Articles by Category: midwifery

Good News stories

I have written a number of times about the Doula project run by the Goodwin Centre in Hull. They have recently been awarded for their efforts - this is an outstanding community based program and very worthy of this recognition. Here is an extract from the Press Release I received today:

Date: 8 July 2008

Doulas Delight at Parliamentary Awards

Goodwin Volunteer Doula Project and Hull and East Yorkshire Hospitals NHS Trust and have been honoured with an award at the All-Party Parliamentary Group on Maternity (APPGM) summer reception. The awards acknowledged several maternity units’ inspiring work in improving local maternity services.

Based on four key themes, the Goodwin Volunteer Doula Project and Hull and East Yorkshire Hospitals NHS Trust received their award for developing inclusive services for disadvantaged groups and communities.

‘Heather Barnes, Project Manager for The Goodwin Volunteer Doula Project said “The day was a great celebration for the volunteers and staff who have been involved in the development of this innovative project across Hull. The award recognizes the effort put in by all the volunteer doulas over the past three years, as well as the great team work across the city by all agencies, ensuring isolated pregnant women get the support they need throughout their pregnancy and birth”

Health Minister Ann Keen MP and Emily Thornberry MP, Chair of the All-Party Parliamentary Group on Maternity (APPGM), presented the awards at the Atrium Restaurant, Millbank on Monday.

The APPGM, which is serviced by the NCT charity, highlights maternity issues within Parliament and brings together health professionals and service users with politicians.

The reception was attended by nearly 200 politicians, leading health professionals and user representatives from the maternity services across the UK.

Emily Thornberry MP, Chair of the APPGM, said; “It is a great privilege to present these awards to such deserving and exemplary maternity units. All the entries were very impressive. The winning units are doing innovative work which will act as an inspiration to other Trusts.”

Mary Newburn, Head of Policy Research at the NCT charity said, “We are celebrating the success of these awards as excellent examples of the good work that happens in local Trusts. “

The Goodwin Volunteer Doula project, developed by Goodwin Development Trust, focuses on listening to the needs of local women from disadvantaged communities to ensure their needs are being met. This pioneering project recruits, trains and matches up volunteer Doulas with pregnant women who need support at what can be a lonely and difficult time. A Doula is a trained and experienced partner who accompanies a woman through pregnancy and childbirth and the first few weeks of family life. The volunteers are trained in child protection, domestic violence awareness, hospital tours, antenatal and postnatal roles, health and safety and breastfeeding.

There were a number of other midwifery projects that also received awards. They are all worthy recipients, and it is wonderful to be able to share these good news stories. I hope you find these inspiring.

Developing inclusive services for disadvantaged groups and communities:

Joint winners

Hull and East Yorkshire Hospitals NHS Trust/Goodwin Volunteer Doula project which focuses on listening to the needs of local women from disadvantaged communities to ensure their needs are being met. The volunteers are trained in child protection, domestic violence awareness, hospital tours, antenatal and postnatal roles, health and safety and breastfeeding.

Ashford and St Peters Hospitals NHS Trust developed maternity services within HM Bronzefield Prison. This includes specialist midwifery care, obstetric ultrasound and high risk obstetric consultant care. Prior to this service, pregnant women within the prison received little or sporadic antenatal care and, in some case, none at all. Since the prison opened in 2004, the Head of Midwifery and the prison directors had regular meetings to discuss the care pathway for pregnant women in prison, and funding was finally obtained in April 2007.

Highly Commended

Pennine Acute Hospitals Trust for employing an ethnic health worker in an area where there is a high percentage of mothers from Pakistani and Bangladeshi communities; she is trained in breastfeeding support, smoking cessation and providing advice on co-sleeping, nutrition and welfare benefits.

Barking, Havering and Redbridge Hospitals NHS Trust where the teenage pregnancy midwifery team has worked closely with young parents and other professionals and community groups to determine what is needed to provide a high standard of holistic care to pregnant teenagers, encompassing continuity of care and support.

The normality of childbirth

Winner

Royal Wolverhampton NHS Trust - in particular New Cross Maternity for the range of measures to introduce and promote a new water birth service, with the aim of increasing normal birth. Over 85% of midwives have been trained and previous waterbirth parents now provide feedback to prospective parents who may want to use the birth pool. They have also provided specific sessions for teenagers and have organised interpreting services for women who wish to attend the preparation classes.

Highly Commended

Shrewsbury and Telford NHS Trust have developed a new midwifery module focussed on promoting and facilitating normal birth. It provides other midwives within the West Midlands the opportunity to address the rising trend in caesarean section rates and raise awareness and understanding on how to promote normal birth within their Trusts.

Responsive, woman-centred, family focussed postnatal care

Winner

Burton Hospitals NHS Trust for the bereavement support service aimed at ensuring those who have lost a baby are treated with sensitivity. An extensive training programme was developed to target all staff who came into contact with bereaved parents and special bereavement care suites have been developed, with ensuites and sleeping facilities for the partner, to ensure parents do not have to receive care in the labour ward.

Highly Commended

Pennine Acute NHS Trust for their production of a light-hearted book which challenges the myths of breastfeeding. ‘Saggy boobs’ aims to raise awareness of the facts about breastfeeding amongst the public and professional bodies.

Involvement of women in providing local maternity services

Winner

Calderdale and Huddersfield Foundation NHS Trust who, despite grassroots opposition to a birth centre, saw the opening of the Huddersfield Birth Centre and Midwifery Led Unit. The key to its success was user involvement and ensuring the Trust listened to what women would value in a local facility through focus groups. A set of evidence based pathways were developed by the consultant midwife to build awareness and confidence in the birth centre concept for the public and local midwives.

Highly Commended

East Sussex Hospitals NHS Trust for its women’s focus group. The group of user volunteers meet monthly to support their local maternity services and work in partnership with the maternity services staff to contribute to the service development within the maternity department.

Portsmouth Hospitals NHS Trust who were nominated for involving women and families in the improvement of maternity services in Petersfield by reopening the Grange Maternity Centre twenty-four hours a day, seven days a week. The Trust was particularly responsive to calls from local families and actively encouraged user involvement in the development of the Centre by asking users to sit on the Maternity Development Group

Posted by andrea at 04:42 PM

Midwifery as the basis for peace

Mindy Levy is a remarkable midwife in Israel, who has established a birth centre in the north of the country near Nazareth, and who also offers a home birth service. She was one of the driving forces behind both of my visits to Israel. On my last visit, she offered to arrange a workshop for Palestinian midwives, which took place in East Jerusalem in June 2005. This was a wonderful event, if somewhat disjointed due to the langauge difficultlies and the haphazard arrival of midwives due to the onerous checkpoint formalities at the border of the West Bank. The midwives from Gaza had been unable to attend because the border has been closed completely for 4 days by the Israelis.

However, we had an interesting day and Mindy said she would like to follow up wirh another meeting between Israeli and Palestinian midwives. Today I received the following email from her - she has achieved her goals at last.

Dear All,

The last 2 days were big ones- the culmination of months of work and years of planning and dreaming. Sponsored by COHI, nine Israeli midwives and nine Palestinian midwives spent 2 days together at my birth center in Beit Lechem Haglilit talking about women, babies, birth, midwifery and mothering in the Middle East.

It was a party. The atmosphere was festive, loving, hopeful, and professional. We learned much about midwifery on "the other side" and had many opportunitied to explore the differences and similarities, the strengths and weaknesses of each health system.

We understood very quickly that midwives are midwives, regardless of their religion and nationality. Our passion about our profession is universal as are the warmth and love that eminate from our bodies and souls. Midwives are midwives are midwives.

We fell in love with each other instantly. We forgot that there had been a time when we were wary about this first meeting, when we felt fearful of meeting the "enemy" and encountering our own prejudices. There was no fear. There was trust, openness to reveal weaknesses and difficulties, a lot of curiosity, and a great willingness to share and to listen.

We are now planning the continuation of this connection and the sky seems to be the limit. When we parted ways this afternoon, we spoke of when we will meet again, not IF we will meet again.

I feel as if I had given birth- happy, exhausted and overwhelmed. And indeed a birth has occurred- the birth of this incredible project. Now we need to hold it, get to know it, nurture it and some day teach it to walk.

When the birth center emptied I could still feel the energy buzzing in the building- the presence of these midwives was a true blessing for the birth center. I am thankful that I had the honor to host this birth.

In the concluding circle one of the midwives raised the possibility that the end to the violence in our region could be begin by eliminating violence in birth. We all agreed that we really do have the power to change the world, one birth at a time. This might sound a bit much to the non-midwives among you, but this is one of the things that gets us through the pain, blood, sweat and guts of birth, knowing that what we do does makes a difference. Birth is important for both women and babies.

Anyone who feels motivated to support this project financially is encouraged to do so through the COHI website or directly to me.

Mindy

Posted by andrea at 11:36 AM

Midwifery education in Thailand

Midwifery in Thailand (as opposed to obstetric nursing) has received a boost with the availability of a new course at Burapha University in Chonburi. Until recently, all nursing courses included six months of obstetrics and this has formed the basic qualification of those wanting to specialise in midwifery.

Burapha University has introduced a new post graduate course that will focus solely on midwifery, providing an avenue for those who want to upgrade their basic nursing skills and develop a midwifery philosophy rather than an obstetric orientation in their practise. This is exciting news and will eventually mean more options for birthing women, who will be able to choose midwifery rather than obstetric care for their pregnancy.

Other Universities may follow Burapha’s lead – this course is proving very popular with many applicants for its limited places. Perhaps the next step will be a professional organisation for midwives, that enables them to develop a real identity and voice as health care providers. Knowing about the slow pace of change in Thailand, I won’t hold my breath waiting for that development, but this new course is a very definite step in the right direction.

