Maternal Request Caesarean Section – is it a choice?

There is much upset in the normal birth world today over the announcement that NICE is going to allow caesareans on request.  However, the real statement goes a little deeper than the BBC and newspaper headlines suggest…

Firstly, it is not saying that a caesarean section is a safe alternative to vaginal birth, it is saying that improvements to surgical techniques and outcomes has reached a point where the risks of elective surgery are reduced to a point where they are in the realms of acceptable, under certain circumstances, and that a woman’s emotional health might be one of them.

My second comment would be that our over-stretched maternity service is going to find it hard to offer this service if many women take it up, because a caesarean is more expensive for the NHS to deliver, several times the cost, it also results in longer hospital stays, more SCBU admissions, more readmissions for mums and babies, more follow-up care and more midwifery time and input.  The answer of course is to seek to make birth as low-intervention, safe and enjoyable as possible for as many women as possible, to free up valuable resources for those few who really need the high level input.  That is more physiological births, more home births and fewer women deeply traumatised by their birth experiences, both as a benefit to themselves and so that there are fewer horror stories and more positive experiences to share with those yet to birth their babies!

With this new guidance, to be published at the end of November 2011 (NICE CS Guidance), Nice is trying to protect the rights and birth choices of women who are seeking to avoid birth for emotional reasons.  The guidance says that women who arrive requesting a caesarean without medical reason need to have a full and frank discussion about what that entails and what the potential risks are (which is more than many women planning a caesarean get from their consultant now) and if it is appropriate, for example women who reveal previous episodes of abuse or birth trauma which is making them afraid of birth, women are to be offered counselling for those issues, regardless of any expectation over their birth choice.  The guidance then goes on to state that if a woman still feels a caesarean is the emotionally safest option for her then her request should be accepted and supported.  The guidance also says that if a surgeon has a moral objection to meeting the woman’s request for section, or if a surgeon feels unable to justify the increased risks to the woman, then they are obliged to pass the woman on to an NHS colleague who is better able to meet their request.  Thus protecting the surgeon’s right to professional autonomy and personal integrity.

In reality this new guidance formalises and provides structure in accordance with what already happens in many areas.  It also provides a clear framework for women to request a caesarean and know that they are going to get good support to do that and to address any emotional issues which might be contributing to their request for major abdominal surgery, which, let’s face it, is not a decision to be undertaken lightly.

It also provides a framework for giving women good quality information about the risks and benefits of surgical birth, and is expected to not only cover the increased risks to the mother and to the baby whose birth is being planned, but the risks to any future pregnancy she may have.  This is not only the small increased risk of rupture during a VBAC , but the much bigger increased risks of issues like infertility, miscarriage, still birth or placental problems such as placenta previa or placenta accreta.  It is very important that women understand that the risks carry over into the next pregnancy, and that those risks are not all eliminated by repeat surgery, and that also, the more caesareans a woman has, the more complicated and risky future surgical births become.  I also hope that the NICE expectation that full information be given to allow women to make an informed decision about choosing a caesarean may even make maternity care teams think more critically about what a caesarean really means for a woman, both short and long-term, and may help reduce the sometimes blasé attitude to surgical birth seen in some maternity units!

Of course it is only guidance, it is not mandatory, which means that at the moment units, and individual practitioners, can pick and choose whether or not to follow them.  However, once women are aware of the guidance and start requesting that their care teams follow the evidence based suggestions within them, it will be very difficult for a compassionate unit to refuse!

I am hoping that this does not become another mantra for blaming women for the rising caesarean rate, there is already enough blame-laying.  Older women are blamed for the rise, women with a high BMI are blamed, those who are duped into believing that it will protect their bodies from the ravages of birth are blamed…  We must be wary that it does not become a situation where women are blamed in large numbers for ‘wanting’ surgery. The number of women who are requesting a caesarean, either for emotional or social reasons, is comparatively tiny when compared with the 180,000 (1 in 4) babies who are currently born by caesarean surgery in the UK every year.

Personally, I think the NICE guidance on this is a good thing.  It paves the way for active legislation on choice, real choice for women over what risks they see as important and what risks they are prepared to accept or not accept for them and their babies.  It sets a precedent for women being allowed to request something which their care team feels increases their physical risk in order to protect their emotional health.  It also allows for discussion on what actually constitutes ‘safe’ and how that evidence is gathered and presented.  Women who are asking for support in their informed birth choices frequently know that what they are seeking is safe in a way their litigation-fearful care team don’t comprehend.  Next stop a total rethink in the way women challenge the ‘home birth is too risky,’ ‘VBAC is dangerous,’ statements.  If you allow me to increase the risks to myself and my baby by requesting a section, you need to allow me the same courtesy to book a well supported vaginal birth.  There can be no argument against that now!

