Articles by Month: February 2007

Active Birth workshops achieve their aims

The feedback from the workshop in Huddersfield indicates that we did achieve our aims of exploring midwifery and active birth in practical terms and bringing midwives together as a unified team. I received this email today from one of the participants:

I am one of the midwives who attended your recent workshop at Calderdale Royal Hospital in Halifax and I would just like to say an enormous thank you for your wisdom, your humour, your honesty and your insight into birthing women, midwives and midwifery practice. I have had a lovely conversation with a friend who also attended the workshop and it seems everyone involved has been inspired and re-energised in your company. I am now looking forward to sharing your ideas and knowledge with some like-minded friends on maternity leave and am even doing an extra shift tomorrow, for one reason only, and that's to put some of these ideas into practice!

This is wonderful news – if I can inspire any midwives to keep on working in the UK, especially in this time of straightened circumstances, staffing crises and general low morale, then I am more than happy to make the journey here from time to time.

I have now moved on to Ireland again for another workshop for the midwifery students in Limerick. The far-sighted co-ordinator of this program, Margaret Crowley-Murphy, has once again found the means to incorporate the Active Birth workshop into the midwifery syllabus, with the express aim of providing an alternative source of ideas and practical solutions from outside the immediate hospital system and course tutors. I always enjoy working with students – they are enthusiastic, open-minded and eager to look at things from various perspectives.

The issue of the theory/practice divide has already come up and I have pointed out that as students they have a big advantage – they are expected to ask questions. In a system as conventional (read: unwilling to change) as Ireland’s, a student asking questions at least challenges the status quo. Answers have to be found – a current question I would ask is: why are women in Ireland being denied access to waterbirths? These have apparently been banned since an incident in a hospital last year – they have thrown the baby out with the bathwater on this issue.

In other developed countries there would be outcry at this curtailment of freedom and rights. One of those in the group mentioned that she had personally seen two women in the clinic both of whom had waterbirths elsewhere (Australia, as it happened) and who were being denied a similar service here. One promptly said that she would travel 12,000 miles and go home to get what she wanted – talk about voting with her feet!

Keeping the lid on demands for alternative birth services is managed by denying women basic information about options (pre-natally through the clinics and classes, in the media and elsewhere) so that hopefully they remain ignorant of what goes on in other places and won’t ask awkward questions. The influx of immigrants from many other countries that has occurred over the past few years as a result of the economic boom may well have an unexpected result – women will be demanding levels of care and services they are used to in other developed nations. Perhaps the Irish will then be forced to catch up. I feel sure they will get there eventually.

Posted by andrea at 06:31 AM

How many midwives does it take to birth a baby?

This is not a joke - one or two?

One of the issues that is influencing the staffing levels in midwifery units is the requirement in many units that there must be two midwives present for the birth of the baby. In a hospital the second midwife maybe a student, but student numbers are also affected by a lack of trained staff. The same “rules” often apply in home births - a second midwife must be called in when the birth is imminent.

I have never understood why a second midwife must be deployed to assist with the birth. The usual response when I ask this question is that a second midwife is needed to “receive the baby”, and of course assist with any problems that many occur. In a hospital, help is always at hand if an emergency occurs - that’s what the buzzer is used for. At a home birth, there are always other adults around, who can help the midwife with the basics of first aid, calling the ambulance etc. At home, there are likely to be fewer emergencies anyway, as the birth is much more likely to stay normal as drugs and interventions will not have been used (one hopes!). Home birth midwives are skilled in resuscitation, putting in a drip, managing blood loss etc and can call on others present to assist. Why call in another midwife, just in case? It is an expensive exercise, and in some areas, the requirement to have this extra professional means that limits are placed on how many home births can be booked.

Birth may not be quite so simple in a hospital, as interventions are more commonly undertaken. As a result, many births will be complicated and require extra assistance. In an emergency a doctor will be called and the midwife will assist him/her. Other staff would also be available if more personnel were required - even the students could lend a useful hand.

Simple arithmetic demonstrates that if only one midwife is required to oversee a birth, then twice as many births could be attended. This might be important in a hospital where staff are run off their feet, and may make home births more accessible for many families. Reducing midwives’ stress levels is important because right now, many are suffering from the constant pressure to fulfill all the protocols, many of which are unrealistic given current staffing levels.

During the workshop yesterday, I reminded midwives that because of the unpredictable nature of labour and birth and the possibility of complications occurring in any birth, it is important to keep the labour and normal as possible from the outset and this means not offering women drugs in labour. Once a woman has been given medication, she is less likely to be physically capable of assisting when a problem occurs (such as turning over if a shoulder dystocia develops) and more likely to be fuzzy in her mind and unable to think clearly (a frequent outcome of narcotic and Entonox medication). The baby will also be affected and this may contribute to a poorer outcome for the baby.