Posted by andrea at 02:23 PM

Childbirth options in Thailand

The birth scene in Thailand is at last changing from one dominated by private obstetrics to one where alternatives, and especially midwifery care, is becoming more available.

I’ve spent the weekend catching up with my friends in Bangkok and learning of the latest developments with the Childbirth and Breastfeeding Foundation of Thailand. This group has been working for some years to promote natural birth and better breastfeeding rates, and although often frustrated by the slow rate of change in this country, they are pleased that their message is being heeded in some hospitals, with outstanding results.

As in most countries, there are two levels of maternity care – the private system and the public health system. In the private sector, the outcome of the birth will depend almost entirely on the practises and attitudes of the chosen obstetrician. With a supportive obstetrician, natural birth is possible, or at least many of the routine obstetric interventions can be avoided. From the information I have gathered this weekend it seems that women wanting to negotiate natural birth options in Bangkok will have the best chance at Rajvithe Hospital in Bangkok (Dr Ekachai), Bangkok Phuket Hospital in Phuket (Dr Suppakit) and at the Samitivej Sukumvit Hospital, also in Bangkok,(Dr Yawaluk, who is a woman doctor).

I have written about the Samitivej Hospital before in My Diary as they have the only Birth Centre in Thailand, but their recent statistics show that support for water birth and physiological management is decreasing, which is both disappointing and alarming. This is probably due to reduced support for normal births from several of their doctors, and it seems that Dr Yawaluk is offering the most flexible approach at present.

In the public sector, there is encouraging news. Smaller community hospitals in rural areas are having great success with upright births (squatting, kneeling etc on floor mats) and mobilisation during first stage. Fathers or other companions are being encouraged to attend and their midwives are very pleased with the good outcomes they are achieving. I have heard great stories about natural births at the Bangnampreo Hospital (in Chachongsao Province, 1 ½ hours east of Bangkok), Somdej-na-Sriracha Hospital (in Sriracha, Cholburi), and Bangtarad Hospital (in Kalasin, in the north east). As often happens, smaller units that are not teaching facilities and where staff have more freedom often produce great results. If a pregnant woman in Bangkok was not able to obtain the care she needed from her private obstetrician, she might want to consider travelling a few hours to get quality midwifery care and the opportunity for a better birth.

The facilities in these small community hospitals may be very basic, with none of the pretty decorations and gleaming technology found in the private city hospitals, but in the final analysis, women in labour are less worried about the décor than the attitude and philosophy of the caregiver who is assisting them. As women discover the benefits of midwifery care over routine obstetrics, and as the successes in these community hospitals become known more widely, it will help drive change elsewhere in Thailand.

Posted by andrea at 02:10 PM

Midwifery in the UK

I have just left the UK after a brief (for me) visit of 10 days during which I presented some workshops and had a short break with friends in Wales. I also spent time with Caroline Flint in London enabling me to catch up with her successful midwifery practice based around The Birth Centre in Tooting.

This Birth Centre was the first one ever established in the UK and has provided a lovely birth place for many babies over the years. As a model for midwifery care it is unequalled – being independent of the NHS system offers women complete freedom to have the birth and care they want without any of the restrictions that must be applied to those birth centres attached to maternity hospitals. It is just a shame that more centres like Caroline’s have not been established elsewhere and crazy that her achievements as a pioneer of the birth centre philosophy in the UK is rarely acknowledged by her peers. The “tall poppy” syndrome that we are so familiar with in Australia seems to have taken hold in the UK as well.

My impressions of UK midwifery, formed on this visit, is that is seems in the doldrums. The midwives I met this time talked about the chronic staff shortages, which have been going on for some time, but this time there seems to be a feeling that the problems will never be fixed. With the mass resignations looming as the average age of midwives advances, many were gloomy about the prospects for midwifery in the future and fear that births will become concentrated in the large hospitals as the only practical way of staffing maternity care. Too many doctors working in obstetrics are having a big influence on the way births are managed and the imposition of strict rules and guidelines (formulated by doctor dominated bodies like the National Institutes for Clinical Excellence – NICE) are overriding the expertise of midwives in facilitating normal births, leading to more and more caesareans. The once proud record of natural births that was the hallmark of British maternity services is under serious threat and the only way to escape the increasing production line approach seems to be having a home birth (if a woman is lucky enough to live in an area that will provide this mandated option).

More dynamic leadership of the Royal College of Midwives might also help. With morale amongst midwives at a very low point, the RCM has a big task ahead if it is to lift the spirits of midwives and take the strong political role needed to get the working conditions improved to attract and retain midwives in the system. What is needed is not just pay rises for midwives, but assertive efforts to have the voice of midwives heard equally with their medical colleagues as policies are formulated and services are planned and implemented. The RCM could also take the lead in establishing strong supportive structures to stamp out the horizontal violence that is endemic in many hospitals. I understand that the leadership of the RCM is about to change and that (gasp!) a man is even being considered for this post. What a refreshing change that might be – will the College be bold enough to take this idea on? The Australian College of Midwives employed a non-midwife as its CEO several years ago and it revolutionised their organisation, giving it new energy, a strong lobbying voice and better internal systems. Will the RCM look “outside the square” on this occasion?

Posted by andrea at 06:52 PM

Birth in India - legal case mounted

I have received an email from Ruth Malik, my contact in India, who is setting up a new childbirth education service for Indian women. She has mounted a legal case to challenge the management of the birth of her second child, which she considers was an unnecessary caesarean birth. She has asked that I circulate the following petition that she has submitted to the Indian authorities, to provide information, support and encouragement for other women in India who may also feel their births were mismanaged. It is an interesting story, and one that will resonate with women in many countries, not just India.

MAY IT PLEASE THIS HON'BLE FORUM TO ACCEPT MY PLAINT AS UNDER:

This Complaint is against the Medical negligence/ Malpractice of the Respondent Doctor and the Hospital as a result of lack of due care, abrupt decision making in carrying out childbirth leading to Emergency Cesarean Section of the Complainant on 24th March 2006.

FACTS OF THE CASE

1. I am a foreign national married to an Indian. I have a 5 years old male child born by caesarean section.
2. . I consulted Respondent No 1 for my second pregnancy and expressed my strong desire for a normal vaginal delivery. She gave me full support for the same.
3. . On my due date (17.03.06) she examined me cursorily per abdomen and declared that I had a lazy uterus and my previous scar was paper thin and thus I was unlikely to be a suitable candidate for normal delivery. I was not satisfied by her statements so I approached another doctor at ...... Healthcare Centre for second opinion ( Annexure A) regarding my chances of having normal child birth. They carried out Ultrasonography (Annexure B) and NST ( Non Stress Test) and assured me that all is well so I stayed home waiting for Labour.
4. . On 24.03.06, Respondent No 2 carried out CTG (cardiotopography) for which I had to lie on my back. A belt was tied around my abdomen to check baby’s heart rate. I felt uneasiness and incredible heat, they said after a few seconds that I would be taken up for surgery.
5. . Though I signed the informed consent for emergency Cesarean section, I was not convinced with the indication verbally given by the attending staff at Respondent No 2. They admitted me at 2.54pm and at 3.05 (Annexure C) I was in the operation theater for a surgery by Respondent No 1.
6. . In the operation theater, Respondent No 1 told me of being misinformed and the doctors who gave me second opinion as QUACK. This further added to my doubt regarding her decision for Cesarean section , but I was helpless for myself by that time.
7. . I had a baby girl, who was pink and healthy when shown to me in the operation theater. I could not relate her to the emergency scene I was shown to be suffering from.
8. . I was discharged from the hospital on 27.03.06, feeling confused and cheated.
9. . I went back to Respondent No 1 after ten months to clear my confusion and to find out what really had happened. She told me that I had rupture of membranes and fluid was leaking out. I pulled my discharge card (Annexure D) and asked her why it was not mentioned there. She grabbed it from me and quickly scribbled scar dehiscence in the mid portion of scar with herniation of membranes.
10. . Respondent No1 again tried to satisfy me by stating that I was lucky that I came in as soon as labour started. I was stunned and told her that I have never had been in labour. She was silent on this. By this time, the mental strain and agony was unbearable.
11. . I applied for and got my indoor case papers and discovered questionable discrepancies, evident of deficiencies of services suffered from both the Respondents as a consumer / an Expectant Mother and at last a Deceived Mother.
12. . What I inferred from my research was that I was wrongly stamped as an emergency cesarean section, what I really needed was careful support and monitoring for a few more days, which (duty of due care) was denied to me by both the Respondents.
13. . An evaluation of Respondent 1’s series of actions demonstrates that she intended the birth to consist of an emergency Caesarean section before I was given to chance to commence natural labour. I must conclude that the surgery was pre-planned by Respondent No 1.
14. . Childbirth is the Reproductive right of a woman. Normal childbirth has a more positive impact on the body, in establishing breast feeding and thus providing good growth parameters for the baby. Researches have further laid down the safety criteria of reproductive organs after normal deliveries. The humane bond between child and mother is being weakened by these increasing rates of intervention i. e. cesarean section. The modern medical technology aims at providing qualitative health care but what I experienced as a woman as well as a mother at Respondent No 2’s care, of being violated, deliberately abused by the doctors on whom I trusted for seeking help of experiencing a normal childbirth which was deserved in my case.
15. .I made a complete inquiry of my case and decided to raise my voice because it concerns the reproductive rights of so many women who have suffered from this deliberate negligence and left confused or misinformed by their gynecologists. When I compared this fact with other countries, I found that it is easy to see the standards for practice of major hospital abroad on the internet but impossible to get an ideal of practice of Gynaec/ Obstetrics in India. I wondered what human care and which standard of medical services is provided to a dependant consumer called “Patient” in these corporate hospitals.