Posted in Birth, Caesareans and Natural Caesareans, Home Birth | Comments Off on Maternal Request Caesarean Section – is it a choice?

Should we ban advertising of formula?

The anti-breastfeeding lobby would say that banning formula advertising takes away choices from parents and makes those who did not breastfeed feel guilty…  For a start, no one can give guilt to another, the guilt surrounding feeding choices is a subject for a whole other blog post, for today I’d like to consider another way of looking at the WHO code’s ban on the advertising of infant formula…

Formula does not need advertising.  Mothers who need it know it is there, they know where to buy it, they can ask their health professionals for information, the instructions for each brand are carefully printed on each packet because it is so very important to make the milk up correctly to minimise the risks of making it too concentrated, too dilute or introducing bugs your baby would be better without.

Advertising formula is simply there to LIMIT parents free choice by making them believe that any one brand is better than any other and it is there to subtly (and not so subtly) undermine public confidence in human milk.  Women who need or want to use formula need good advice that they don’t get from advertising and they need to know about any applicable public health schemes which help with the high cost of feeding babies a human milk substitute.  Women also need to know the relative health costs and benefits of their choices and they need good support when they choose to breastfeed to ensure that they stand the maximum chance of it being a successful and fulfilling relationship.
Advertising formula as ‘as close to breastmilk as possible’ feeds into the guilt system, subconsciously reminding parents that the product is only almost as good, and ensuring that those who do choose formula remain fiercely protective of their decisions and are hostile to those women who succeeded or made a choice that was not available to them.

Formula advertising removes choice.  It is the hottest fuel for the anti-breastfeeding debate and parents don’t even realise that is what is happening or that they are being manipulated by the multi-million pound advertising budgets of those with a vested, profit related, interest in ensuring that women do not breastfeed, either through ‘choice’ or through a lack of support to ensure that breastfeeding works.

Formula advertising should be banned to protect the rights of mothers and babies to choose how they feed their babies free from commercial pressure.  If the demand is there from a basis of need, as an essential food product, then advertising is completely unnecessary and banning it would not matter in the slightest.

Support for parents is not helped by fostering hostility towards those who make different choices or have different opportunities.  It is time for proper support for those who want to breastfeed, and proper support for those who do not.  Banning formula advertising, in all its guises, would go a long way towards achieving both.

Posted in Baby Feeding, Breastfeeding, Parenting | Tagged , , | Comments Off on Should we ban advertising of formula?

Wear your baby with pride

I was talking to a friend who is a new mum the other day. Proudly she told me all of her new baby boy’s achievements, his smiles, his beautiful eyes, his ability to poo his own bodyweight- your average mum-like praise & wonder at this amazing person… then she told me how clever he was as he had slept all night in his own room. We talked some more over coffee in that way that all mums value. She told me how at times she finds it hard- it’s the not knowing why he’s crying…

Later I went home & sat & thought. With my first baby I was invincible, I had endured and survived the birth with all the machines that went ‘beeep’, I proudly told my community midwife about taking my 3 day old baby out for pizza and couldn’t understand why she looked taken aback. I did all the things a modern westernised woman can do. Only- I wasn’t invincible, my baby wouldn’t feed, I didn’t know why he cried in his lovely seat, his pretty bouncy chair, his perfect Moses basket that I had sewn the covers for myself.

With babies no 2 & 3 I did things differently. We baby-mooned. We had skin to skin time. We revelled in being in bed close and cosy. When it was time to go out we used slings. Not always successfully- I nearly garrotted my husband with a ring sling once… but that’s a different story. Sometimes we used the techy one with straps & buckles, sometimes the pouch one that I’d sewn. The difference was that my baby was always near me.

The difference made a difference. I was chilled, relaxed. I could talk to my babes, smell their wonderful heads, if I was Esme I’d probably have licked them. I could sense them and they could sense me. Like indigenous women have known for centuries and like the primates we are I could do what is natural and respond to my baby before he cried.

No-one can tell you how to parent your baby in the right way. There is a huge industry in books, magazines, websites and advice. I’m not going to tell you how to do it. What I am going to tell you is to be close, to use your senses, to let the attachment be. Trust your instincts, your gut feelings, be woman, mother, love.

Hold your baby, smell your baby, wear your baby with pride 

Posted in Birth | Tagged , | 1 Comment

Birth or delivery- what’s in a word?

