out about midwifery in Dundee, specifically in Ninewells Hospital.

Posted by andrea at 05:03 PM | Comments (4)

Ireland and Scotland

The workshop in Kilkenny finished on a high note, with everyone having had fun and with lots of requests to come back to do another one soon. The Irish are so hospitable and it is a lovely country. There is no doubt that change is underway here, but midwives have a tough battle on their hands, considering the stranglehold that theobstetricians have on their maternity care system. I will be back next March for a workshop In Cork, an area with a large population of “alternative lifestylers”, so that will offer some different perspectives.

Today I am travelling to Edinburgh and have a 24 hour break before going on to Dundee. Scotland has a reputation for great midwifery, but in my experience so far, almost all women are given diamorphine (synthetic heroin) in labour, something that is unheard of in other countries. I can never understand how a woman would accept giving her unborn baby a dose of a drug she hopes that child will never become addicted to in later life. It is probably a measure of how a woman in strong labour, particularly around transition, will accept anything without thinking of the consequences, if they think it will ease the pain of labour.

I am looking forward to finding out what they do in Dundee.

Posted by andrea at 10:22 PM | Comments (3)

Prenatal education in Kilkenny, Ireland

Ah, Kilkenny, Ireland!

The workshop here has been interesting. A number of midwives from Waterford had to pullout because of the “vomiting virus” that has struck their hospital. This is a virus, apparently endemic in Ireland at certain times of the year, with symptoms that sound a lot like food poisoning. It is highly contagious and when people come to hospital because of dehydration from the vomiting etc it can then be spread throughout the hospital. If it is found in the hospital, staff are not allowed to attend programs elsewhere for fear of carrying the virus with them and in extreme cases, hospitals have to be closed down temporarily until free of the virus.

It is clear that prenatal education has still a long way to go in Ireland. The whole maternity system here is very much dominated by obstetricians (the old “active management” extends beyond the woman to the midwives as well) and midwifery is just starting to establish itself as an entity in some places. Waterford has the only midwifery led unit in this part of the country, but there are some stirrings in other places as well. Many women have to travel to give birth in centralised hospitals, so classes have to cater for women to will give birth away from their home town.

The formats of the classes varies a lot but several people in the group explained they do only two sessions which is hardly adequate. Most programs cater for women only with perhaps a fathers night at the end, and the idea of doing small group work (or interactive exercises and activities) is new and a bit daunting for them.

Private care is very common in Ireland, and when I explained Sally Tracy’s research on the outcomes for women with private care they were a bit shocked and adamant that they couldn’t mention this kind of research in their classes because it would upset the doctors! I initiated a discussion about informed consent and the role of the educator as the member of the team who makes sure women have the necessary information to inform their decisions. This was a new concept and one which caused a degree of discomfort. The Irish are used to authority figures ruling the roost and there is a general pattern of strong beliefs and opinions that people are keen to express. If someone has an opinion that is different from the prevailing views, it could be very hard for them to get a hearing, so change is slow, especially when it involves challenging medical practice.

There is no midwives association or organisation in Ireland, and this will need to change if midwifery is to get the recognition it deserves. Midwives here are very much a part of nursing, and it is interesting that there seems to be no movement to establish a separate identity. The relationship between doctors and nurses is as hierarchical as ever.....

Posted by andrea at 05:55 PM | Comments (2)

Britain's first conference for childbirth educators

It’s been a hectic week (as usual!).

Thursday was the conference in Birmingham: “Antenatal Education, but not as you know it”, which was billed as the first conference for antenatal educators in Britain. The event was the brainchild of Julie Foster, the Parent Education Coordinator at Birmingham Womens Hospital, who, with the help of NCT on the administrative side, put together a program of presentations from a long list of people, including Mavis Kirkham, Jean Sutton and Judith Schott. There were 400 enthusiastic educators in attendance and it is likely to become an annual event, perhaps moving around the country to give everyone a chance to attend.

One of the most interesting papers was from a member of Fathers Direct, a new organisation that evolved out of an NCT postnatal coffee group. He talked about ways of involving fathers and gave some interesting perspectives on the role fathers do play and would like to play. He said that men don’t really se themselves as “parents” and respond more readily to the term “fathers” or “dads”, so to increase participation rates publicity could include these words, for example” Programs for Expectant Mums and Dads”. Their group is expanding rapidly and are now looking at ways they can become politically involved, for example, by seeking better legislation for paternity leave etc.