THE MAIN DEFICIENCIES OF SERVICE I SUFFERED:

During my pre-delivery care.

1. . My doctor and I never had time to talk to each other which is highly unethical, and extremely dangerous for the patient. I felt I was a burden to my doctor rather than a woman paying a huge amount as a consumer for availing her medical services.
2. . My mother had all three children delivered normally ten days overdue. As a literate woman I assume that my post maturity may be because of this genetic factor. I mentioned this every time to my doctor during my regular ( Ante Natal Care) checkup in expecting a rational and scientific explanation from a qualified Medical professional What I got was as answer was, her silence.
3. . She was under professional obligation of satisfying my queries. But I was left confused. It was my right to know my status as an expectant mother and then only I would have been in a position to exercise my options about my baby’s birth. Respondent No 1 has totally neglected her duties as a medical professional.
4. . Because of this deliberate negligence of Respondent No 1, I had to seek second opinions from other professionals expending more time and money in my last few stressful days of pregnancy.

   During my stay at Hospital

5. . Respondent No 2 had supported Respondent No 1 in carrying out an unethical surgery, in interest of revenue generation.
6. . When I was admitted on 24.03.06 at 2.54pm at Respondent No 2, I was not having any pain, fluid leaking from vagina or decreased foetal movements etc. As a routine practice, a detailed history and complete checkup ( external and internal) has to carried out, but the attending doctor ( Registrar Gynecology) at Respondent No 2 did not examined me internally ( that is per vaginally). In her notes (Examination per Abdomen in Annexure C) my uterus was found to be relaxed (that means not in Labour) but in the consent form for surgery, I was stated to be in labour (that is Rhythmic contractions of uterus). Can this be possible or acceptable to man of rational thinking?
7. . It was a pre planned surgery on part of Respondent No 1. Respondent No 2 ( also being a healthcare professional) did not bother to inquire and justify the consultant’s decision and thus supported her in this deliberately planned act of negligence and money generating Malpractice.
8. . At the time of taking consent for the surgery, the reason given to me was postdated pregnancy overdue by 7 days. I was with 41 weeks gestational age on 24.03.07 I was not convinced this to be the reason for emergency cesarean but the hype was deliberately created by both the Respondent so as to avoid me in making decision about my surgery. They put me on the Operation table on 3.05pm. Is this brief time period with so many misinformation, can allow an expectant mother to understand the so called informed consent and assent to it?

   I was made to sign the consent under undue influence

9. . In the operation theater, when Respondent No2 labeled the second opinion giver professional as QUACK, I was surprised to see the dirty politics of medical fraternity, (in which ultimately innocent patients are being victimized.)
10. . Because of her abrupt decision about my cesarean section, I was prevented from experiencing the natural bliss of being a mother, left with an unnecessary scar on my abdomen and a feeling of guilt. I suffered a lot of mental agony and stress from this incident which is supposed to be a wonderful and blessed part of every woman’s life.
11. . Now I already have two unnecessary cesarean which had further reduced my chances of having normal delivery in future. My reproductive rights had been deliberately violated.
12. . I was denied by both Respondents the duty to care (careful monitoring of maternal and foetal well being) for at least few days, owed by me. So I would have equally exercised my choice in the process of decision making about child birth , signed the Informed consent with consensus, not with confusion . At last I may have achieved a normal vaginal birth and enjoyed the motherhood more healthier both physically and emotionally.
13. . Respondent No 1 failed in her obligation to reasonably pursue the option of a VBAC birth as we had previously discussed and agreed upon. By confusing me with unsound medical information she failed to serve my best interest as her patient and failed to provide appropriate services to me as a consumer of health care.

Posted by andrea at 02:39 PM

Midwives workshop in Iran

After the excitement of the obstetricians workshop and the first waterbirth in the new birth centre came a change of pace for me as I facilitated a workshop with the midwives. A group of 50 had assembled and it was great to meet many of the midwives who had been in my previous group 18 month ago. There were lots of hugs and stories to be told and I spent much of the day having my photo taken (these new mobile phones make it easy!) with old and new friends.

The workshop itself was great. I had decided that the theme would be pre-natal education, as midwives have a major role to play in this area. Since my last visit, a number of programs have been launched to begin addressing the lack of prenatal education in Iran, which is very encouraging. During the day we explored the various kinds of programs that might be suitable, their location, format and content. We also had some fun trying a number of interactive activities that could be included in a program.

This group were very animated and the level of interaction and discussion was high. They were happy trying new games and were full of ideas for improving and extending the programs they had started.

Towards the end of the day, I received a message form one of the obstetricians in the previous group – she had returned home and already started using the new ideas we had presented. In the previous 24 hours she had assisted at two births – one a primip and the other expecting her 3rd baby. Both births were spontaneous, with no oxytocin used and intact perineums in both cases. She was ecstatic and so was Kirsten when I told her the good news. The final activity in the obstetrician's group asked them to consider how they could make changes:

It seems that natural birth is Iran is getting started at long last. Tomorrow we have a meeting with UNFPA and the Ministry of Health to map out the next steps and explore ways of keeping this momentum going.

Posted by andrea at 11:02 AM

Waterbirth in Iran

We’ve just completed our second workshop for obstetricians in Iran. This group was terrific and we have had many animated discussion about a whole variety of birth related issues. I think the absence of a cameraman in the room has helped – Iranian women feel very uncomfortable when men are around in situations like these and are unable to fully relax when a man is present.

Once again we were hoping that a woman would come into labour at the right time and we could provide a first hand experience for this group. Luck (or Allah) was on our side and when we arrived this morning for the final day, we were greeted with the news that a woman expecting her second baby was in labour and willing to try a normal physiological birth.

Dr Kirsten Small who is travelling with me was able to assist her in the new birth room. Here is Kirsten’s account of this exciting event:

What a day it turned out to be! There was a noticeable drop in numbers given the holiday today, but the obstetricians who were there were real keen. Not long after we started into the morning word came through that a woman had arrived in labour who would be suitable for me to care for during her birth. I’m not entirely sure, but I believe that this is Tehran’s first water birth outside of a research trial.

Here is her birth story -

Her name is Maryam and this is her second child. Her first child is a daughter and the scan says this is a boy. Her husband has just finished a night shift at a factory making knitted winter clothing. It is almost winter so they are working longer hours than usual.

Her last birth was - by Iranian standards - straight forward, a vaginal birth with an episiotomy in lithotomy position. Her pregnancy has been uncomplicated, she is at term, she started contracting at 7:30 am, and her membranes ruptured spontaneously at home. She arrived at the hospital soon after and had an admission VE (standard Iranian practice) revealing that she was 8 cm dilated. She was moved to the Birth Centre area and I came and met her, while Andrea brought the group to the room with the video screen to watch the events unfold. She was obviously in transition - making the noises women make in transition. Fataneh (Obstetrician who was in the first workshop) came with me, as did an obstetrician from Shiraz who has not done the workshop, and the same midwife that we had in the previous attempt. Fataneh told me that Maryam way saying “Please Allah don’t inflict this pain on one of your creatures” or words to that effect - much the same as the Australian version of “Jesus Christ this is f&*(ing ridiculous!”.

I started by sitting her backwards on a chair and rubbing her back, sitting behind her. She was bothered that she couldn’t see me and asked them to bring a mirror so she could keep an eye on what I was up to back there! I didn’t realize what was going on until the mirror was produced and it was explained so I moved to another chair and sat beside her. That didn’t last long as she was very restless and was soon on her feet rocking her hips and clutching at us for support. Fataneh was impressed that everything we had said about transition behavior was playing out in front of her eyes.

We heard involuntary pushing at the height of some of the contractions, and she said she felt like going to the toilet. We let her try without success, but I was keen to get her back from the toilet quickly. I didn’t want our demo birth to result in the child diving head first into the toilet bowl! Her toes were now curling and I showed Fataneh the legendary “red line” - which is of course dark brown in an Iranian woman.

We had been running the bath - which was tediously slow - and as it got to about 3 inches deep she climbed in - night dress and all. She rolled onto her knees and leaned on the edge of the bath. The bath is just a bit too shallow as with it up to maximum the water level was under her introitus. So we broke one of the rules and asked her to move for our convenience - into left lateral so that all the important bits were submerged. The pushing started to get more serious, but was a perfect demonstration of physiological pushing with a fair bit of open glottis pushing (aka screaming!) and a few short grunts in between. We had a few bath “floaters” and I had to try to explain what a strainer was and how to use it for this, and in the meantime we pretended they weren’t there. We also discussed using a mirror and a torch to make easier for the observer.

After about 20 minutes in the room the head came onto view, and it was basically about 5 contractions from then to birth. The shoulders were a little slow coming with the next contraction so I reached under to the posterior shoulder (which mostly delivers first underwater in my experience), to discover the babies hand emerging beside the head. I wiggled it free and WHOOSH - we had a baby, and the promised boy emerged at 9:55 am. He was bright and alert and breathed quickly. He went straight to his mother’s arms and we covered him with a warm wet towel. There had been absolutely no bleeding into the bath so I was pretty confident that the perineum was intact.

The Shirazi obstetrician was very quickly by my side with cord clamps and scissors and was a little confused when I said no to her kind offer. After about 5 minutes I asked Maryam if she would like to move and she said she would like to lie down on the bed. I took the blasted stirrups off the bed and tried to hide them where they couldn’t find them again (I don’t think I was very effective though). I took the baby in a small wrap and helped her to the bed. The group were getting restless so Andrea took them upstairs again for morning tea.