Birth-it’s something we plan for, build our daydreams around and in some cases fear right from the moment that we realise that that little life inside us is going to want to make its way out into the world at some point.

As a brand new student midwife I remember standing clutching my little red book that was the key to having all my competencies signed off- my pathway to registration and an entry into the esoteric world of birth support.

In that little red book were all my hopes & dreams for my birth as a midwife, a supporter of women, someone who would empower and enable, support and nurture my sisters as they grew in life and became mothers.

My little red book had a section for the number of normal births the midwife assisted in and another for those with higher risk factors- epidurals, induced labour, labours where oxytocin support was needed. The interesting thing is that from the moment I started collecting those NHS numbers the whole process focussed on ‘deliveries’. “How many have you got now?” “how many do you need”- the standard collecting of proof that you have been at enough births to conduct them alone competently and safely.

And here is the thing- subtly the language had changed. From discussions about birth as a normal physiological process to collecting deliveries like a demented statistician- the change is stark. For women this shift is important- it takes a strong midwife to hang on to that belief that birth is what we are all about. There are many many wonderful midwives who are out there actively supporting birth, but there are many obstetric nurses who are helping to create speedy efficient deliveries.

I’m sure there are people who are going to think –well hang on- its just words. But you see it isn’t. Its about philosophy, about paradigm shift and ultimately its about what we as women want for our sisters, our daughters, our friends and ourselves.

Do we want deliverance? Do we want to be saved from our own bodies, from our children? Do we want our memories to be of intervention, of being done to, talked at and finally submitting to whatever is suggested?

Or do we want birth? Do we want the gradual unfolding of a dark mystery, the growing of a woman, the rite of passage that takes us back to a primal force that rips us apart and builds us anew, stronger, undefeated and primed to start a journey that will take us through many trials, battles and joys as we nurture new life.

There are many times where we need to collide with the harsh world of science, where lives can be saved and terrible damage prevented by intervention. There are just as many times where we need to remember that birth is nature’s way of perpetuating the species and that left to its own devices the female body can do amazing work.

As a midwife I wanted the most normal, safest and most empowering births for the women whose lives I had the privilege to enter. As a woman it is my hope that I can always advocate  a philosophy that values birth and motherhood, that celebrates woman and all of our strengths. That is why the words are important- birth makes us who we are.

Posted in Birth | 1 Comment

Was your birth OK?

Why settle for ‘good enough’ when it could be AMAZING? When you really listen to women who say they had a good hospital experience they often describe some awful things, and they almost always say, “We are OK and that is all that matters,” as if they were talking about something like a car crash rather than the birth of their baby.

Women talk about trading safety for a good experience but actually, a good experience is SAFER for mum and baby, physically and emotionally, and the better a mum feels, the easier it is for her to be a caring and responsive parent.  Surely that can only be a good thing?  Safety and positive birth experience, the two go hand in hand, it is not a one or the other choice.  A calm and peaceful birth is safer for baby, safer for mum, more likely to lead to successful breastfeeding (for so many reasons, including that stress in labour slows the hormonal start to milk production so gets in the way at the very beginning), it is less likely to result in SCBU admission, has less need for narcotic painkillers (which depress feeding and breathing reflexes in babies and can be very dangerous, even fatal), results in lower blood loss, less jaundice in babies ….  The list simply goes on and on.

Women have been duped for a long time into thinking that birth is dangerous and is becoming more so, but that is spin, with no grounding in reality.  Our bodies have not evolved to the point where we grown babies too big for our pelvises, nature has simply not got it wrong in the last 300 years or so.  We are healthier and fitter and live longer than ever before, and we are in a better position than our ancestors to grown and birth a healthy baby, not less.  It is not true that women and babies died in vast numbers giving birth prior to the advent of modern medicine. If that were true, the human race would be struggling for survival, rather than overpopulating our planet as we now are.  Historical archives such as the diary of Martha Ballard (in 1700s New England) show that even then midwife-care was safe, few women died (and they did not die of childbirth itself) and few babies did either.  Yes, babies who were very premature died, but sadly most still do, and of those that survive a high proportion will require life long care and suffer from brain injury.  There was no antenatal screening then, nor termination for those babies who stand a low chance of survival or normal life.  In recent years (since the beginning of screening and resultant termination of pregnancy) the overall number of pregnancies lost has changed little, it is just the timing of death that is changing, and the rates of cerebral palsy are not altering.  Contrast that with the work of Alexander Gordon, who was vilified, lost his home, his family, his job, because he dared to suggest that childbed fever (puerperal sepsis) was transmitted by the birth attendants, and in a hospital setting there was little chance of escape.  He knew nothing of bacteria, nothing of the benefits of proper hygiene, he was a long way before the discovery of penicillin, but he discovered that something they were doing was killing women and he tried to say so…  His peers drove him out and it was a very long time before anyone accepted that he was right!