I was asked to present a one hour workshop, before the main program and again at the end. I chose the topic “Informed choice or pot luck - making prenatal education relevant” but somehow this was changed to “Empowering women to have a natural birth”. Still, for an hour it didn’t really make much difference! It was really just a taster for my longer workshops and they were well attended - even those who came at the end of a long day (when we were all feeling a bit brain dead after an intense day in a very hot venue) managed to participate and find some energy.

One of the main benefits of these events is that it gives a lot of educators the chance to catch up and network. It was great to meet a lot of people I’ve had in workshops over the past 10 years and to get some amazing feedback. One midwife told me that after attending my Active Birth workshop she enabled her daughter to give birth to a 10lb baby at home, when she was under pressure to be in hospital “because the baby was going to be big”.

The only problem I had with the day was the word “antenatal”. As you know, this is a term I have real problems with, given that it creates a negative impression, even though it is supposed to just mean “before birth”. That’s why I use the term “prenatal” and every time I hear “antenatal” I flinch. Did a lot of that on Thursday!

Yesterday I spent all day travelling to Kilkenny in the south of Ireland. Today I am presenting a weekend workshop for educators and I will definitely be raising this issue of language with them!

Posted by andrea at 05:48 PM | Comments (2)

More feedback on doulas

I've received some more feedback about my previous comments on doulas.

Lynley wrote:

Well I really want to be involved with women giving birth, i think giving birth is a magical experience. After having two children of my own I have just wanted to help other women support them and help them achieve a birth they can forver be happy with. I want to become a midwife but with my youngest son still only 7 months old i can't start going to uni yet. So i became involved with Doulas. I have been doing the denise love course and have nearly completed it by correspondance. I also have a workshop coming up with terri shilling which i am also looking forward to. I am just really eager to help women and I someday hope to be like you andrea. that is my goal. be able to teach people the way you do, you help so many people. With my first pregnancy your book preparing for birth- mothers was the only book i could find that had everything i wanted to know in it and i often use it during my studies. I have always look up to you since becoming interested in childbirth. But with the veiw you have on doulas i just can not work it out. I think the number one prioty is what the pregnant woman wants. I'm sure they have planned their birth out and either through doulas, midwifes, or their own sister or mother i think as long as she gets that birth or attempts that birth that is the main thing. If a woman feels she needs a doula i think that is up to her. But you have a very strong opinion one that people really listen to especially pregnant women. I think saying what you did about Doulas isn't very good when having a doula could quite possibly help a woman and in my opinion would help a woman. I had a very rough birth with my first son and i had my mother and husband right by my side. but i'm sure if i had someone next to me who could help me to work through my contractions who knew about birth it would have made all the difference. i did have one midwife through the duration of that birth who stood by my side and helped me to breath and work through the contractions. she was brilliant but when shifts changed i had a midwife who seemed not to care at all. at least with a doula i would have had the exact supporrt i needed. You are right when you tell midwives to talk to the women they have looked after to try and save their ward or hospital. maybe you should do the same ask women about their experiences with doulas then give an opinion. thanks for listening.

My reply to Lynley:

Your thoughts on the doula issue are similar to many of my own. I have been a birth companion for many women over the years, and I appreciate what you are saying. When you've been involved for a while, especially when you find yourself in a difficult situation as a doula, perhaps you will see what I am getting at..... for example: I can well remember being a support person for a young woman who had no-one else to be with her. She was doing fine through the labour and was handling the labour without drugs. This was in a hospital in Sydney (now closed). The midwives were obviously rather put out by my presence, and I sensed this, so I made sure to stay with the woman all th time. Eventually I had to go out for a pee (they made me go down three floors to a visitors toilet, even though I knew there was a staff toilet nearby - shouldn't have asked where the nearest toilet was!) and when I came back a few minutes later, the midwife had given the woman pethidine. When I queried this I was marched outside and backed against a wall and, with her finger pointing at me, was dressed down by the midwife "we only want what is best for her, don't we?"

It is these kinds of experiences that expose the vulnerability of being a doula and the very limited role that one has. You have no authority and your presence can, on occasion, be an actual hindrance to the labouring woman. I'm telling you this not because I want to put you off, but because the reality can be quite different to the imagined role you picture yourself fulfilling.

With the current trend toward paying for a doula service, there is another element. If the parents have paid you to be with them, then there is a certain expectation on their part - a contract if you like. As a doula you will have no influence on the outcome, which will be a reflection of the primary caregiver's attitudes and practices, and so there is a potential for the parents to feel you have let them down if things work out differently from what they expected. This limited role of the doula needs to be very clear before labour starts.