Once on the bed I checked the cord, which had stopped pulsating so it was clamped and cut. Farah (midwife and chief hospital childbirth educator) knows that we have fathers in our birth rooms all the time, so she went and grabbed Dad and the mother’s sister who where waiting in the always crowded reception area for news, and brought them in. Dad was pretty pleased and I told him that he had a very strong wife who gives birth easily, which made them both pretty happy. They had some questions for me - where was I from, why was I here, did I have children and so on, and whether the baby’s testicles were normal (just like an Australian father would!). At one point they expressed some concern as they didn’t think that they could afford to pay the foreign doctors fee for the birth (even in the public hospital there is a fee for care). I explained that the only payment I wanted was to be able to take her picture, which was met with much graciousness.

After 20 minutes there were no signs that the placenta was imminent (physiological third stage of course). I suspected that the presence of the father was inhibiting this, as the baby was feeding well, so we asked him to step out. I had a feel of her fundus and could feel that the placenta had separated and a gentle tug revealed easy cord lengthening, so I asked her to push again and we had a placenta. There was about 10 mls of blood loss (seriously!) and of course she was completely intact. Dad was returned to the room.

I have to say I was pretty relieved, and pleased with myself and Allah that it went according to plan so perfectly. Fataneh was impressed and I think we have changed her view of birth forever today. I wrote up some notes which will be translated into Farsi for her record, and returned to join Andrea and the group to report back. It would have been good to also simultaneously have been in the room with the group to see their reactions.

At lunchtime I took a photo of my own children and my camera to the postnatal ward. Mother and baby (who is named Amir-Mahdi) were resting quietly together. You can see them together in the photo. He weighed 3650 g and was 50 cm long - quite large by Iranian standards (did I mention the intact perineum?). I asked her if this was an easy birth and she said it was. So I asked her to tell her sister and all her friends that this is the hospital to come to if you want a great birth!

While this wonderful birth was unfolding, the rest of the group was in a room across the corridor, watching the event through a video link. We were joined by various other staff who had heard that something different was happening that was worth watching. It was fascinating to observe the group’s reaction to this event. There was concern that the birth was taking its time (30 minutes in second stage is quite normal, but these obstetricians are used to going in fast, using directed pushing and fundal pressure to speed the birth, cutting an episiotomy and pulling the baby out without delay, followed by immediate cord cutting and timely stitching. Sitting and patiently waiting is a skill they will need to learn if normal births are to occur. This birth was a revelation to many of them and will hopefully encourage them to try some of these techniques themselves.

It was an amazing day for us all!

Posted by andrea at 02:30 PM

My second visit to Iran

For the next two weeks I will be in Iran, once again facilitating workshops for the Ministry of Health. There will be three workshops, two three-day events for obstetricians and a one-day follow on program for the group of midwives I worked with last year.

I am travelling with Dr Kirsten Small, an obstetrician based at Selangor Private Hospital in Nambour. I was asked to bring a woman obstetrician with me this time as the main groups would be all doctors, and Kirsten was an obvious choice. Her role is to cover off the evidence that supports natural birth and to challenge re-thinking the standard obstetric approach to birth, which includes shaves, enemas, lithotomy and episiotomy. Inductions or augmentations are also routine and the caesarean rates are very high.

The first program began yesterday. We were lucky with the unbelievable traffic and actually arrived early, which is considered very bad in Iran. If you are early you clearly have nothing better to be doing, even at 8.15 in the morning! The group was about 40 people, and included some staff from the Ministry of Health as well as the obstetricians. After the opening ceremony, we got down to work.

We began with introductions. Each doctor told us where she was from, how many births they had in their unit and their caesarean rate. It is astonishing to hear how many maternity units have 1000 births per month – almost all were over 600 per month. The caesarean rates they quoted were for emergency surgery and averaged 30 – 40%. I am sure they were not including the elective caesareans in this number as the overall figure I know is around 60%. I think there was some under quoting going on as well.

Then came agenda setting. This was not an activity they were expecting, but we wanted to know what was important for them to discuss, and we made a list. The usual topics were there, including legal issues and changing women’s attitudes. It was clear they felt they were only doing what the woman wanted – a quick and painless surgical birth just like everyone else has experienced!

We ploughed on to explore the outcomes they wanted from births (healthy mother, healthy baby, low mortality, low morbidity, increased self esteem for women etc) and then I asked them to list the methods they used to assess whether these outcomes were being achieved. This was difficult for them as they hadn’t really thought beyond the statistical collection that is compiled and the feedback from women at the 7 and 42 days post natal visit.

Kirsten then presented a lovely slide presentation on natural birth, using some of Lynne Staff’s birth photos and some of her own. There were gasps at the end when one of Kirsten’s beautiful slides appeared on screen of a mother breastfeeding her baby, sitting on a birth stool, with the cord still attached and a second twin emerging by the breech.

Following this came a small group exercise to explore the role of the obstetrician, midwife and mother in achieving a natural birth. There was confusion all round as I used the colours of the rainbow to form small groups (“what is ‘violet’?, what colour is indigo?” etc) but eventually the group work got underway and ideas were accumulated.

The pelvis exercise was tackled after lunch. A large Persian rug (of course!) was rolled out on the floor and I was able to persuade most of the group to join me in exploring how the pelvis works. They were shy and I must say is wasn’t easy with everyone in full hijab, and with long coats over their clothes. Still, the message was conveyed and they were interested to discover how positioning can prevent or solve potential problems.

To consolidate the message I showed the second part of “Giving Birth, Being Born” which describes the cardinal movements of the baby using animation, the benefits of upright postures for labour and birth using clips from actual labours and clearly shows women giving birth without shaves, enemas and drugs.

It was a full day and we were all exhausted at the end. We battled back to our hotel through unbelievable traffic chaos (think dodgem cars writ large with stray pedestrians in amongst the moving mass and you’ll get the idea) and set about fine tuning today’s session.

At the start of the day we were confronted by a large mass of black shrouded women, looking grumpy and unwilling to be there. By the end of the day there were some smiles and nods happening and I could see a distinct softening in their attitudes and approach. Today we’ll concentrate on more of the practical measures they can use and tackle keeping women off the bed. One comment yesterday was that if women got off the bed and walked around in labour there would be “no way to control them”!

We are also hoping to see the labour rooms in the hospital toady as preparation for a planned activity for day three. We’ll take some photos and I will include them in my next report.

Posted by andrea at 01:28 PM

Avoiding midwifery burnout

This weekend I am in Cairns, presenting an Active Birth workshop. The group is lively and fun, with representatives from Cairns Base Hospital and others in the extended region.

An interesting theme emerged yesterday. We were talking about how it is often the motivated who attend these workshops, and how important it is to give those who are keen to support women through natural births a regular dose of encouragement and enthusiasm. Unless this happens there is a real chance they will burn out, get fed up with battling rigid policies in their hospitals and leave midwifery altogether. This has happened in many places and I have often had these stories related to me. Many midwives have also said to me that an Active Birth workshop was a pivotal pointing their decision to stay on and keep working for change.

One of the participants commented that it was notable that none of the core midwives at the local hospital was in the group. Many of the team midwives had made the effort to come on a precious weekend, but none of the senior midwives in the unit were present. This is a shame as the midwives in this workshop group have many issues with current policies in a number of areas and a general discussion on these topics would have been useful. Instead we have talked about how the rank and file midwives can approach their senior staff to stimulate reviews of outdated policies etc. It is hard for junior staff to approach their managers and seniors, yet it is the newer midwives, often fresh out of midwifery school, who are most up to date with current research and practice.

At the end of the day, changing a health care system is difficult, whether at a very local level or across a broader region. It is a huge beast that is slow to rouse, often affected by entrenched habits and routines and change is hard to stimulate. Midwives have the advantage of working with healthy women who are quite capable of taking an active role in their own care, and stating their own needs (if given the opportunity). I believe the best way for midwives to stay focused, satisfied and rewarded is to work one woman at a time, listening to her desires, creating her special birth place and enabling a very individual event to take place. It will be women she serves that offer the best rewards for midwives and every woman who has a natural birth has an impact on the wide health care system.

We’ll have more to explore today as we look at very practical measures for keeping birth normal.

Posted by andrea at 08:12 AM

Essential Educator and Active Birth workshops

Over the last three days I have been presenting the Essential Educator workshop in Sydney. We had a terrific time exploring the possibilities of prenatal education and the practicalities of facilitating programs for parents.

The group were from all over – UK, Japan, Melbourne, Brisbane, Canberra, rural areas and of course, Sydney. It was a lovely mix of experienced and new recruits and we all had a lot of fun working through a variety of teaching strategies, based on the Essential Educator kit we have developed.

I’ll be scheduling more of these workshops next year – one in the UK in April and others in Australia from mid-year. It seems unreal to be planning workshops so far ahead, but the year is racing by.

Next weekend I am in Cairns for an Active Birth workshop and the midwife from the UK is also attending that program. She works in a midwifery led unit near Sheffield and will be using all these ideas in her work when she returns home from a year long holiday in sunny Australia.

I am also putting together an Active Birth schedule for next year and will be happy to accommodate any requests from readers. As I have several overseas trips in the planning stages as well, even an overseas workshop could probably be squeezed into the calendar. Just send me an email and we can talk dates: andrea@birthinternational.com

Posted by andrea at 09:06 AM

Australian midwives' frustrations

A recent request on the ozmidwifery mailing list (anyone can join in this fantastic conversation between midwives and others) asked midwives about their frustrations with their work. The response was quick and extensive. Many midwives responded, often with similar gripes, sometimes relating to where they worked in a regular labour ward, a midwifery service (team, caseload or midwife led unit) or due to their geographical location (city/rural).

I thought I would share some of these with readers because midwives I meet in other countries often think that the conditions they struggle with are unique to them, when in reality midwives the world over often share similar situations. Australia may be seen as progressive in many ways and it is true that we have a number of birth options available for women, many more than we had ten years ago, for example. Expanding these services, and making sure they are immune from political whims is a constant battle requiring vigilance and dedication. The age-old territorial struggles between obstetricians and midwives also continue, and no doubt will be a feature of the maternity services landscape for years to come.