The things which have dramatically improved birth safety are good hygiene (things like washing hands, clean homes, flushing loos, cheap and available soap, good ventilation, reduced crowding, keeping our livestock outside) and antibiotics.  The things which make it less safe are things like the loss of women’s knowledge and confidence in their bodies, a loss of family support and a cross-generational confidence in birth (where young girls know about birth from being there and they help with babycare etc.) so they don’t need specific education for it, they are just prepared.  However, the biggest barrier to safety is medical intervention itself…

Lets start with position.  The practice of birthing on your back is damaging to the labour process as you work against gravity, it increases pain, slows birth, restricts the pelvis, reduces blood flow to the baby, yet it is still the most common position for medical staff to encourage a woman to adopt.  Staff don’t even have to say, “Get on the bed,” although they frequently do, women see birth shown like that and think it is what they need to do, they even put it on their birth plans because they don’t understand why it doesn’t help.  So they get on that bed, conveniently placed in the centre of the room with nowhere else easy for them to sit, and they stay there, in increased pain, ignoring the cues from their bodies telling them to move, until someone actively suggests they try something else…  If that suggestion doesn’t come, or if they are encouraged to have pain-relief and a monitor instead because they or their baby aren’t coping, then the birth becomes a medical event…  When a woman puts that in her plan, staff respect it and encourage it, saying it is what she wants, but when a woman asks to remain mobile, or use water, or to do lean forwards then the excuses come thick and fast, “Just 10 minutes on the monitor first,” “the pool is in use,” “the midwife has bad knees and can’t help if you are on the floor,” and all of a sudden the birth plan is ignored and the woman is persuaded to change her careful plans.  If she does not have a clued-up and assertive partner to help her, then she is very vulnerable and likely to remain doing as she is told because her brain is so focussed on labour.

Which moves me on very neatly to the second big risk factor, oxytocin.  Or more to the point, all the things which stop it.  Oxytocin is essential, it drives the birth process.  It promotes healing, it promotes natural pain management, it promotes calm and relaxation.  Not for nothing does Michel Odent call it the Hormone of Love, nor Kerstin Uvnas-Moberg call it the Hormone of Calm and Connection.  It is the opposite of adrenaline, the hormone of fight and flight.  The two can not run together, and so, if threatened, startled or stressed, our bodies produce adrenaline which stops the production of oxytocin until the threat is past.  Since oxytocin only lasts about 1.5 minutes in our blood stream before it breaks down, the effects of its removal are both instantaneous and long lasting.  It is a primal response and its control is somewhere far beyond our rational brain.  So, here goes with the list of things which can increase the amount of adrenaline flooding our system and cancelling out the oxytocin which drives the process of labour and helps us feel calm, in control, free from pain and filled with love (and also ready to receive, bond with, protect, nurture and feed our baby) and safe.  All things which increase adrenaline, especially those things which cause a flood, are DANGEROUS because they stop labour and they reduce the amount of blood flowing to your baby.

In no particular order:

Bright lights – light is a stimulant, all stimulants increase adrenaline, it is the first phase in how the body is stimulated.

Strange sounds – sound is a stimulant, note how you startle at a loud bang, a strange noise outside when you are sleepy, the shout of a child, a cry of distress, all those things flood your system with adrenaline.  Now think about how many strange noises you are going to hear in a busy labour ward, and how many are distress calls from fellow humans…

Smell – our most primal sense.  If things smell foreign they smell of danger until proven otherwise, be that potential poisons (don’t eat that, it smells off) or the smell of predator.  Anything which does not smell of the safety of your own nest has the potential to smell of danger.  The smell of adrenaline on those around you is a key one here…  A frightened partner, a midwife who is constantly bustling and running, an over-tired doctor, the man in the room next door who has driven 20 miles flat out with his loved one in labour, not only give off physical signals of fear and distress, they really do smell of fear.  Animals are good at recognising it, and so are labouring women!

Touch – calming touch, erotic touch, massage all increase oxytocin.  Painful touch, unwanted intimacy (think internal exam) needles, force, lack of movement causing increased pain, all increase adrenaline.  Look for the balance in a birth situation and you will see that little of the touch commonly associated with birth is calming, mostly it increases adrenaline.