I am not against doulas per se, because I have often done this work myself. After all, being with a person who needs comfort is something anyone would hopefully do for another human being. It is the commercialisation of social support and sometimes unrealistic expectations on behalf of both parents and doulas that I am concerned about. I also wouldn't want women to get the idea that a doula is a person to engage ahead of close family and friends, and once money comes into it, the relationship between the various parties inevitably changes.

Since you mentioned that you would like to post a reply to the Diary entry that I wrote, I will post it there for you as a reply to an earlier entry. I will also post my reply to you so that others might read it as well. It is certainly a hot topic and I am glad it has got people thinking!

Posted by andrea at 10:15 PM | Comments (2)

The UK birth websites

If you are expecting a baby in the UK, choosing an appropriate birthplace has never been easier. The Dr Foster website (an initiative linked with Boots Chemists) has a listing of all the maternity units in the country and details about the services they offer together with their birth outcome statistics. Another website, set up by a group of childbirth educators and a statistician, has similar information. For those without internet access, The Times newspaper has published extracts - in July 2001 the whole Sunday Supplement was devoted to birth, using the Dr Foster statistics as a starting point for a series of articles about that childbirth that were extensive and useful. This year they followed up again unduly with a series of supplements in the Sunday edition over 5 weeks. These updated the information given the previous year and contained additional notes for parents on a whole range of issues associated with pregnancy, birth, breastfeeding and early parenting. A book has also been published that contains the same data as the web site.

The only potential problem for expectant parents in using these figures to choose a birth place is the difficulty in being able to access services outside the area in which you live. In the UK, health services are provided by a series of Trusts or Primary Care Groups, which handle the budget for the area nd decide which services will be provided. Their geographical area of responsibility can be quite small and larger cities will be divided up into a number of Trust areas.

In Britain, people are not able to shop around for health care as they can in other developed countries. Each person must “sign on” with a local GP, who is paid per patient to provide medical care when needed (the patient pays nothing directly to the doctor). Each GP is allowed to carry a specified caseload and this determines, to a large extent, the salary that will be earned. If your preferred GP has no vacancies on their list, you must approach another until you find one willing to take you on. If you find you don’t like the doctor, it can be very difficult to change, because you must first find another willing to accept you as a client before you can move on and “shopping around” is frowned upon.

Like all systems, it has pros and cons. For example, there is no tendency for doctors to over service their patients in order to make more money, but there is also no incentive for doctors to see you as they won’t get paid for each visit you make. People can’t visit several GPs to get extra prescriptions, for example, and costs of providing health care can be determined in advance, to a large extent. However, if your GP is against home birth, you will not get much support and you may find it daunting to find another GP who is supportive and willing to have you sign on to their list.

In a similar way, it can be hard to make use of the birth outcome statistics offered by these internet guides. If, for example, your local Trust does not have a Birth Centre (and very few do), but the one next door does, you may have difficulty in accessing it, because this will require special funding arrangements between Trusts, a procedure that is available, but discouraged. This “postcode lottery” has been often discussed in the press here and can have major implications for those who require specialised services that are only available in some centres in the entire country.

The availability of these guides to maternity care is wonderful, but it seems to me, of limited value unless women are actively encouraged to seek out the care they want. A free enterprise system would encourage this, but socialised medicine is not well set up to support the idea. Those who have money an can afford private care will be able to choose a private hospital anywhere and therefore can exercise their right to choice, but those reliant on the National Health System may have very few options.

Another example of the double standards that are so prevalent in maternity care: there are a range of choices in maternity care in this country , but make sure you choose the local hospital, whether it meets your needs or not! If you have money, however...... (the rich win again!)

Posted by andrea at 12:04 AM | Comments (2)

Arriving in London

Have finally arrived in London and am ensconced with Caroline and Giles Flint. Long delays getting here and fatigue is setting in, so will have to write more tomorrow. Facing a Tube strike for 24 hours form 8.00 p.m tomorrow and the need to get to Birmingham for the first Conference for Childbirth educators to be held in Britain (where I am presenting two workshops) will be the first challenges of public transport for this trip.

Tomorrow I will go out to our office in Kent - it is blissful location in a farm unit (many farms have converted now unused buildings for use by businesses) on a large farm that has horses and sheep as well as crops of various sorts. The manor house dates back several hundred years and has a moat that leads off the Darenth River that runs through the property. We often have ducks and even swans on our doorstep! It is about 2 miles from Otford Station, near Sevenoaks and I will walk to the office along

Posted by andrea at 12:54 AM | Comments (2)