Here are some of the issues frustrating Australian midwives:

In Hospitals

• Outdated policies
• Policies based on some, often unknown, persons preferences and not on best practice
• Staff who do not keep their skills/knowledge up to date (Midwife)

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• I hate the language used in the hospital where I work: "will try to breastfeed", "Has lost nearly 10 percent".
• Women who appear to expect things to turn out badly.
• The constrained role of the midwife and lack of belief in all going normally. It too often seems staff are looking for problems rather than emphasising positives. Where I work that means both midwifery and medical staff.
• I loved having babies and breastfeeding, it was truly enjoyable and gave me pleasure. Here the women come in expecting grim times ahead. Perhaps while expectations are so low this will continue. I relish when I get to meet pregnant women and talk of parenting and birth in a positive light, as it seems so rare these days.

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• the lack of respect for the role of the midwife
• the practice of non - evidence based medicine
• that we are teaching student midwives to work in this way

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• lack of evidence based practice
• lack of trust in women's body/birth
• lack of autonomy as a midwife

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• The word 'allowed' should definitely NOT be allowed. Since when has any medical professional ever had the power or the gall to allow, or disallow a woman to do something? They have somehow mistaken their role as advisor or guide, for role of rule maker and enforcer. This awful paternalism by (mainly male) Dr's and carried through by(mainly female) midwives, and disrespect shown to women at a time of their lives when they are doing the very thing that qualifies them for womanhood, is just sickening. The implied power and control that telling someone that they are or aren't allowed is criminal.
• Condescending 'talks' used to manipulate women and their partners into capitulating for the greater good... The "martyr" talk, the "you've got a big baby" talk, the "you'd better have some pain relief now, you're not really coping talk", the "you wouldn't want to put your baby at any risk" talk (as was said, there is no situation without risk), the “don't be a silly girl now” talk...do I need to go on? I've even been witness to the "you're a selfish bitch" talk, in those very words to a teenager who wouldn't consent to antibiotics because she was of unknown GBS status...makes me want to cry. None of us have the right to talk
• Our inability as midwives to band together, get some professional backbone and see [how] all the awful divisive, nasty, bitchy, horizontal violence we throw at each other because of our different vested interests means ultimately our inability to see the woman as a self determining and intelligent human being [who] deserves to be given the information. The AMA [Australian Medical Association] will never have to put too much effort in keeping us in check, we do it for them.

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Birth Centre

• Lack of professional indemnity insurance for midwives
• Horror stories. Young women are so scared to birth because........
• Lack of trust in women’s bodies to birth without epidurals and other interventions

Small rural hospital

• Unnecessary intervention, eg induction for post-dates such as 7 - 10 days past due date (usually ends up with the well-known cascade), or augmentation of labour instead of waiting (also usually ends up with epidural and assisted "delivery".
• Lack of belief in women's bodies to do what they are designed to do, both by doctors and midwives (linked with the above item).
• Use of CTG's in a low risk unit despite evidence to the contrary.

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• My first thought is the excessive number of ultrasounds done. We can have women booking at 12 weeks and they have already had 2 or more for no discernable clinical reason. So many think it is ok etc and ask for more as the pregnancy goes on.
• My next thought is the word “need”. You need this intervention, you need that intervention etc, etc. Similarly “have to have”.
• Related to the above is the expression some women use "they gave me" a c/s or some other intervention. Like a present. Like something nice.

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Home birth

• professionals who don't appreciate that the woman has a right to chose, her care provider her birth space and how her birth happens. Regardless of risk, as long as a woman is well informed and has chosen the set of risks she wishes to accept ( because nothing is without risk), it is our role as midwife is to be with woman, not judge them or try to control them.
• People who make sweeping untrue statements to intimidate women into a choice they think is acceptable or who advise care based on policy and guidelines instead of evidence based research.
• People who think that all the crap we dish out we did because the woman wanted it or asked for it or it was their own lack of education on birth that lead them into this trouble. In reality in an ideal world why should women have to arm themselves with reading education, and a doula before going to birth their baby? Why can't they just believe they can do it and go and rely on the system to hold the space for a great birth?
• I have one more. I get so frustrated that people think homebirth midwives are mad lefty hippy's when in reality we are well educated professionals with passion and conviction to stand up for what we know to be right and support women to birth gently and safely. The hospital system treats us with contempt and advocating for women rights, even if it's not the system’s decision or even the best decision, is what all midwives should be doing.

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There are some powerful feelings being expressed here. It is important to find a means to express these frustrations as this is a first step to finding some solutions. Some of these issues will be addressed at a forthcoming conference to be held in Melbourne from April 27 - 29. The program for the Australian Birth and Post-natal Services Conference lists a number of speakers who will offer their experience from the business and political worlds in an effort to explore new ways of promoting midwifery, implementing better services and surviving the struggle. I will be there, to speak and meet people and perhaps I will some of my readers?

Posted by andrea at 02:13 PM

Training midwives and TBAs in Uganda

Jill Moloney writes about midwifery training in Uganda:

The students are about to take their final exams and hopefully they’ll be able to bring some positive changes to the maternity ward. I met with the “Matron”of the hospital today and have started to line up further training for the staff already working on the ward (again it will entail supporting the normal physiology of labour). The District Department of Health is also co-operating in releasing midwives from the health units for the same training, which will then (hopefully, all going to plan)lead into the next phase of creating “mother-friendly”birthing environments.

Then I’m hoping to introduce Kangaroo Mother Care” - the tutors of the midwifery school seem to be up for it so I hope the hospital and health unit staff are, too, and particularly the funding bodies.

Here are some more images from Uganda:

This Elder wanted to take “Africane”home with her. Some other community members came to see the doll and also posed for the photo.

Another TBA holding “Africane”taken in front of our office -the huts behind were constructed by the people internally displaced by war.

This photo shows some birth attendants practising abdominal palpation - the man is obviously playing the role of the pregnant woman and it caused much laughter in the group. The fetal doll is under the “skirt” and so can’t be seen.

Posted by andrea at 02:02 PM

Midwifery in Croatia

There were some midwives in this group who told their side of the story as well. They too were frustrated and sometimes traumatised by what goes on, and some had taken steps to find another way. One group, from Varazdin (north of Zagreb) had evolved a good working relationship with a young Obstetrician and they were providing midwifery care that was humane and more woman centred. Another group on the coast were proud of their hospital where water births and birth stools were commonly used. Some of these midwives had spent time in Amsterdam learning how to facilitate water birth and midwifery care and they were keen to show others in Croatia how this could be done.

Midwifery training in Croatia is very basic. Most go straight from school at age 15 - 16 into a three year course in nursing/midwifery and leave at 18 -19 to take up jobs in hospitals. There they act as handmaidens to the doctors as they have no skills in managing pregnancy or birth on their own. They are not even taught how to undertake a vaginal examination, and have very little practical experience before they graduate. Their final year, which is spent in hospital, is a year of observation, not practical skills training or supervised learnng.

It is illegal for midwives to assist at home births, which is probably wise in these circumstances. Older midwives with many years of hospital based experience may be capable of assisting at a home birth, but it would entail risk for her and the mother, which may be unacceptable.

Croatia will be joining the European Union soon. Once this happens they will be required to comply with many EU Directives. Some of these will benefit midwives and birthing women - the laws relating to discrimination and equal access and equity will apply as well as basic human rights. Midwifery training will have to comply with that in other EU countries and midwives who have worked in other countries will have to be allowed to work in Croatia. This might bring some much needed educational opportunities for Croatian midwives, who now have no chance of learning from seeing different ways of assisting births.

The Croatian Midwives Association is struggling to make any political headway with the hospitals or the Ministry of Health and there is a distinct lack of enthusiasm for change of any sort if it involves the doctors. Once the borders between Croatia nd its neighbours come down and travel becomes easier and more popular, it will open people’s eyes and stimulate much needed change in many areas, For women giving birth in Croatia today, these changes cannot come fast enough.

Here are some scenes from the workshop, held in a gymnasium in Zagreb.

Posted by andrea at 05:56 AM

Giving birth in Croatia

Last weekend I was in Croatia as the guest of RODA - Roditelji u akciji (“Parents in Action”).

On the Friday night I addressed a public meeting that was well attended by pregnant couples, and on the weekend I facilitated a workshop for 40 women, including a number of midwives, some pregnant women and a number of members of RODA. Everyone was keen to learn what they could do to improve the birth experiences of women in Croatia and to formulate some plans for achieving change.

I began the workshop by asking everyone to introduce themselves and tell a little of their history and involvement in the birth scene. It took 1 ½ hours and became a kind of group therapy. Story after story tumbled out about their births, most of which were horrendous and traumatic. By the end we were all exhausted with emotion and overwhelmed by the sheer magnitude of the suffering of Croatian women during birth. It was sad, and the pain was obvious, but the passion for doing something about it was palpable and impressive.

In summing up the birth scene in Croatia, I would have to say that it sounds like torture for the women. Pregnancy care is also characterised by demeaning and humiliating experiences. Many of the aspects of maternity “care” being inflicted are outdated, without scientific foundation and could, in some cases, be considered physically, emotionally or psychologically dangerous.

Here are some of the facts I gathered from these women, many of who had given birth once but were reluctant to go through the process again (unless they could travel to another country).

Throughout all of this ordeal, the mother is often treated rudely and controlled through both bare threats to her baby and innuendo. There are few avenues for women to find out any information and choice is non-existent for most.

Listening to story after story revealed the depth of some women’s pain and suffering and was a humbling experience. The birth rate is falling in Croatia and it is clear that many women never want to repeat the experience and risk suffering further emotional and physical trauma.