Taste – allied to smell, and the reason why tea from your own tea bags, in your own mug is more soothing than any other kind…

Brain Power – when flooded with oxytocin a woman will retreat into herself.  Anything which requires her to leave that state (often described as labour land) requires adrenaline to stimulate it, which means less oxytocin.  Things like asking questions which require more than a grunt to answer (name, date of birth, what pain relief do you want, can we discuss your birth plan) all increase adrenaline and reduce oxytocin.  See the problem and the pattern here?  Moving location can also cause this, so transferring from the safety of your nest to hospital would do it.  Add to that list the more complicated things, like learned fear (from hearing horror stories, from not knowing enough and not trusting our instincts), harsh words, disempowering comments, insistence on a particular course of action or insisting on something when a woman has said NO and you are flooding her with adrenaline at the expense of labour.

In the animal world it is widely accepted that anything which might stress or disturb the labour process is potentially dangerous and should be avoided at all costs, yet we expect women to cope with it, and it is because our bodies and brains are actually designed BETTER for birth than most mammals that we do birth in such stressful situations with a great degree of success and with the minimum of damage to ourselves and our babies!

So, from a biological point, well supported home birth IS safer than a hospital with all the medical facilities on hand.  When it stops being safe is when hospital practices, such as lots of lights, breaking waters artificially, internal exams, lots of questions and a rush of adrenaline are introduced at home without the backup of medical expertise to rescue the situation.

This is only the start of the explanation, but it is probably enough to start you thinking and reading.

Posted in Birth, Home Birth, Supporting Birth | 1 Comment

Did you have a choice?

I read recently that the majority of women say they were offered a choice of place of birth, yet 98% are still having their babies in hospitals, despite a very large body of evidence which leads to the conclusion that home births are safe for mums, safe for babies, and have higher levels of satisfaction.  A small number of women will have their baby in a birth centre, which can range from the amazing, free standing, autonomous resource centre to a corridor on an obstetric unit with similar practices and policies.  However, these places are not geographically available to all women, and the acceptance criteria can be quite tight.  So, why?  How can Wales have a home birth rate of about 8%, how can places like Torbay and the axed Albany practice have home birth rates of 40% with outcomes as good (and even better) than the hospital?

This is because women generally are NOT being offered options, or not in a way which makes them real and accessible…  Imagine asking a first time mum, who has been told (and believes) that birth is awful and that she should take every painkiller on offer, where she would like to have her baby.  You pretend that you are offering her an open choice, but you offer her little or no information or chance to educate her decision making, and then when she says ‘hospital, where the drugs are’ you write down that she has ‘chosen’ hospital birth…  You do this when she is about 12 weeks pregnant, and you set her expectations on a decision made at that point in time.  Did she really have a choice of a home birth or a birth centre?  The choice might have been there on paper, or even kind of asked, but the chances of this mum accessing that choice were virtually nil.

Imagine listing the hospital run places for birth like a menu, and then, with raised eyebrows and incredulous voice say ‘Or you *could* have your baby at home’ without making sure that the woman has understood the value of doing so.  She isn’t going to be very likely to book it, unless she’d have been asking for a home birth even if you hadn’t ‘offered’ it.  Did you really let her have a choice, or give her the information she needed to make an informed decision about how she wanted her baby to be born?  No, you set her up to ‘choose’ hospital again.

Or how about when a woman books a home birth, without the security of knowledge and confidence from having a 1:1 MW, and then sees her GP, Obs, other MW even, who sucks her teeth, says home birth is dangerous, throws about a few incorrect statistics and says ‘and you wouldn’t want anything awful to happen to your baby would you, because it is horrible watching a woman bleed to death’ or any such claim.  Interestingly, when you ask them when they witnessed that awful situation, you find it was whilst they were a student eons ago, or something that they didn’t even see for themselves, only heard about …….  When the woman then ‘changes her mind’ and ‘chooses’ to transfer her care to the ‘safety’ of the hospital, who can blame her!

Most women are OFFERED a choice, few are actually GIVEN one 😉

The places where women frequently and successfully give birth outside of the hospital system have very different choices.  Usually the discussion begins with talking about how birth can be, and giving the woman true freedom to ask questions and to digest the information in a way that is accessible for her.  She may or may not be ready at this stage to make a choice and work towards that goal, but no assumptions are made about her birth, and no ‘booking’ of a place made.  The woman’s pregnancy progresses with the support of a caregiver the woman knows well and trusts because the communication is open.  If there are complications, then the woman and her supportive caregiver address them, sometimes together, sometimes with the help of extra professionals.  The woman gets to decide here how things will proceed, and she alone gets to decide which pieces of advice and information she wishes to act on, and her decisions are supported and respected, in the safe knowledge that she has made an informed decision.  When she chooses to decline offered interventions, that is respected without pressure.  There can be no choice, and no informed decision, unless you have the complete freedom to reject a choice or make a different decision from that recommended.