The more midwives work to keep the birth normal, the less likely there will be problems in second stage and the need to call in extra staff. In a health service that is completely stretched and working under incredible restrictions, reducing inductions, encouraging mobility at all times, not offering drugs for pain, using intermittent auscultation rather than CTGs and using more relaxed time lines will be important, not only for increasing safety at birth, but for reducing the epidemic of midwife stress that seems universal.

Posted by andrea at 05:26 PM

The sick NHS in Britain

I’ve heard a string of stories today from midwives in the Huddersfield/Halifax area that illustrate the terrible state of the NHS in the UK.

Despite the Government’s many initiatives, policies, legislation and regulations that support midwifery across the UK, the enormous hole in the budgets in many NHS Trusts has meant that many programs are being cut or scaled back and restrictions on staffing are putting labouring women and their midwives at risk.

One of the midwives in my group ducked into the Labour Ward at the first break to grab a cup of coffee and discovered that the Manager was frantically phoning around trying to find some staff for the night shift this evening. The midwife was made to feel that she should be on duty or else her colleagues would be struggling and working under duress. She had to leave the workshop so she could get sleep and organise her child care in preparation for turning up for the night shift.

This was described as a typical problem in this area (and I suspect, many others). A full complement of staff cannot be found for many shifts and those on duty find they are having to work in conditions that are clearly unsafe for women. It was suggested that several incidents (one that ended in tragedy) were exacerbated by the extreme stress of midwives who were doing their best, but working way under safe working conditions.

Several midwives mentioned that even basic equipment, such as Sonicaids, was in short supply and that even CTG machines, often vital when a baby is in trouble during labour, were sometimes hard to find. There is a new Birth Centre being constructed in this area, but there is concern that its facilities and equipment may be limited by the stringent budgets in place.

The midwives in this group are committed and dedicated, wanting to practice their skills as they know how. Many are totally frustrated and angry with the way the NHS is taking advantage of their willingness to do the best for the women in their care. One wonders how much worse it will all get before improvements finally arrive.

I hope tomorrow to give them practical measures they can implement within their own scope of practice. When things are bad within the system at large, perhaps this is the time to think local rather than global: working with each women, one at a time, and making her experience the best it can be, so a midwife can gain some personal rewards for her work.

Addressing the issues at the broader level will take group action, commitment, and strong political action. The midwives here have good leaders, willing to support and encourage change so I hope they see the potential of a collective approach and work as a unified group to achieve what they want as midwives.

Posted by andrea at 05:33 AM

Aiming for a VBAC

My first workshop in the UK was once again in Hull. It was primarily intended for the incoming group of doulas who have joined the very successful team of volunteer doulas that are matched with vulnerable women for support during pregnancy, labour and the post partum period. This is my third trip for this program and they are achieving some excellent results. It is a very good example of how social support can improve birth outcomes, especially amongst the disadvantaged.

There were two pregnant women in the group as well and a number of midwives from various hospitals in the area and from further afield. One of the pregnant women was hoping for a VBAC so I had a chat with her about how she might achieve her goal. Changing consultants to a known advocate of VBAC would be an important first step - the vague support offered by the Registrar in the clinic that her wishes would be respected is too tenuous to rely on. When a VBAC is planned, the most important step towards achieving this outcome is, I believe, finding a support team who are positive and enthusiastic for vaginal birth after previous caesarean. Many women are paid lip service on this issue during pregnancy only to find, when it is to late to change doctors easily, that they are being carefully and inexorably pushed towards a repeat caesarean. A few scary words, a hint of a problem with the baby, a throwaway line about the size of the baby and all too soon women find they are back on the operating theatre table with another incision being made. I encouraged the woman in my workshop to shop around and keep her options open. Trust in her own body and belief in her ability to give birth well is important as well. I hope she succeeds, and as a result lays to rest some of the doubts about her capacity to give birth.

Several of the doulas in the group recounted their own birth experiences, which were not always positive. One said that she had now realised that she must deal with her own disappointment with birth before she could properly support another woman through the birth experience - she realised that this had to be the woman’s journey and not her own. I was impressed by the degree of insight and maturity in this comment, and I feel sure that now she recognises her own vulnerability and needs she will take the appropriate steps her help resolve her own issues before she works with other women.

I wish that health professionals (midwives and doctors) would adopt this approach and acknowledge that many of their management strategies and behaviours for labouring women have their roots in their own personal disappointments and griefs about birth.

I’ve moved on to Huddersfield now and will have the opportunity to work with midwives in this area over the coming weekend. But first, another Essential Educator presentation for CBEs in this area.....

Posted by andrea at 05:14 AM

2007 off to a busy start

The year has begun with a rush. After the hard work of putting the 2007 Birth International catalogue together (click here if you would like a copy posted to you), we quickly geared up for the first workshops.

The first program was an Active Birth workshop in Darwin. The “Top End” is a fascinating part of Australia, firmly within the tropics and at this time of the year, a wondrous mix of storms, heavy rain squalls and ever present heat and humidity. The gardens are lush and green, growing rapidly while you watch!