There were women who had heard of the prospects in Croatian hospitals and had decided to go elsewhere. A number of women in this group had gone to Austria, Germany or the Netherlands to get a better chance of a normal birth, and many had succeeded. One women had decided to birth her second baby alone at home after a successful first birth in The Netherlands, because she didn’t want to risk herself or her baby in the local hospital in Zagreb.

It is a pretty bleak picture, but one I gather is common throughout many eastern European countries.

Posted by andrea at 09:39 PM

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

Horizontal violence in midwifery

The issue of horizontal violence in midwifery units has again surfaced, as it does from time to time. In the UK there have been several enquiries and some useful research done to investigate ways of attracting newcomers into midwifery and maintaining midwives in the workforce, as falling numbers and the rising average age of midwifery staff start to ring alarm bells.

The telling outcome of these studies is the main reason that midwives leave their chosen profession is a lack of job satisfaction and recognition for the work they do. Many midwives cite a lack of support from management and poor relationships amongst their peers as underlying their decision to move on. Much of the behaviour they have suffered would be classified as “horizontal violence” and it seems that nursing and midwifery are particularly prone to this terrible phenomenon.

Many midwives struggle in unhealthy, unrewarding workplaces, and many cave in and leave, in the hope of finding more success elsewhere. As they depart, the work falls on fewer shoulders, adding further strains to the stretched services, and the cycle continues.

Many of those who remain are older and have developed ways of surviving in this socially toxic environment. They become hardened and withdrawn, going through the motions of “getting the job done” with little regard to the needs of women or their colleagues. Others become bullies, taking out their own frustrations and insecurities on others, who then have to find ways of dealing with the abuse or (more likely) dodge the issue by leaving.

It is a real problem and one that takes strong management and sensitive handling to eradicate. Good team work and the building of a strong shared goals and vision are important. There are midwifery units where these conditions have been developed with great success and unsurprisingly, these are usually the units where birth outcomes are also good, reflecting the way that happy staff have more time and energy to create happy birth places for the women they are serving.

For those who are interested in reading more about these issue, I can recommend these articles from our website:

Dying for the Cause by Carolyn Hastie

Horizontal Violence in the Workplace by Carolyn Hastie

Both explore the issue in depth and offer suggestions for ways of overcoming this insidious problem that in many ways is hampering the birth reform movement for women and their midwives.

Posted by andrea at 08:56 AM

Wales moving ahead with midwifery

The group in Canterbury (the next day) were also very interested in the kits. They could see immediately how elements of the kit could be used in various specialised classes, such as VBAC or refresher groups. They are working to re-vamp all the programs they offer and are especially keen to attract some women who do not normally come to parentcraft sessions.

Friday, I travelled to Wales to facilitate a one-day workshop for a group of midwives who had already purchased The Essential Educator kit and others who were planning to buy soon.

I walked them through a number of activities so they would feel confident in presenting these exercises themselves and we also explored some of the practical tips and suggestions for adding zing to the classes as a whole.

In the evening I had dinner with Polly Ferguson and Sandy Kirkman (both speakers on our next Future Birth tour). Polly is the Midwifery Advisor to the Welsh Assembly and she is very excited about these kits, having already instructed all the heads of midwifery in Wales to consider using them in their hospitals. After more than a year of working to standardise the classes across Wales (and not achieving any concrete outcomes as yet), Polly has suggested that these kits will do the task for them simply and easily.

I will be back in Wales in February to facilitate another workshop for 20 midwives who will be using the kits by then. Wales has a very proactive approach to midwifery services and has some very dynamic leaders. They have tackled the problem of caesarean rates and introduced the All Wales Pathway for Normal Birth, which has helped to keep birth normal and avoid interventions.

I am glad that I spent my last day on this trip in Wales. Britain’s NHS is in such disarray at this time, with huge budget overruns and general gloom and doom that spending time with a bunch of people who are upbeat and going forward has been a welcome change.

I am hoping that my next visit will be in better circumstances and that some measures will be in place to lift the spirit of midwives across this country. Off home tonight and back in Sydney on Monday.

Posted by andrea at 03:55 AM

Are Irish women wimps?

I made a day trip to Dublin today, to showcase The Essential Educator to a group of midwives and educators from across the country. They were very keen on this teaching package and no doubt many will want to use it in their work.

After my presentation, we had a general discussion about childbirth education and some fascinating points were raised. One educator (from Holles St - the National Maternity Hospital) pointed out that at her hospital (the “home” of The Active Management of Labour) the epidural rate was now 70% and that this had not produce poor outcomes. The caesarean section rate was 15% and they also had a low rate of forceps/vacuum (not specified). She felt that if there were no poor outcomes then there was no way she could encourage women to consider alternatives to epidurals, especially if women demanded them and the hospital was to “keep up” with the services offered in other Dublin maternity hospitals.

What is going on here? It was apparent that Irish women are being denied information about the adverse effects of epidural on their babies, which is a primary motivator for women in other countries to manage their labours without drugs. When I demonstrated the role play from The Essential Educator that enables women to understand exactly what is involved in an epidural, I was told that this might “frighten” women. Eductors felt they should censor the information they gave in case women might be upset by some of the possible side effects or potential outcomes.

Irish women are, of course, used to being given information that someone else has deemed “allowable”. Feminism has not really surfaced in this country, where for generations, women’s lives have been ruled first by the Church and now by the doctors. All kinds of limitations are imposed on women in Ireland that would be completely unacceptable in other western countries: the freedom to speak out (lots of whispering behind hands goes on); the freedom to voice opposition or even question policies of all kinds (lots of undercurrents of threats to jobs and plenty of backstabbing); restrictions on who can be involved at births (no extra support people, be they friends, family or a doula); domination of midwifery by obstetricians (ridiculous policies and protocols); restricted services (closing small maternity units, denying the right of women to have home births); and various political manoeuvres that protect vested interests at the expense of women’s rights.

The one shining example of modern maternity care - the Birth Centre in Drogheda, which was established as a pilot project, is apparently under threat, from internal bullying of staff and restrictions that are so onerous that its availability is restricted to very few women. Other small maternity units are being closed and there seems little political will to fulfill the promise of rolling out maternity services modelled on this pilot projects, across the country.

Of course, none of this will be discussed in the open, although I will gets some personal emails. The maternity care system in Ireland is being used to keep women in their place - flat on their backs, unable to help themselves and under the direct control of the doctors. The epidural is a modern form of subjugation that robs women of their dignity as it ties them up with tubes, monitors and catheters. Anaesthetised, unable to even manage their own bodily functions, women have their babies pulled from their bodies or are bullied to push them out according to instructions from their “caregivers”. It is a modern, ritualised form of torture.

When looking for a counter argument to present against the epidural for labour, one has only to look at the baby, and the psychological impact this form of treatment has on the mother. One of the most insidious effects of anaesthetising women and babies during labour is the disruption that occurs to the nurturing hormones (oxytocin and endorphins) which are vital for forging a close bond between mother and baby at birth. Artificial oxytocin does not produce the caring and nurturing behaviours associated with naturally produced hormones. The baby, full of drugs, will not breastfeed well, and is at risk of being fed formula as a result - not the best nutrition for babies.

What is happening in Ireland is an example of what can occur when medical dominance of women is allowed to flourish unchecked. Women don’t find their own power and strength through giving birth unaided; babies are not bonded to their mothers at birth through the natural flow of hormones; breastfeeding rates are low, leaving babies to survive on less than ideal formula foods, and women’s voices are stifled through systematic subjugation by powerful, vested interests. Fear is rampant, women are afraid to speak out and leaders who are willing to take up the challenges are ostracised or even punished. For this to happen in poor oppressed nations struggling to provide the basics for human survival might be almost understandable, but to see it in a wealthy first world country which claims to be affluent and progressive is unacceptable.

One measure of how well a country is doing is to examine their health care system. Until options are in place that freely offer women choices for childbirth, births that don’t compromise the baby’s health through the use of obstetric medications, professional practice based on evidence, home births, water births and other non-invasive comfort measures for labour - in other words mother and baby friendly services - no country or hospital can claim to be civilised.

Posted by andrea at 06:20 PM

Cutting the umbilical cord

One lively topic we discussed at the Stoke Mandeville Active Birth workshop today was when to cut the umbilical cord.

The typical approach in hospitals is to cut the cord as soon as the baby is born, before the placenta arrives. If the mother has been given Syntometrine or Syntocinon ( oxytocic drugs) to speed separation of the placenta the midwife will probably not wait for the cord to stop pulsing first, clamping and cutting the cord as soon as possible after the birth. Left alone, nature has provided a safety mechanism for the baby immediately after birth, when it may take a few minutes for breathing to be established. The cord continues to pulse, gradually phasing out as the cold air causes the cord to constrict and reduce the blood flow. The whole process takes a few minutes, although with a birth in water, the cord may continue to pulse for longer.

Once the cord stops feeding oxygen through to the baby, it is unimportant when it is cut: many midwives will leave it alone until after the placenta arrives, then clamp and cut. Others cut the cord earlier, leaving the placental end to drain a little, which reduces the pressure in the placenta and makes it easier to separate from the uterine wall.

The benefits of leaving the cord uncut until its work is done are now clear. The baby will get extra blood which is now known to be protective and important for preventing anaemia in babies. (Delaying cord clamping reduces anemia Pediatrics 2006; 117: e779-86). If the baby doesn’t breathe immediately, it still has a lifeline supplying oxygen. Earlier fears that delayed clamping will leave the baby with extra red blood cells that may precipitate jaundice are unfounded - some jaundice in the newborn is natural and excessive levels are more likely to be the result of the baby’s kidneys struggling to metabolise drugs such as artificial oxytocin and opiate drugs that were passed on from the mother during labour.

