Articles by Month: March 2006

Conference - shaping up well!

This past week I’ve mostly spent in the UK office. It’s been a pleasant change from dashing around the countryside and its given me time to work through the final details for the Preparing for Birth Conference at Reading University in July. The publicity is out now and the registrations are rolling in - it looks like being a very popular event.

One of the messages we were given on our evaluations last time was that there was still some unresolved feelings between the community based educators and the hospital based people. This Conference is a great way of bringing these two groups together, to discover what each group is doing and learning about other ways of working. Educators based in the community often tend to work with rather homogenous middle-of- the road couples and could benefit from learning about the more diverse groups their colleagues in the NHS have in their programs, and vice versa.

As an icebreaker for these two groups, we’ve devised some fun activities for everyone after dinner on the two evenings when we are all staying on campus. I won’t reveal what’s in store, except to say we have something very different up our sleeves which is guaranteed to give everyone a great deal of fun.

The list of speakers is impressive (even if I do say so myself) and we’ve covered the topics most requested by everyone who came last year, plus some new issues of interest to educators and midwives. For full details, click here.

I have also just finalised the speaking team for the next Future Birth tour in Australia which will happen between March 20 and 27, 2007. Watch for the announcements soon on our website and through our E Bulletins - this is an iconic event for us in Australia and one that midwives never want to miss. It seems a long way off right now, but we are racing through this year already!

Posted by andrea at 12:52 AM

More on the NMC Statement on home births

Last night I was discussing the recently released statement on Home Birth from the UK Nursing and Midwifery Council with my good friend Caroline Flint. Her perspective on this important document was very interesting and important, and she raised several issues that the NMC will have to address.

The statement makes it very clear that midwives must support women in the choices that they make. However, as Caroline points out, what does a midwife do when a woman goes against all the advice she is given and makes a decision that is clearly risky for herself or her baby? Some women have completely unrealistic expectations, which they maintain even when faced with a dangerous situation that they could avoid. If a midwife does the right thing and support this woman, carefully documenting everything and clearly enunciating the position, what happens when the woman, at a later date (perhaps even months later) decides that the resulting poor outcome was due to the midwife and demands an investigation? Will the NMC support the midwife in these circumstances, or will the midwife be subjected to months of harrowing inquisition, before eventually having the case cleared? The midwife may support the woman, but the authorities (Midwifery and others) do not usually support the midwife in the same caring way.

There is a real blame culture in the health services in the UK. People (staff and patients) seem unwilling to accept the idea that mistakes are made, not every decision will be the right one and that outcomes are unpredictable. It is rare for natural births to go wrong, but when they do, a scapegoat must be found, and often the blame falls on the midwife. Even when risks have been carefully explained, disclaimers have been signed, consent has been given in writing and contract provisions have been spelled out in detail, there is no guarantee that human nature will not kick in and retribution sought when the unexpected happens. Midwives are sitting ducks because they really do care, they often have a closer relationship to the woman than hospital staff, and are easier to target. In addition, midwives may feel they are powerless to complain about their own treatment if they feel the weight of a punitive system breathing down their necks.

I can see where Caroline is coming from when she talks about the woman who, despite outstanding care and consideration, turns on their midwife because the birth did not happen as expected. Caroline has been subjected to a number of high profile inquisitions (and acquitted of wrong doing) just because a woman has the right to complain. If the NMC is serious about enabling women’s needs during a home birth to be respected, then it must develop a quick, simple, supportive and fair system for hearing complaints and righting wrongs. The midwife must have the same degree of support and understanding as the woman concerned, in recognition that everyone has lost when tragedy strikes, and everyone is entitled to help with their own particular grieving process.

This new NMC statement offers some powerful messages about women’s rights in regard to homebirth. Midwives will now be waiting to see how the NMC will go about protecting the midwife’s rights in this new era of openness and expectation around the provision of homebirths.

Posted by andrea at 11:11 PM

Chichester Home Birth Conference

Yesterday the Chichester Home birth Group presented their sixth Conference, an event they stage every 18 months. This time, they had decided to venture further afield, and chose a venue in Bristol for the program. This was a good move and 160 people assembled to hear a number of speakers, including myself.

My paper was titled “Have Women Changed?”, question I decided could be answered with a “Yes” and a “No”. I’ll put the paper on the website soon so you can read my impressions of women today and consider whether I have managed to do them justice.