In that situation, when the woman finally begins to labour, she is supported at home and makes her decision as to whether or not she wishes to transfer her care to hospital at that point.  She will make that decision based on the information about how well she and her baby are, and on her personal preferences.  Whatever she chooses will be accepted, valued and supported.  Interestingly, the majority of women in that situation seem to choose to stay within their nest, and birth happens smoothly and well, the outcomes are as good as in a medical facility, but the striking difference is how the woman feels about her birth.  It is rare for women who have been through that experience to talk about birth being ‘painful’, ‘degrading’, ‘frightening’ or most telling of all, ‘worth all the pain and trauma because I have a baby.’  Her satisfaction levels are high, she is empowered and she is on top form to begin being a parent.  Is that not the way it should be?

Choice is a funny thing, and the illusion of choice is one which will continue until we start to support and educate women so that they can make real choices and not just the ones that the system wants them to make.

Posted in Birth, Home Birth, Supporting Birth | Comments Off on Did you have a choice?

So, why does the system feel challenged by doulas?

Doulas struggle with issues like the fact that the vast majority of committed and caring health professionals are not able to provide safe and effective care within the system.  Their practice is constrained by policies and procedures which are often not based on best evidence, but on a complex formula which balances the risk of a successful lawsuit and consequent payout should something go wrong with that policy.  This is damage limitation and not evidence based best practice.  Add to that the situation where learning time for those professionals is limited and stops the professionals from keeping up with best evidence and new research.  Hospital policy usually has the insurers best interests at the core, and not the best interests of the woman or her baby.  That makes it VERY difficult for staff because they are torn between following the rules their employer lays down and doing what they know gives a woman the best chance of a good birth and healthy baby.

Add to that the fact that most maternity units are overstretched and understaffed.  Midwives will typically be caring for two or three women at a time, all women they have not met before, and so building a supportive long-term relationship is just impossible.  A doula, on the other hand, has the time to meet with a woman enough before the birth for them to trust each other and for both to know what the woman really wants from her birth experience.  A healthy baby is a very important outcome, but certainly not the only measure of a birth which leaves a mum feeling ready for the challenges of parenthood!

Consider the difference with an independent midwife, or with the model so successfully demonstrated by the Albany Practice…  A woman discovers she is pregnant and she goes to see a midwife, and the midwife (with her back-up) cares for that woman throughout her pregnancy, through her birth and for some time afterwards, even if there is a need for medical help, the same midwife is there to help the woman understand what is happening, what is on offer and help her make decisions.  The woman feels safe and supported and trusts her midwife.  Compare that with the more common situation, a woman does a positive pregnancy test, she goes to her GP who ‘confirms’ her pregnancy and refers her to a midwife and to a consultant.  The woman then sees a variety of midwives for health checks and a medic who is a specialist in things going wrong, but has no real need to see a woman for whom everything is OK.  She sees several different people and her care becomes focused only on the medical aspects, forgetting or minimizing the emotional ones.  She then goes into labour and regardless of whether she goes to hospital or stays at home, she meets, usually for the first time, the midwife who will guide and support her through an intensely emotional, vulnerable, physically demanding, private experience.  It is asking a huge amount of that midwife to expect her to know this woman’s wants and needs from the outset, so the discussions are had, medical checks are done and that stress makes labour more difficult, longer and more painful.  The presence of a doula does not create conflict here, it preserves the woman’s labour!

Good, supportive and caring midwives know that the situation they work in is not serving women and their babies well.  Those midwives welcome a doula with open arms.  The presence of a doula means they don’t have to worry that the woman and her partner (who probably has no more birth experience than the mother) will lack knowledgeable emotional support when the midwife needs to be elsewhere.  The doula is not bound to keep endless notes which take time to write and take away face to face care time.  The doula can advocate for the woman and thus help preserve the hormonal and psycholocical state of easy labour.  The doula can support the woman when she makes a decision which does not follow the lawyer-prescribed policy, and believe me, a midwife who knows that the policy was not right for this woman thinks that is a huge bonus.  I could go on and on, and I probably will in another article, but I hope you get the picture.