When the cord is wrapped tightly around the baby’s neck at birth, delaying the birth of the shoulders, the cord should also be left uncut. In this situation, a sudden surge of oxytocin (perhaps triggered by the baby’s potential distress signal) causes a big contraction and the baby will tumble out all at once, enabling the cord to unwrap itself from above. It is frightening for the midwife to wait when the baby appears to need help, but once again nature will take over and provide a rescue. Once the pressure is off the cord, the blood will again flow, giving oxygen to the shocked baby (who might also need a little oxygen via bag and mask). The cord should not be cut, and help should come to the baby, rather than taking t he baby away to be assisted.

There are always important biological reasons for the mechanisms involved in natural labour and birth an we should leave well enough alone. Cutting the cord provides a means to speed up the third stage of labour and gives the attendants something to do. Why not wait - what’s the hurry?

Posted by andrea at 06:13 PM

Breech babies

I have started to include a reprint of my article on turning breech babies using Moxa sticks in my workshop participant packs. The issue of breech birth always comes up when we are exploring ways of reducing the caesarean section rate and given the current protocol in western hospitals to manage all breech births with caesarean operations, it seem sensible to look for ways of turning the baby to a head down position during the pregnancy. Once the baby is in a vertex position the problem of the baby being breech disappears, along with the need for a scheduled caesarean.

The use of heat to encourage the baby to turn is simple, costs almost nothing, can be done by the mother in her own home and is safe. Moxa sticks can be bought very cheaply at any shop selling herbal remedies, especially Chinese remedies, or if there are none of these outlets available, then on-line.

The article can be downloaded by expectant parents, who can follow the diagrams, photos and instructions for themselves.

For midwives, I always recommend the book “Breech Birth, Woman Wise” by Maggie Banks. This straightforward, “how-to” manual sets out the basic principles of managing a breech birth safely in any settling and the research, photos and case histories offer practical tips and reassuring messages. Given that breech babies are still being born vaginally, often having been mis-diagnosed during pregnancy, midwives need to be prepared to manage an unexpected breech birth. This book is therefore essential reading for anyone working with labouring women.

Posted by andrea at 11:53 PM

Visiting Scotland

I’ve spent my last few days in Inverness in the north of Scotland. I won’t be posting any blogs from here though, because the standard of internet service in British hotels has once again let me down and getting any access to email or the internet is next to impossible (and expensive). I’ll put these messages up as a block as soon as I can find a workable connection.

The group in Inverness was a mix of local midwives and a large group of students. Raigmore Hospital in Inverness has about 2800 - 3000 births each year and a caesarean section rate of around 30% - typical of many hospitals in the UK. We ranged across the usual spread of topics in this program, and I was particularly asked to address how to avoid intervention when labour was progressing slowly (midwives are often under pressure to conform to pre-determined birth plans typified by partograms), building midwives’ confidence in facilitating normal birth and the management of third stage.

The students in the group also voiced their concerns that although they are being taught from a woman-centred care perspective, they are often frustrated by the requirement to adhere to caregiver and hospital system based protocols (often not evidence based) when they undertake their practical placements.

Once again I heard of silly health and safety, and infection control measures that are stifling any kind of lateral thinking or common sense approaches to providing comfort for labouring women. The lack of floor mats (condemned as hotbeds of infection in this area!), restrictions on the use of hot packs for easing labour pain (deemed as unsafe) and the requirement to have women give birth on beds because anywhere else may place a strain n the midwives’ backs, were all examples quoted by the midwives here.

As ever, I provided examples from other units where these issues have been successfully addressed through lateral thinking and co-operative effort, for everyone’s benefit. I find it frustrating that midwives in the UK don’t bother to look beyond their own hospitals for examples of best practice and innovation that are not only more professionally appropriate, but more importantly, benefit the women they are supposed to be serving. There are many good stories to be told in the UK, but a general lack of curiosity and an almost rigid need to maintain the status quo is affecting forward thinking and innovation in many places. Midwifery is going backwards at the moment in the UK, and is at great risk of being subsumed by medicine into a maternity service staffed by obstetric nurses.

I am hoping for more positive news from my next group in Aylesbury (England). In the meantime, I am hoping that I have been able to give the midwives in this area a glimpse of other ways of doing things and perhaps a vision of how they can achieve more personal satisfaction with their work.

Posted by andrea at 11:45 PM

Perineal Massage

A recent review of trials of manual perineal massage during the last weeks of pregnancy (Kuehn 2006) has concluded that this technique can help prevent tears to the perineum in first time mothers and reduce the need for episiotomies during normal vaginal births. The reduction is not large (15%) and no doubt is also dependent on the practitioner in charge of the birth (other research has shown that midwives have a better track record than doctors in maintaining an intact perineum) but it is encouraging. Many women hope to have no stitches at the end of the birth day and it is also a goal for many midwives, who see perineal management as a key professional skill.

Of course, not all births will result in no tears, even if great care is taken. Some babies decide to arrive with a hand or arm over their heads; others rush out, leaving little time for the tissues to stretch. Anaesthetics and drugs that upset a woman’s ability to stay in touch with what is happening in her body can also make it hard to give birth slowly and gently, especially if the perineal area is numb and there is no feedback to work with.

Many women are interested in using perineal massage in the last weeks of their pregnancy. A useful place to learn more about this technique can be found on this site sponsored by the University of Michigan.

Some women find that using the Epi-No is a good way to prepare their perineal area for birth. This useful tool can also be used for strengthening the muscles after the birth, to reduce postnatal (and menopausal) incontinence problems due to poor pelvic floor muscle tine. There are more details about the Epi-no here.

Kuehn B. Massage during last weeks of pregnancy reduces episiotomies during delivery. JAMA 2006; 295:1361-1362.

Posted by andrea at 05:26 PM

Ultrasound in pregnancy - not as safe as you think?

Many years ago (1980s) questions were raised about the safety of ultrasound scans for the unborn baby. Concerns centred around an effect which had been observed when cells were bombarded with ultrasound waves at levels used for visualisation. It was noted that cells that were normally arranged in orderly rows became jumbled up and erratically organised. This led to speculation that growth may be affected - cells in the developing fetus that were. not in neat alignment may grow haphazardly, perhaps resulting in a smaller size of the baby. This proposition was reinforced by a landmark study done in Western Australia by Dr John Newnham who was investigating the effects of serial ultrasound scans during pregnancy on the baby. He found, unexpectedly, that those babies scanned more than twice were smaller than those scanned less often - not a great difference (around 30 grams) but still significant.

Another concern raised was the impact that scans might have on the ova present in unborn baby girls. These cells are fully developed in the ovary very early in pregnancy (around 8 weeks) and it was suggested that ultrasound waves that disorganised these specific cells may have later ramifications for fertility. This proposition has not been tested (to my knowledge) but makes sense from a biological perspective.

The simple fact is that there is very little evidence of the long term effects of ultrasound scans on the baby during pregnancy. It is clear that there are no major effects, since these would have shown up quite early but more subtle effects, like a tendency towards left-handedness have been demonstrated in babies who were subjected to several scans before being born. Less obvious impacts, such as smaller stature, impaired fertility etc would take considerable effort to investigate fully, and there just doesn’t seem to be enough concern or incentive (or resources) to undertake this work.

At the same time, there is an increasing market for scans and the equipment being used is becoming much more advanced and powerful. These days 3-D ultrasounds can provide a very clear picture of the baby, and to achieve this prenatal snapshot, the baby must be subjected to much higher intensities of ultrasound waves for longer periods. Shop front ultrasound stores have sprung up, encouraging expectant parents to get early pictures (even movies) for their albums, and the operators of this highly sophisticated equipment may have no medical training.

Recent articles in the British press have highlighted this development and warned parents that they may be exposing their babies to unnecessary risks and unknown consequences when they buy these images. After years of promoting ultrasound as “safe”, the medical profession is finally admitting that there are potential problems with overexposure to ultrasound waves in pregnancy. Parents don’t often realise that the hand held sonicaids and dopplers used to listen to the bay’s heartbeat also use ultrasound and that the information provided by electronic fetal monitoring, which is heavily relied on to measure fetal well being during labour is also acquired through continuous ultrasound waves beamed at the baby, often for many hours. Baby’s developing systems are therefore experiencing ultrasound waves quite frequently, adding up to a considerable level of exposure over the entire pregnancy.

Various medical bodies in the US, UK and Australia have warned of over exposure and suggested that pregnant women limit their scans to two during pregnancy. However, the seductive nature of the advertising, the natural curiosity of pregnant parents and the money making opportunities presented by ultrasound scans (for doctors and shop-front operators) are powerful influences.

As one of my colleagues noted in a wry comment on the Australian midwifery email list, “I've personally wondered if ultrasound isn't a way that will naturally limit white middle class populations. A ready built population control mechanism. One way of dealing with the crazy consumerism plague of western civilisation.” She might be onto something there!

More useful information can be found in in "Ultrasound Unsound".

Posted by andrea at 01:05 PM

Birth with two wombs

Last week there was an interesting program shown on SBS Television in Sydney. It was the story of a woman who was born with two wombs, two cervix and two vaginas, who conceived in each uterus at the same time.

Being born with two complete reproductive systems is extremely rare and is often associated with infertility. However, despite the odds, this mother became pregnant, with one baby a girl and the other a boy. The pregnancy was carefully monitored by her obstetrician (this was in the UK), because each uterus was about half the normal size and there was concern that this may hamper the baby’s growth and development.

The film followed the mother through her pregnancy, interviewing her and her husband, the obstetrician and her mother. There were several scares when ultrasound scans suggested there may be problems (once it was the shape of one baby’s head) but these proved to be false, and the babies grew well. The plan was to maintain the pregnancy as long as possible, with a caesarean birth scheduled around 36 weeks.