Mary Cronk is a midwife with a reputation for fierce protection of midwifery skills and natural birth. She is a champion of vaginal breech birth and vaginal twin births, and firmly believes that women can almost always give birth successfully, providing they have good midwifery care. The statement on homebirth from the Nursing and Midwifery Council had just been released (see my previous Diary entry) and as most in the audience were unaware of its content, Mary spent some time going through this, highlighting the important statements that will give real impetus to improving the home birth rate.

Mavis Kirkham addressed the issue of the “Postcode Lottery” when it comes to home birth and took us through a number of factors that could be used to promote midwifery models of care. She also touched on the findings of her research projects that have explored workforce issues - why midwives leave the profession, what makes them stay, etc. Her main point was that it is “stroppy women” who generate the change and lead the charge and we should celebrate their contrary ways and admire their dogged determination in pushing for reforms that will benefit both midwifery and women.

Lynne Leyshon, from Torbay, offered us some useful insights into how they have achieved an average 11.5% home birth rate across their area (some sections are over 25%). This program has been running since 1994, and it incorporates all the “best practice” indicators that enable midwives to offer and sustain the service and gives women real choices for birth. Her “secret” is the deliberate avoidance of booking women into a birth place, or even discussing birth place options until 35 weeks of pregnancy. At that point the midwife might then raise the issue with a women in this way: “Let’s talk about where you might give birth. Home is the first option and if something is not going well, then the hospital is available.” As Lynne pointed out, marketing people understand that the first option presented to people is what is usually remembered best, so by presenting home as the first option and hospital as a backup if things are not going to plan, home is accepted as the norm. This is a clever ploy and one worth remembering!

Jonathon Montgomery, a lawyer, explained the rights and responsibilities of the health service and women in relation to home birth. He also discussed litigation and assured midwives that if they were practising within their professional capacities, and in accordance with the currently accepted norms of their peers, they had very little to fear from litigation. I am sure the many midwives in the audience were heartened by his presentation.

The final panel of the day was made up of a selection of stories who described their decision making regarding home birth and recounted some of their experiences, both with independent midwives and also NHS midwives. For the parents in the audience it was a chance to hear from their peers and for the midwives, an opportunity to get some feedback from parents using their services.

It was a full day, with stimulating papers and an interesting cross section of speakers. I look forward to hearing about their next event, in October 2007.

Posted by andrea at 02:12 AM

Guidelines for midwives at homebirths in the UK

Midwives in the UK have a number of laws that govern their practice. One of the most useful is a law that requires the midwife to remain with the woman at a home birth when complications arise, especially if the mother refuses to move to a hospital against the midwife’s advice. This protects midwives from being hauled into court if disaster strikes at a home birth - the midwife must stand by and do whatever she can to help even though she has made it clear that there are problems and medical help is advisable.

In recent years, some Hospital Trusts have used various “legal” means to get around clauses such as this, and have refused women the care of the midwife because of staff shortages or unwillingness to provide a service. Many women have been forced into hospital births against their wishes and some have complained loudly. Trusts have justified their stand using various anguments, such as taking staff from hospital wards to attend a home birth will increase the risks faced by mothers giving birth in hospital.

There have also been cases where women giving birth at home have been refused a waterbirth because it is claimed the midwives “don’t have the training” or “there is no policy in place for waterbirth”.

To help clarify the responsibilities inherent in a homebirth for the mother and her midwife, the Nursing and Midwifery Council has released a document covering home birth. The full text can be obtained here. The following are some key statements:

• Midwives are experts in normal birth and the NMC's standards require them to be competent to support women to give birth normally in a variety of settings including in the home.
• Whilst a midwife must not provide care that she is not competent to give, it is not acceptable to refuse to care for a woman on this basis and take no further action.
• Research over the last couple of decades suggests that home birth is at least as safe as hospital-based birth for helathy women with normal pregnancies.
• Midwives may have some anxieties if there is a clash of a woman's choice versis the percieved risks of caring for women in a home setting. If there is a clash then the midwife must continue to give care but can seek support by discussing her anxiety with her supervisor of midwives.
• It is a midwife's duty to make all options and choices clear and to respect the choices a woman makes if she is legally competent to make that choice.
• Whilst an employed midwife has a contractual duty to their employer, she also has a professional duty to provide midwifery care for women. A midwife would be professionally accountable for any decision to leave a woman in labour at home unattended, thus placing her at risk at a time when competent midwifery care is essential.
• Should a conflict arise between service provision and a woman's choice for place of birth, a midwife has a duty of care to attend her.
• Women have the right to make their own decision on these issues if they are competent to do so and midwives have a duty of care to respect a woman's choice.