Then, we have the defensive practitioner, the one who is bogged down and jaded by the system.  They are generally the ones who want to do their job and go home, they don’t want to learn more than they have to and they are not keeping up with current research.  They generally care too, but are at the end of their reserves.  Sometimes they like doulas because that takes the pressure off, some times they feel challenged that someone else has more to offer the birth than they do and they are aware that things are not right in their job.  They want policy followed to the letter because that makes the paperwork easy and the system feel safe for them.  They are kind in their words but their actions pressure women into changing their minds.  In these situations the doula must be supportive of the midwife too, and nurture her a little also (so long as that adds to the situation for mum and does not take care or focus from her) because it is clear she is not nurtured by her job.

Then we get the group who are arrogant and not really understanding of mammalian birth.  This is the group who are experts in medical care but not in nurturing or supporting birth.  These professionals are almost invariably intolerant of doulas and frequently rude to them.  This is the most challenging situation, and the one that doulas need to rant about.  Managing these situations so that the woman’s needs and wishes are respected is a tough job.  These professionals hate doulas because they stand for the woman’s right to be a part of the care and to make decisions.  This is a small group, but as they old adage says, it only takes one bad apple to sour a barrel.

I hope that helps.  Women need an advocate, sometimes they get that in their midwife, she becomes a trusted friend and ally, but how can you have confidence that will happen if you have no idea which of the 40+ midwives on the rota is going to be the one who turns up to your birth?

Doulas rarely hate doctors and midwives, they frequently hate the system.  Doctors and midwives frequently feel threatened by doulas…  Whilst that is the case women will continue to need a doula to protect their birth space.

Posted in Birth | 2 Comments

Is a good birth down to luck?

So, is a good birth down to luck? Certainly if you’ve gone down the standard NHS Consultant Unit route and you come out at the other end thinking you’ve had a good birth, then yes, it is ABSOLUTELY down to luck.  You may just have timed your labour to coincide with the shift of a fantastic, woman-centred midwife who still has enough fight left in her to treat the guidelines as exactly that – just guidelines rather than rules.  You may have been lucky enough to have been encouraged to stay active in a quiet, dimly lit room, to have been encouraged that yes, you could do it without being drugged, and to have managed to give birth before this brilliant midwife finished her shift and was replaced by someone not quite so keen on natural birth.  You may have been lucky enough to give birth at a time when the unit was quiet so that this aforementioned midwife didn’t have 2, 3 or 4 other women in labour to look after…………..

I attended a home birth last week.  First time parents, E & A, late twenties, well educated, intelligent.  Most of their friends have started having babies and E’s best friend gave birth last year in the local consultant unit.  She was one of the unlucky ones.  Suffice to say, if she is ever brave enough to have more children after what she went through, they will be born at home.  As a result of her experience, my client was scared enough to think about homebirth, perhaps not the ideal start to a pregnancy but as it turned out, her friend’s misfortune became the making of her own “lucky” birth.

Her partner, A, was not keen on the idea initially, he knew no one else who had given birth at home.  Indeed, most of the men he knew who had talked about their partners’ births thought that it was a ridiculous idea – after all, their women had all needed lots of medical help, many of them had even needed caesareans…… He was eventually persuaded to go to a local home birth group to find out more and as time went on he started to come around to the idea.  In the meantime, E had done a lot of homework, read books, trawled the internet and was adamant that home birth was for her.  The decision was made to hire a doula and with that extra support, A entered fully into the spirit of things.

E’s waters went some time before labour started, but despite protestations from the hospital, she stayed at home to wait for labour to start.  She knew enough about how to prevent infection, and enough about her rights, to know that she didn’t have to accept the hospital’s kind offer to induce her.

Labour started slowly the next day and after spending a relaxed day together, things picked up enough in the evening to call me.  By the time the midwives arrived late evening, E was in active labour and soon got into her pool.  We had put together a short birth plan to ensure that the midwives knew what E did and didn’t want, and it was stuck to.  Before long, E and A’s baby was born straight into the waiting hands of his daddy – a calm, quiet, fast birth, without the use of drugs, stitches or any medical interventions.  A physiological third stage followed.

A couple of hours later, I left this new family tucked up in their own bed, baby feeding well and everybody happy.  When I mentioned to someone the next day that I had been at a lovely home birth to first time parents, they said “gosh, wasn’t she lucky?”  Yes she WAS lucky – lucky that she had had the foresight to put such a huge amount of planning and research into doing what she could to make sure she had the best birth possible………………….. 😉

Posted in Birth | 4 Comments

Am I a midwife?