By 34 weeks, the scans were being done every two weeks to determine growth. At the 34 week visit, the obstetrician announced that the fluid surrounding one baby was reduced and he scheduled an immediate caesarean, for later that day. The poor mother was very upset, and not at all emotionally ready to give birth, however she agreed for the sake of her babies. Given that very few cases of a double pregnancy like this have ever been recorded, and none had produced two live babies, it is easy to see how everyone was trying to achieve a positive outcome in this case.

The scene after the caesarean was heartbreaking. The mother was shown in a bed, sobbing because she had not seen her babies. They had been whisked away in theatre to be cared for in intensive care as both had respiratory distress (a typical problem of premature births) and after two days, she had still not seen her children. She was bereft and clearly distressed by this separation, which had started suddenly, out of the blue on a day when she thought she was going to have a routine check-up.

Finally, after a long wait, she was taken in a wheelchair to the ICU where she was helped to cuddle her babies against her skin, while a midwife helped with all the tubes etc. The change in her was dramatic - at last she held her precious bundles and expressed the joy of holding her child and what it meant to her.

While this was an interesting story, and no doubt one of great historical interest, I felt it showed some glaring inadequacies in the system at the hospital in Exeter. Why was the mother left for two days without even seeing her babies? She was quite well and there was no apparent reason why she couldn’t have been taken immediately she left recovery, to at least see her babies. To deprive a mother, especially in her special circumstances, of the opportunity to affirm her babies were OK, after all the concern raised by this complex pregnancy, seems cruel and unusual punishment.

A caesarean birth is not one that most women anticipate, yet sometimes they are necessary. When a caesarean is indicated, especially in an emergency, why can’t basic humanity prevail and steps be taken to minimise the trauma that will accompany such an event? There are many things that can be done to ensure the emotional and psychological well being of the mother and her family at that time: holding the baby in theatre, having skin to skin contact while in the recovery area (and early breastfeeding), unrestricted access to the neonatal intensive care unit and help with expressing colostrum for the baby. The needs of the father must also be considered as he is often traumatised as well, and he needs unrestricted access to his partner and baby too.

On another note, I was surprised that the obstetrician made the snap decision for an immediate caesarean based on one reading of a scan that suggested some reduction in the amniotic fluid surrounding one baby. Surely the appropriate course would have been to monitor the situation, taking readings every two days to ensure that the fluid was decreasing. A single interpretation of a scan may have been incorrect, or it may have indicated reduced fluid that was stable and not a cause for concern. I couldn’t help wondering if his rushed decision had something to do with the theatre schedule, and the presence of the TV crew that day. The babies were as well as could be expected at 34 weeks and respiratory distress (the result of being born too soon) was reported as their only problem. Why couldn’t they have stay safely inside until both they and their mother were ready to take the next step into the world?

Posted by andrea at 10:29 AM

Birth centres and language

This week I presented a workshop at Queen Charlotte’s in London. This famous hospital relocated a few years ago to a new site, with a new building and all mod cons. The plans had been on the drawing board for some years and by the time the service was established, it was realised that the number of births in the area had grown and they needed extra capacity. It was decided that the extra births (around 1000 per year) could be accommodated if a Birth Centre was established, so part of the adjoining Hammersmith Hospital was converted for this purpose.

The Birth Centre at Queen Charlottes is a very well appointed service. The rooms are spacious and well equipped with large floor mats, huge bean bags, birth balls and birth stools and each has an en-suite bathroom and a large tub. The small regular bed sits in the corner and has a pull-out trundle bed for the father if he wishes to stay after the birth. One room has a hammock-like sling hung from the ceiling that women can use for support during labour or to hold onto for the birth.

The midwives who work there are carefully chosen for their experience and skills with normal birth and the outcomes, as you would expect, indicate that the midwifery model of care is very effective for keeping intervention rates down (the caesarean rate in the main part of the hospital is 36%).

The participants in the workshop were from several hospitals and all were involved with either caseload midwifery (one-to-one) care or were employed in a birth centre. It was stimulating to have such a group of experienced midwives to work with - all were familiar with home births and all were deeply committed to providing woman centred care.

Yet even so there were issues that we needed to explore. Two of the midwives were Italian and both had provided home births in Italy. Given the lack of opportunity for this approach in Italy, they had decided to come to England - “the home of midwifery” - so they could work freely as midwives. They discovered that in England, even amongst midwives, birth is often medicalised. They were shocked at the regulations and rules that are all pervasive in the maternity services, often stifling midwifery practise and forcing women and their midwives to fit into predetermined moulds. Both worked in a birth centre and were able to facilitate normal births, but declined to use Entonox and TENS, for example, which are both “very British” inventions and almost unknown outside the UK.

We also discussed the language issue at length. One of this group talked about “confinements” to the surprise of the others and all were very fond of the “delivery” word. Since they had identified communication with women as a theme they wanted to explore during the program, we talked about the way words impact on women’s impressions and emotions, especially during labour and how a few well chosen words can confirm the faith and trust of the midwife and build a woman’s confidence in her ability to give birth well.

Two of the group are involved in the setting up of a new birth centre service in the Mayday Hospital in Croydon just outside London, and we talked about the impact that the language can have in creating the right impressions in both the staff’s and the women’s minds. I encouraged them to think about designing paperwork that used the “birth” word rather than “delivery” as a starting point and gave them a copy of an article ai have written on the subject of language to stimulate further thinking around this subject.

Queen Charlotte’s Birth Centres uses an adaptation of the All Wales Pathway for Normal Birth to record labour progress, which I was delighted to hear. More about this wonderful tool later - I am off to Wales today to give a short presentation and will be talking to the creators of this outstanding midwifery innovation this evening. I’ll write it up further in a later Diary entry.

Posted by andrea at 05:33 PM

Giving birth in Letterkenny, Eire

I am presently in Letterkenny, Donegal in the north of Ireland. It is a beautiful part of the country and an area I have wanted to visit for quite some time.

The group I am working with are all from the local hospital, which has about 1700 births each year. As we introduced ourselves, it was clear that these women had wide experience of many hospitals and almost all had trained elsewhere (often in the UK) and often worked abroad too, before returning to this area to settle.

They offer a midwifery model of care here for those women not under the care of private obstetricians, which is very different from much of Ireland. Last year I had met some midwives from Letterkenny in a workshop I presented in Dublin and it was clear then that their approach here was (thankfully) out of step with the more rigid approaches in most other Irish maternity units.

I am told that they have a midwife shortage and this is hampering their plans for expanding their midwifery care. A new section of single labour and birth rooms has been built but cannot be opened because of these staff shortages and its location away from the current unit. This is a great shame because right now in this is the only hospital women are labouring in shared four bedded rooms before being moved to the second stage room. The lack of privacy in the shared first stage area means restrictions on the number of support people who can be with the labouring woman and everyone knows this is far from ideal.

However, despite their less than ideal physical set up, they have achieved low caesarean rates and low intervention rates generally. It reminds me of “the olden days” when shared facilities were very common and midwives felt that women spurred each other on as they laboured together. It will be interesting to see what these midwives offer in response to the group work exercise they did yesterday on ways of making the labour room feel “safe” during labour. If women feel protected and safe then their adrenaline levels will be low and labour will be shorter and more comfortable. I am wondering how they can achieve this when they have to work in these outdated facilities.

I have an inkling of how they achieve this from some comments about drug use in labour but I will wait to see what they offer. I certainly hope they can recruit some more staff - they are offering a great service already and will do even better if their new unit can open.

Posted by andrea at 05:41 PM

The Belmont Birthing Service

Following from my previous Diary entry, here is some more information about the Belmont Birthing Service near Newcastle, NSW. This is taken from an email written by Carolyn Hastie, the Manager of the Unit. I will post the statistical outcomes when they are available.

”The midwives have provided comprehensive 1-2-1 care for 187 women since we started a year ago. We also have over a 100 women who are currently booked with our service.

Many of the women who book with us were/are considered 'unsuitable' (ACMI Guidelines for referral and consultation) for birthing at Belmont, which is completely 'stand alone' in that there are no doctors on site and no core staff. If, according to the ACMI guidelines, the women are considered safer at the tertiary referral hospital for birth, the midwives provide all antenatal care with appropriate referral and consultation with the obstetricians at John Hunter and then accompany the women in labour to birth at JHH. The midwives then followed up those women at home for three weeks, just the same as if the birth had occured at Belmont.

Education and information sharing is ongoing. Births through water are popular as the women love our big baths! All babies and mothers for both groups of women are well and healthy. Breastfeeding initiation and continuation rates are high. Skin to Skin for mothers and babies at birth and beyond is explained, promoted and encouraged. We have a weekly discussion group, weekly lullaby group, weekly parenting education sessions and breastfeeding information and education sessions every two months. The midwives don't see the third day blues (which is also really interesting), women are happy and babies are calm. Women are very satisfied with their experience and their care. We will release a full year of stats and information as soon as the year is up.

In the interim, you may like to know that the stats are wonderful for both 'low risk' and 'high risk' women. Low low caesarian and instrumental delivery rate (<10%), low low PPH rate (< 5%); three premature babies; one person with antenatal preeclampsia (which I think is really interesting).

Testimony to women, birth and great midwives - the power of love. The team is fantastic. The families are wonderful too, very supportive.

The fact that BBS exists is very much due to the power of Maternity Coaltion and the absolutely indefatigable efforts and energy of Carol Chapman and Justine Caines without whom none of this would have happened.”

This wonderful service is certainly testament to the power of women when they get organised as a group and keep lobbying/ fighting. I look forward to seeing pictures of their first birthday party with the Minister for Health being feted once again by mothers and babies.

Posted by andrea at