I am grateful to Beverley Beech of AIMS UK for drawing attention to this recent release. She has been campaigning for years for better access for women to midwifery services, especially for home births and the release of this document must be very pleasing for her.

Posted by andrea at 10:19 PM

Another reason to keep birth out of hospitals

There is a report in the Times newspaper today about the problems with hygiene in NHS hospitals in Britain. It appears that about one third of hospitals are unable to provide their staff with immediate access to basic hand washing equipment and this is fuelling concerns about the rising rates of MRSA infections.

Some hospitals I have visited ask everyone to rub an alcohol based cleaning gel on their hands as they enter the building and others have similar stations outside the entrances to the wards. The spread of infection is a serious problem and can be brought into the hospital, and taken home as well. It is well known that staff are the main carriers of infections (nose and mouth as well has hands) and I wonder about the risks to families when a someone who works at a hospital takes home bugs on their hands, or clothes that contain bacteria to be washed.

The general public is worried about the cleanliness of hospitals, as they should be. However, it is one issue that rarely seems to be raised in connection with childbirth. Here we have healthy women going into a dirty hospital setting to give birth. We know that many do acquire bacterial and viral infections that are hard to beat, especially if surgery has taken place. Many women will have infections following caesarean births and some of these will lead to infertility and chronic illness. Yet this is an aspect of the medicalisation of birth that is rarely discussed. Perhaps women think “it won’t happen to me” and don’t properly consider the post-natal implications of a hospital acquired infection when they are focussing on the birth itself.

Seems to me this is a powerful argument for homebirth. People don’t pick up nasty bugs in their own home and newborns will already have immunity to the bacteria found there, through the antibodies passed on by their mothers. Of course the chance of surgery being performed in the home are zero, which clearly reduces the risk, but MRSA infection in hospital is not only contracted through wounds - it can develop following skin contact.

Funny how some issues get a lot of airtime and others are overlooked. When it comes to managing risk around childbirth, keeping out of the system and leaving nature to work as intended are plain common sense. Perhaps one day the health care system will “come clean” about the hidden risk of infection and the very real possibility of going into hospital to give birth in a healthy state and coming out sick.

Posted by andrea at 03:07 AM

Another good reason to keep birth out of hospitals

There is a report in the Times newspaper today about the problems with hygiene in NHS hospitals in Britain. It appears that about one third of hospitals are unable to provide their staff with immediate access to basic hand washing equipment and this is fuelling concerns about the rising rates of MRSA infections.

Some hospitals I have visited ask everyone to rub an alcohol based cleaning gel on their hands as they enter the building and others have similar stations outside the entrances to the wards. The spread of infection is a serious problem and can be brought into the hospital, and taken home as well. It is well known that staff are the main carriers of infections (nose and mouth as well has hands) and I wonder about the risks to families when a someone who works at a hospital takes home bugs on their hands, or clothes that contain bacteria to be washed.

The general public is worried about the cleanliness of hospitals, as they should be. However, it is one issue that rarely seems to be raised in connection with childbirth. Here we have healthy women going into a dirty hospital setting to give birth. We know that many do acquire bacterial and viral infections that are hard to beat, especially if surgery has taken place. Many women will have infections following caesarean births and some of these will lead to infertility and chronic illness. Yet this is an aspect of the medicalisation of birth that is rarely discussed. Perhaps women think “it won’t happen to me” and don’t properly consider the post-natal implications of a hospital acquired infection when they are focussing on the birth itself.

Seems to me this is a powerful argument for homebirth. People don’t pick up nasty bugs in their own home and newborns will already have immunity to the bacteria found there, through the antibodies passed on by their mothers. Of course the chance of surgery being performed in the home are zero, which clearly reduces the risk, but MRSA infection in hospital is not only contracted through wounds - it can develop following skin contact.

Funny how some issues get a lot of airtime and others are overlooked. When it comes to managing risk around childbirth, keeping out of the system and leaving nature to work as intended are plain common sense. Perhaps one day the health care system will “come clean” about the hidden risk of infection and the very real possibility of going into hospital to give birth in a healthy state and coming out sick.

Posted by andrea at 03:04 AM

Challenging the status quo in midwifery

I’ve been using the new Labour Pain charts in my workshops, to help the groups to focus on the information that parents need to have about the importance and significance of the pain of labour. The charts help me to focus on the main points too, and although I don’t usually need to go into the same level of detail with the midwives as I would with parents, I feel it is important to remind midwives of the main interactions between the various hormones that are active during labour and how they can influence their release.