OK, I’ll answer that if I can…  In the current climate, I would rather gouge out my own eye balls.  Here’s why…

Midwives have to jump through too many hoops for the sake of the lawyer-driven policy and right now they really struggle to provide good midwifery.  If I could do direct entry to independent practice and bypass the NHS, or train somewhere with a stand alone unit, I’d do it like a shot, but I couldn’t work in a large consultant unit where care is compromised for fear of litigation…  A place where a midwife is overstretched and may be caring for several women at once and unable to give her full care to any, where she may not get a meal all shift, where sometimes she might even have to hold off going to the loo because she is spreading herself more thinly than is safe already.

Right now, I serve women better by being a Doula, by giving high quality evidence based information and support, by encouraging women to understand their own needs and make their own decisions, by offering high quality, consistent and effective support for breastfeeding.  I help more by campaigning for women centred care than I would as an over-stretched NHS midwife, having to give what I know is substandard care because I am serving three women and not the 1:1 I know is right. I’d be so miserable having to compromise my principles and the best evidence like that.

As it is, I can educate and empower women and support them to make their own choices and to get the care they deserve.  I can provide support when it is needed most, especially in those situations where a woman wants something which goes against management policy.  For me it is easy because my job is not on the line if I support the woman’s wishes and evidence-based, sensitive and individualised care against a ‘one size fits no-one’ system.  My job is on the line if I fail to support the woman in a woman-centred situation. I have never met a midwife trying to practice real midwifery who has not been glad to have me there.  Those who want women to blindly do as they are told, regardless of their own needs and perceptions think I am a pain in the butt.  I can live with that if it means someone gets a better birth and early parenting experience than they would have got otherwise.

So, no, I am not a midwife.  I am an advocate for women, I am an educator, I am support.  I am a Doula and it is the best job in the world.

Posted in Birth | Comments Off on Am I a midwife?

Want a good birth?

As a doula, I’m not allowed to tell women what I think they should be doing regarding their forthcoming births – I can only let them know what their options are and what the pros and cons of certain things might be. Even when I have presented things to the best of my abilities, occasionally women will still choose the “option” that I KNOW isn’t the best one! I would like to use this space to tell it like it is – if there is something that I really think you would be mad to do, I will say so. If there is something that is pretty much guaranteed to improve your birth experience, I will say so.

I have a handful of children myself and after much research, soul searching, and truly awful “advice” from the medics, I chose to VBAC after multiple caesareans. I didn’t explode, and my baby and I didn’t die. I have witnessed many births since then and I have helped many more women to achieve births that were memorable in a GOOD way.

Our culture is such that most women seem happy to go along with whatever their doctors tell them they have to do, without taking the time to do their own research into what is best for them. We are shown images of horrific childbirth (mostly huge works of fiction) on tv, and the competition between women to see who has had the worst/longest/most painful birth seems to be growing all the time. Caesarean section is NOT the safe easy option that is portrayed, and vaginal birth does NOT have to be an experience filled with fear and pain. We do NOT have to be drugged up to the eyeballs to get through it and big babies are nothing to be afraid of.

Let’s reclaim our rights! Say NO to unnecessary induction, NO to unnecessary caesareans and YES to giving birth in a better way and let common sense prevail

I am not anti-caesarean, far from it. It is a brilliant operation that is an essential tool for skilled obstetricians to use to save the lives of the small percentage of babies that require it. However, if it were used simply for those who really need it, our CS rate would be between 1 and 5%. The average in the UK at the moment is more than 1 in 4 births which includes “emergency” and repeat caesareans. ONE IN FOUR!!!! That is ridiculous!!!!

In some hospitals, whole wards are devoted solely to the women who come in daily for induction of labour, most of whom are only there because they are “overdue”. 40+10 is NOT overdue! Unless there is a good medical reason for induction, stay at home ladies. The Guidelines state that a woman should be able to choose regular scans instead of induction to check on her baby’s well being, placental function and amount of amniotic fluid. So why doesn’t this happen? It doesn’t happen because it hospitals have more control over their intake if women are induced. God forbid that they should all wait till labour starts naturally and come in without having made a prior appointment…….. of course, the party line is that your placenta will stop working at 42 weeks and your baby will die. But this is why regular scans are recommended in the guidelines, so that everyone KNOWS what is happening……..but still women go in every day, like lambs to the slaughter, because they “have” to.

If just one woman reads this blog and thinks twice about what she has been told she “has” to do by her doctor, and that woman takes the time to educate herself a little more about childbirth and goes on to make a truly INFORMED decision about her care, I shall consider my time well spent

Posted in Birth | 8 Comments