Because of its isolation, the people in Darwin fall into one of two main groups: those who are visiting on extended travels (often work related) and those who have made it their home. The population is young, with lots of children and young families, and the birth rate is quite high by national standards. A number of midwives in the group were in Darwin for a short period, working and chilling out whilst deciding where to move to next.

One thing that is very noticeable in the Northern Territory is that there seems to be plenty of Government money available to support a variety of community groups and programs. There were people from both the YWCA and Anglicare in this group, who are working with the young and pregnant as part of funded initiatives. They were not midwives, but experienced youth workers and they were looking for specific detail to include in their groups for expectant mums.

I also had midwives who worked with the Aboriginal population. Pregnant Aboriginal women are routinely sent in from outlying stations and towns to give birth (a dreadfully disruptive plan, that has major social ramifications for their families) and they congregate in various hostels awaiting the birth of their babies. Many have health problems brought on by inappropriate lifestyles (often the result of intrusion by the white population) and the perinatal mortality and morbidity in this group is disgraceful - real third world standards. Many efforts are being made to address this problem and the training of Aboriginal health works has been a practical solution that is improving results. It is hard to escape the fact that a lack of midwifery care, including birth services, in their own communities must be a major contributing factor.

On my final day in Darwin, the Childbirth Education Association sponsored an opportunity for me to present an Essential Educator showcase for a group of women who are providing prenatal programs in Darwin. CEA Darwin has been very active over many years, and has received finding to set a variety of parent support groups in the city and nearby satellite towns. Their energy and commitment are outstanding!

There was a lot of interest in the extensive contents of this kit, and many agreed that the quality and scope of the activities and resources included would be very useful for their work. Many educators don’t have access to specific CBE training, however using this kit will enable them to offer appropriate and effective group activities that enhance learning for participants.

We had quite a bit of fun trying out some of the activities, especially the Epidural Role Play and the Cascade of Intervention. Everyone felt that these were brilliant for making sure that women were fully informed about these options and these educators could see the potential for using them in their classes.

I left the group to work together on the development of new programs for parents in Darwin, and made my way to the airport to catch a flight to London, via Singapore. After the heat and humidity of the tropics, the cold and wet of a freezing Britain was quite a contrast!

Posted by andrea at 04:28 AM

2007 off to a busy start

This year has begun with a rush. The usual hard work in putting the Birth International catalogue together (click here if you want a copy posted to you) has been followed with the first “tour of duty” workshops.

My first program of the year was for a group of midwives and eductors in Darwin in the Northern Territory of Australia. It is tropical monsoon season in the north right now, a very spectacular time of massive storms, lots of heavy, sharp rain showers and high humidity. Everything is very green and lush – you can almost see the plants growing as you watch!

The first workshop was on Active Birth. In this part of remote Australia, there is a largely transient population, with many people staying for a period of around 2 years and then moving on. There is a stable group of “old timers” who have made this part of the country their home for many years and one result of the isolation of this region is that there is a tendency for these stalwarts to get stuck in a routine, unless they get regular exposure to developments in other parts of the country. This is true of maternity care to an extent, although as a reaction to the rather medicalised hospital birth system, there is a flourishing home birth population, who have been assisted by a fantastic team of midwives, who have extensive experience of home and water births.

One thing that is always notable about the “Top End” is that there seems to be plenty of Government funding for community based projects. The Territory has a young population, and a high percentage of children and young couples. Community services are available for a whole range of needs and my group had representatives from the YWCA and Anglicare, both of whom are providing programs for the young and pregnant. These women were well trained in group work and group facilitation, and were looking for specific birth information and activities to incorporate into their work.

The Childbirth Education Association in Darwin has been energetically and comprehensively supporting pregnant and post natal women for many years and is well funded by the Government. They have undertaken a number of outreach projects, including establishing new groups in nearby satellite towns, whilst leading the push for better birth services in Darwin itself, offering a range of pregnancy and birth classes and a comprehensive postnatal services.

The new Birth Centre is being constructed at the Darwin Hospital and is due to open in a few months. The policies that will underpin its services are still to be finalised, but it will at last offer a real choice for women who want neither a home birth or a birth in the private or public hospital. I should think it will be especially popular with Aboriginal women who can meet their entry criteria (many have underlying health issues that would exclude them from using the service), as for this group, giving birth near the land rather than on the 6th floor of a tower block is very important. I look forward to checking it out when I next visit.

The final day in Darwin offered me the chance to make a presentation on The Essential Educator kit which many educators have been keen to see. I took them through the extensive components of the pack and there was general agreement that this comprehensive set of teaching materials would be invaluable for many of the programs that are being run in Darwin. Many facilitators don’t have formal training in either childbirth (midwifery) or group facilitation, so a package that enables them to effectively present a variety of teaching activities (with full instructions and scripts) is very attractive and practical.

After a great morning with an enthusiastic bunch of childbirth educators, I headed for the airport and the long trip to the UK.

Posted by andrea at 06:37 PM