This discussion around the normality of pain in labour usually raises discussion about the various drugs that women have come to reply on. Today in the group, the midwives were surprised to learn that Nitrous Oxide (Entonox) is not used during labour in Europe or in the USA. It is interesting how habits and techniques can become very regionalised, and how little midwives often know about the way that birth is managed in other countries.

There are two Canadian midwives in this group and one of them commented that she worked as an obstetric nurse in Canada for four years before coming to the UK to learn midwifery. She was surprised how medicalised labour is in Britain, and said that she was able to facilitate normal labour and birth more easily in Canada. She explained that there seemed to be more of a collaborative approach there, with less of the hierarchy that seems to operate in the UK. If a nurse wanted to challenge what was being suggested for labour management, she could “ask for clarity” and everyone present would stop and consider what was being done, with explanations all round. I can’t imagine this working in the UK - no-one would dare to request (or expect) this kind of teamwork. It’s probably because of the stratification in UK society generally - doctors have a definite place and are called either “Doctor” or, in more rarified circles “Mr”. The idea of using first names between staff members would be seen here as disrespectful, yet it is a good starting point for forging an equality between colleagues that can lead to much better teamwork.

The students in the group expressed how difficult it is to question what is done, and how unapproachable some senior midwives can be. I’ve had students mention this to me many times, and where it happens it could easily stifle healthy curiosity and valuable personal reflection. Such a shame - a student’s questions are often a useful trigger for consideration of alternatives. This would only happen if the senior staff did not feel threatened or uncomfortable by perceived challenges to their authority. I think all midwives should read the very useful article “Fish can’t see the water” to sensitise them to the institutionalisation that occurs in many hospitals.

Posted by andrea at 05:13 AM

Irish medical scandal enquiry report released

Irish maternity (or should I say Obstetric) services are under the microscope at the moment. For many women in Ireland, having a private obstetrician’s care for pregnancy and birth has been regarded as synonymous with status, prestige and excellent medical care. That may be under challenge now that a report into the shameful behaviour of one obstetrician has been released.

The story began some years ago, when a consultant at the Our Lady of Lourdes Hospital in Drogheda began exercising his own form of retribution on young, unmarried women giving birth. He began performing hysterectomies on these women following caesarean sections, without their consent. These unfortunate women would wake up from their anaesthetic to be told that they had lost their uterus and, in often patronising and demeaning terms, be told they should now go home and care for their baby as it would be the only one they would ever bear. The ultimate irony was that these women were primarily his private clients - those women in the public system but under his care, largely escaped his sadistic surgery, because hospital staff, who knew what was going on, were better able to protect the women from harm.

The whistle was finally blown by a midwife, who could not in all conscience, stand by and watch him remove another uterus without consent, just because the young unmarried woman had become pregnant. The complaint reached the Medical Council, who eventually struck him from the medical register and the doctor, having re-organised his finances so that he would be protected from potential lawsuits, escaped to Spain where he now lives.

The Government set up a public enquiry, headed by a Judge and it is his report that was released last week. The fallout has been inevitable: the case has attracted considerable media attention and the Department of Health is under pressure to make sure that policies and procedures are changed to protect women from such assault in the future.

All maternity hospitals have been sent a document that sets out a number of changes to be immediately implemented. Practice audits of are to be carried out on a regular basis; policies are to be reviewed and updated, and collaboration between doctors and midwives on all committees etc is to become standard. Outcomes will have to be justified and rigorous checks made to ensure that some transparency will finally enter the system as a whole.

These changes have been sorely needed in Ireland for a long time. For too long the midwives and women have been ruled by a tight knit obstetric fraternity, led by “the Masters” of the main maternity hospitals in Dublin. Just the existence of a person who is referred to only as “The Master” says it all really - such a situation would not be tolerated in any place outside Ireland. Perhaps a change of title will be one change that will result form the sweeping overviews that is now being demanded by the Government.

Meanwhile, the women of Ireland are getting a wake-up call. In the past, I suspect that Irish women would have tended to protect and defend their obstetricians when a scandal such as this one broke. Modern women may not be so inclined to be charitable, given that they are more worldly wise and more demanding of value for money.

It will be interesting to see how the ripple effects of the shocking revelations play out. Will midwives seize the day and demand support and recognition so they can protect women from unnecessary surgery and medical meddling? Will the women rise up and demand more choice in maternity services? Will the Government set in place genuine reforms that guarantee some transparency of the services the taxpayers are underwriting, so that, for example, all birth outcomes are published and freely available for public scrutiny? Will midwives et up their own College, breaking away from the Nurses Association to create their own autonomous professional organisation? Will the doctors start treating midwives as professional equals and work happily in collaborative ways to ensure clinical excellence for women and babies?

None of these issues are being discussed amongst midwives on their Irish Midwifery Mailing list, so it seems they have either not been registered on midwives’s radar (which I would find hard to believe), or else the topic is too “hot” to handle or broach publicly. This could be the greatest rallying point that midwives in Ireland have ever had. I hope they see the potential and get their acts together. Midwifery in Ireland could finally come of age as a result of this terrible tragedy where dozens of women’s reproductive lives were sacrificed for one doctor’s desire to play God. It would be some small consolation for their terrible losses.

Posted by andrea at 02:42 PM

Up, up and away

Today I am leaving for another trip to the UK. My first stop will be in Ireland where I will be once again presenting an Active Birth workshop for the midwifery students in Limerick (and others). This is my fourth visit to Limerick and talking to students there has become a regular event. The first workshop in Limerick happened as a result of a request from Kiwi student, who wanted some input on normal birth in her training. She finished her course, and after some months consolidation in Ireland, has now moved, with her family, to Derby in Western Australia. I can’t think of a greater contrast - from green Ireland to dry, dusty Derby! I am sure that she will get wonderful all round midwifery experience in Derby as it is in one of the most remote parts of this country.

After Ireland, I have workshops in a number of places in the UK. They are all listed here and promise to be an interesting series of events.

On the way home from this trip I will be detouring to take in Iran, where I will be presenting a three day workshop for the Iran Ministry of Health and the United Nations. They are concerned about their rising caesarean section rate (just like the rest of the world) and are looking for ways to keep birth normal. Working with the Iranians will be a challenge and also very exciting. I have been reading about this ancient land and am looking forward to meeting the people and learning a little about their culture and lifestyle. I’ll post some pictures when I get home.

Posted by andrea at 12:59 PM

The drought is over.....

It’s been quite a while since I wrote up My Diary. I have never been busier than I have over these past two months, mostly with writing projects, so finding a moment to update here has been in the “too hard basket”. However, things are settling down now and I can get back to recording what’s going on more regularly.

There have been two major projects taking my attention. The first is a new initiative that is a world first - "The Essential Educator”. This is a teaching kit for parent educators that provides everything they need for facilitating effective parent education programs. It is in production at the moment and will be available in May. There are details of this comprehensive teaching kits on the website, so click on the link to find out more. As the project gathers pace, we’ll add more specific information about the component parts.

The other project has been the first Birth International Conference for Childbirth Education to be held in Sydney. This event was last weekend at Sydney University and we had a wonderful time, with 160 people participating in Plenary sessions and workshops on a variety of topics. The program has two international guest presenters - Mary Nolan from the UK and Sherokee Ilse from the US and both were sensational. I am delighted that they will both be appearing on our similar program in the UK in July - those who attend are in for a real treat.

We had many other presenters at the Conference, most of whom have been involved in our Graduate Diploma in Childbirth Education. They offered a host of practical teaching tips and activities that the participants can incorporate into their own classes and all the workshops were lively affairs.

Some of the Plenary papers will be available on our website in the next few days and I will let you know when you can access them. The workshops, being based on experiential learning, don’t lend themselves to written outlines that make much sense - you have to be there to understand what they are all about.

A number of the speakers on the Sydney program will be part of the presentation team at the preparing for Birth and Parenthood Conference at Reading University in July. The “Core of Life” team have a wonderful workshop on working with pregnant teens that was highly praised and Julie Clarke will be facilitating several workshops on small groups work.

Bronny Handfield will be showing her fabulous hour long DVD on the media’s interpretation of birth. These clips, taken from many well known television shows explain how women form their views about childbirth (often making it very hard for educators to debunk various myths). Some of it was quite shocking (remember that terrible episode of “ER”?) and a lot of it was very funny - it is a marvellous mix that was entertaining and also illuminating about where community attitudes are formed. I am sure it will be resonate with British audiences as well.

Full details of the UK Conference are now on the web site and I recommend early registration to make sure you get your workshop choices. We already have a long list of people waiting for the details to be posted so they can register, so as they say, “first in, first served”.

Posted by andrea at 10:20 AM